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VOL.8 NO.1 PAGES 84

Knowledge Are you ready to capitalise on disruptive healthcare technologies? Strategy Healthcare policies for progress www.expresshealthcare.in JANUARY 2014, `50


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CONTENTS MARKET Vol 8. No 1, JANUARY 2014

Chairman of the Board Viveck Goenka

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STRAND LIFE SCIENCES TO SET UP STRAND CENTER FOR GENOMICS AND PERSONALIZED MEDICINE

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PORTEA MEDICAL RECEIVES RS 48 CRORES FUNDING FROM ACCEL PARTNERS AND VENTUREAST

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WHITE HOUSE RECOGNISES SAP FOR ENABLING REAL-TIME PERSONALISED MEDICINE

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HAIRLINE INTERNATIONAL SIGNS MOU WITH MERISIS THERAPEUTICS

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INDIA TO STRENGTHEN R&D OF NEW DIAGNOSTICS, VACCINES AND TREATMENTS FOR NTDS

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APOLLO MUNICH HEALTH INSURANCE INTRODUCES ‘ENERGY’

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HEALTH MINISTER LAUNCHES REVERSE DOT BLOT HYBRIDIZATION THALASSEMIA DIAGNOSTIC KIT

Editor Viveka Roychowdhury* Assistant Editor Neelam M Kachhap (Bangalore) Mumbai Sachin Jagdale Usha Sharma Raelene Kambli Lakshmipriya Nair Sanjiv Das Delhi Shalini Gupta DESIGN National Art Director Bivash Barua Deputy Art Director Surajit Patro Chief Designer Pravin Temble Senior Graphic Designer Rushikesh Konka Layout Vivek Chitrakar Photo Editor Sandeep Patil MARKETING Deputy General Manager

POLICIES FOR CHANGE Experts share their views on healthcare policies in India and their role in driving progress,with Express Healthcare| P42

KNOWLEDGE

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ARE YOU READY TO CAPITALISE ON DISRUPTIVE HEALTHCARE TECHNOLOGIES?

26 28 29 31 32 34 41

ATANU GARAI

Harit Mohanty Assistant Manager Kunal Gaurav PRODUCTION General Manager B R Tipnis Manager Bhadresh Valia Sr. ExecutiveScheduling & Coordination Rohan Thakkar CIRCULATION Circulation Team Mohan Varadkar

RAVI RAMASWAMY DR KAUSHIK D DEB DR P GOPINATH

STRATEGY

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HEALTHCARE POLICIES FOR PROGRESS

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EFFECTIVE IT POLICIES TO SAVE LIVES

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NATIONAL HEALTH POLICY: NAILING IT RIGHT!

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INTERVIEW: DR CLIFF BLEUSTEIN

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ROOTING FOR MEDICAL DEVICES REGULATION

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BSC COMMUNITY HEALTH VS MBBS IN INDIA’S RURAL HEALTHCARE SYSTEM

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GOVERNMENT HEALTH SCHEMES: CHALLENGES AND THE ROAD AHEAD

VIRAL SACHDE TOP TEN INNOVATIONS INTERVIEW: DR INGEBORG HOCHMAIR

IT@HEALTHCARE

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Express Healthcare Reg. No. MH/MR/SOUTH-252/2013-15 RNI Regn. No.MAHENG/2007/22045. Printed for the proprietors, The Indian Express Limited by Ms. Vaidehi Thakar at The Indian Express Press, Plot No. EL-208, TTC Industrial Area, Mahape, Navi Mumbai - 400710 and Published from Express Towers, 2nd Floor, Nariman Point, Mumbai - 400021. (Editorial & Administrative Offices: Express Towers, 1st Floor, Nariman Point, Mumbai - 400021) *Responsible for selection of newsunder the PRB Act.Copyright @ 2011 The Indian Express Ltd. All rights reserved throughout the world. Reproduction in any manner, electronic or otherwise, in whole or in part, without prior written permission is prohibited.


EDITOR’S NOTE

Poised for progress in 2014

A

s we enter a new year, Express Healthcare marks its 14th anniversary, with a new layout and design. In fact, with general elections around the corner, the nation seems to be gearing up for change on all fronts. The healthcare sector too is ripe for change. For our anniversary issue, Express Healthcare decided to analyse two important drivers of change: technology and policy. Our cover story (Are you ready to capitalise on disruptive healthcare technologies?; pages 22-25) profiles six such technologies. This is followed by industry experts talking about how each technology already exists in India via their products and services or is being researched at their laboratories. (Pages 26-33) We round off the ‘Technovations for 2014’ theme with the Cleveland Clinic's list of top 10 up-andcoming technologies predicted to have a great impact in the year ahead. (Pages 34-40) All the technologies in the world need an enabling policy framework and most important, good implementation of these policies. Our ‘Policies for Change’ section has industry experts analysing existing policies and regulations which have the possibilities to transform India and its healthcare sector and what must be done to plug the gaps. (Pages 42-55) For instance, mobile phones are today much more than communication devices. The mHealth wave has already touched the shores of rural India: ASHAs update health information as part of the NRHM, BBC Media Action's Mobile Kilkari project sends SMS reminders to pregnant women across eight districts in Bihar. Urban India has already taken their health into their own hands, aided by nifty gadgets like glucometers with embedded sensors which transform them into personal health monitors. These gizmos also link them to the expanding ' Internet of Things', a repository of health information, which can be accessed by both patient as well as clinician anywhere, any time. Companies are churning out prototypes of technology tools previously limited to sci-fi movies. For instance, advanced robotics has given

8 EXPRESS HEALTHCARE January 2014

All the technologies in the world need an enabling policy framework and most important, good implementation of these policies

amputees new age prosthetics which they can control simply by small muscle contractions. Further research might even allow them to control their prosthetics with just their brain waves! Moving further into the realm of science fiction, with next-generation genomics tools, we could actually 'play God' by creating custom organisms simply by writing or re-writing DNA sequences. We have already created advanced materials like gold nanoparticles, which are part of experimental life saving medicines while 3-D printing will one day allow organs, tissue and medical implants to be 'printed' in laboratories. India is no stranger to innovations. In fact, in her Presidential Address at FICCI’s 86th AGM, Naina Lal Kidwai reminded us that way back in 2009, the Jaipur Foot made it to Time magazine's list of the world’s 50 best innovations. She also spotlighted healthcare icons like Aravind Eye Care and Narayan Hrudayalaya which have proved to the world that complex cataract operations and heart surgery can be done at a fraction of the costs, while still maintaining top quality. But these are triumphs of private enterprises. Are policy makers playing their part to facilitate such innovations in healthcare delivery? Also, how do we ensure that these disruptive waves do not bypass our rural populations? For instance, not every woman in our villages is empowered enough to own a mobile phone and even if she did, would she be literate enough to use it? There have been hiccups in the roll out of NRHM as many ASHAs themselves found it difficult to key in data into their phones. But there is hope and these glitches are being fixed so that the mHealth revolution spreads to every district. Here's hoping that 2014 will see better implementation so that the vision behind these policies becomes a reality for every citizen of India. Do write in with comments and suggestions on our new design and layout. And of course, best wishes for the year ahead ! VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com


LETTERS QUOTE UNQUOTE

Indian healthcare system is still in an embryonic stage. But, India will be able to prove to the world that health can be dissociated from affluence. Within five to ten years, every person in India will get access to quality healthcare Dr Devi Shetty, Founder and Chairman, Narayana Hrudayalaya Group of Hospitals (At the convocation ceremony of National Institute of Design (NID)

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MARKET NEWS

Strand Life Sciences to set up Strand Center for Genomics and Personalized Medicine Partners with US-based El Camino Hospital for the venture STRAND LIFE Sciences, a global life sciences company headquartered in Bangalore, is collaborating with the San Francisco Bay area based El Camino Hospitals to locate a Strand Center for Genomics and Personalized Medicine at the Genomics Medicine Institute of the El Camino Hospital to accelerate the adoption of next generation sequencingbased research panels and counseling services by the physicians at the hospital and its partner clinics. A Letter of Understanding was signed on December 4 by Dr Vijay Chandru, Chairman and CEO, Strand Life Sciences and Dr Eric A Pifer, Chief Medical Officer of El Camino Hospital. This signals the start of a collaborative effort to bring advanced genomic tests in cardiology, oncology, pharmaco-genomics and personalised medicine to the community served by the El Camino Hospital. The signing was in the presence of the Mayor of San Francisco, Edwin M Lee and delegates from El Camino Hospital

Strand Life Sciences signs an MoU with El -Camino Hospital, San Francisco, US.

and the Palo Alto Medical Foundation who were visiting Bangalore as part of the “San Francisco - Bangalore Sister City Initiative”. Speaking on the occasion, Dr Vijay Chandru, Chairman and Chief Executive Officer, Strand Life Sciences said, “It

gives us immense pleasure to partner with El Camino Hospital, a leading Healthcare provider in the US. The Strand Center will provide them with genomics-based analysis and interpretation for improved health outcomes. Strand has a distinguished team of over 200

scientists and researchers working to create some unique solutions in Genomics and Personalized Medicine. This partnership is recognition of our commitment to bringing best in class technologies for healthcare closer to people all over the globe.”

Dr Eric Pifer, Chief Medical Officer for El Camino Hospital said, “El Camino is very excited to work with Strand Life Sciences on a series of projects around bringing genomic medicine to clinical practice. ECH is focused on the practical aspects of clinical medicine, while Strand’s expertise, as embodied by their tagline, lies in providing ‘Algorithms for Life.’ So it is a perfect marriage between partners with diverse expertise and a unified vision.” The El Camino Hospital has an active Genomics Medicine Institute that has been engaged in continuing education in genomics for physicians and some genetic counselling of patients. Strand has been a pioneer in the delivery of advanced clinical genomics solutions for healthcare institutions in India since early 2013. Coming from this new focus is StrandOmics, a proprietary solution for clinical interpretation of genomic variants in patient samples with deeper insights leading to informed decisions by physicians. EH News Bureau

Narayana MultispecialityHospital, Jeedimetla installs Artificial Pancreas System It is being touted as a revolutionary way of treating diabetes and its complications NARAYANA MULTISPECIALITY Hospital has launched the Artificial Pancreas System (APS) to manage and combat diabetes. The APS results in a new type of dynamic homeostasis. It mimics normal pancreatic insulin stimulation of the liver, and helps to

normalise carbohydrage and lipid metabolism. Reportedly, it also prevents complications and needs to be used only two to four times a month to achieve these results. After approximately six months, some patients can be treated at home. APS is a product from

Trina Health’s Dr Ford Gilbert. Sudhaker Jadhav, Facility Director, Naryana Multispeciality Hospitals Hyderabad said, “As a part of our quest to bring a new and innovative healthcare delivery system to the masses at affordable prices, we are partnering with Dr Ford to give

this little piece of miracle which might be turning out to be boon for those millions of patients of diabetes who are suffering with co-morbid ailments like nephropathy, retinopathy and coronary artery disease.” Dr GJD Rao, Senior Physcian and Diabetologist said

that off late he has been seeing at least two to three new diabetic patients per day. He seconded that APS is going to be the future and will mark a revolution in the treatment of diabetes management. EH News Bureau

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MARKET

Portea Medical receives Rs 48 crores funding from Accel Partners and Ventureast Reportedly, largest Series A venture capital investment in a home healthcare company in India PORTEA MEDICAL has received a combined Rs 48 crores in Series A funding from venture capital firms, Accel Partners and Ventureast. Portea will use the funding to fuel its growth in 2014 and beyond as it looks to grow both organically and via acquisitions, to a further six Indian cities in addition to the four cities (New Delhi, Mumbai, Bangalore and

Chennai) where the company’s home healthcare services are already available. “We are delighted to have Accel Partners and Ventureast as our partners. The quantum of funding is the largest ever Series A VC investment in a home healthcare company in India; we believe this development is a striking endorsement of Portea’s leadership and

growth prospects in the rapidly expanding home healthcare sector in the country,” said Meena Ganesh, Co-founder and CEO at Portea. “The funds will help us strengthen our offering even as we accelerate our expansion across India in the coming months, and invest in advanced diagnostic and remote monitoring technology to support our

clinicians as they deliver a range of in-home healthcare services,” she said. Following the development, Mahendran Balachandran from Accel Partners and Venkatadri Bobba from Ventureast will join the Portea Medical Board of Directors. Portea works with hospitals, insurance companies and individuals to improve health outcomes by providing a continuity

of care in the home setting from doctors, nurses, physiotherapists, nutritionists, counselors, and home health aides. The company has five tier-1 corporate hospitals as partners, a network of hundreds of referring physicians all over India and handles around 2000 home visits a month. EH News Bureau

Gene experts join forces in new generation of DNAresearch

Silencing signals sent by parasite could aid sleeping sickness fight

Edinburgh Genomics facility to bring experts together to focus on unravelling and analysing genetic code in large-scale studies

The research was conducted at the University of Edinburgh with University of Dundee

GROUND-BREAKING research in human and animal health, the environment, and sustainable food production will be supported by a new world-class centre of DNA expertise. The Edinburgh Genomics facility plans to bring together experts in the field to focus on unravelling and analysing genetic code in large-scale studies. It aims to be at the forefront of the emerging personalisation of medicine, in which treatments can be tailored according to patients’ genes. The Centre claims that its technology will enable scientists to quickly compare hundreds of DNA samples from patients with particular diseases, to pinpoint key genes and inform development of therapies. Scientists at the centre, based at the University of Edinburgh, will also seek to break new ground in agriculture, by identifying genes that could contribute to animal well-being or

A NEW discovery by scientists could help combat the spread of sleeping sickness. Insights into how the parasites that cause the disease are able to communicate with one another could help limit the spread of the infection. The findings suggest that new drugs could be designed to disrupt the flow of messages sent between these infectious microorganisms. Sleeping sickness – so named because it disrupts sleep patterns – is transmitted by the bite of the tsetse fly, and more than 69 million people in Africa are at risk of infection. Untreated, it can damage the nervous system, leading to coma, organ failure and death. During infection, the parasites – known as African trypanosomes – multiply in the bloodstream and communicate with each other by releasing a small molecule. When levels of this molecule become sufficiently high, this acts as a signal for the parasites to stop repli-

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The new venture aims to merge the existing facilities of Edinburgh GenePool and ARK-Genomics crop disease. The centre will enable environmental scientists to learn more about the natural world, and facilitate a fast response to diseases that pose a risk to plants or wildlife. Edinburgh Genomics will make use of the University’s expertise in supercomputing and informatics to analyse the massive amounts of data generated in large DNA studies.

The new venture aims to build upon decades of experience by merging the existing facilities of Edinburgh GenePool and ARK-Genomics, which is funded by the Biotechnology and Biological Sciences Research Council. The facilities’ scientists and technology will contribute to the work of the new centre. Professor Mark Blaxter, Director of Edinburgh Genomics, said, “We will work with clinicians to apply new knowledge in the clinic, with farmers and breeders trying to improve our food supply, and with scientists aiming to understand the genetic underpinnings of how our ecosystems function.” Edinburgh Genomics is supported by the Medical Research Council, the Natural Environment Research Council, and the Biotechnology and Biological Sciences Research Council. EH News Bureau

cating and to change into a form that can be picked up by biting flies and spread. A team led by researchers at the University of Edinburgh was able to uncover key components of the parasites’ messaging system. They used a technique known as gene silencing to identify those genes that are used to respond to the communication signals and the mechanisms involved. Professor Keith Matthews, of the University of Edinburgh’s School of Biological Sciences, who led the research, said, “Parasites are adept at communicating with one another to promote their survival in our bodies and ensure their spread – but by manipulating their messages, new ways to combat these infections are likely to emerge.” The research, carried out in collaboration with the University of Dundee, was published in the journal Nature, and funded by the Wellcome Trust. EH News Bureau


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MARKET

VP Kamath is Nova’s new Group COO He will be responsible for the general management of Nova’s surgical hospitals, infertility clinics, IVIOMICS genetic testing lab and ART bank businesses spread across 20 locations NOVA MEDICAL Centers, India's leading chain of short-stay surgical centers and fertility clinics, announced the appointment of VP Kamath as the Group COO. Based out of Bangalore, Kamath will be responsible for the general management of Nova’s Surgical Hospitals, Infertility Clinics, IVIOMICS Genetic Testing Lab and ART Bank businesses spread across 20 locations. Announcing the appointment, Suresh Soni, Chairman & CEO, Nova Medical Centers, said, “Kamath is a well-respected veteran of the healthcare industry, with over 25 years

of experience in leadership, general management, operations, sales and marketing and business development with some of the top players in the field. His vast experience, leadership skills and industry insights make him a very strong addition to Nova’s management team.” During his career, Kamath has been associated with healthcare majors such as Wockhardt Hospitals, Apollo Hospitals, Nicholas Piramal, and Johnson & Johnson. He holds a Master’s degree in Microbiology and an MBA degree, both from the University of Mumbai. He has also attended the Advanced Man-

agement Program at the Walter A. Haas School of Business, Berkeley, California. Commenting on his new role, Kamath said, “The Indian healthcare industry is at an inflection point in terms of opportunities and growth potential. Nova Medical Centers is at the forefront of this change and has already carved a niche in the surgery and fertility space. It is not only very exciting to get associated with such a dynamic company, this opportunity also allows me to get closely connected with the society at large and make a difference to people’s lives. Joining Nova comes

White House recognises SAPfor enabling real-time personalised medicine

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hanian, Head of Computer and Information Science and Engineering at the National Science Foundation. “Collaborative efforts like those featured at Data to Knowledge to Action are advancing the role that Big Data can play in future innovations across all sectors, from education to healthcare.” The SAP HANA platform targeted to the needs of healthcare aims to offer researchers, hospitals and pharma and insurance companies with biological, lifestyle and clinical data to help optimise patient health by personalising prevention, treatment and health maintenance. In a SAP-funded collaboration with Stanford University Professor of Genetics Carlos D Bustamante’s lab at the Stanford School of Medicine, researchers are using SAP

The goal is to develop new treatments for autism and cardio vascular disease HANA for real-time analytics to help uncover genetic variants that contribute to population health and disease. Since using SAP HANA, Stanford researchers have seen significant improvement in performance, with 17X to 600X faster computations when analysing their genomic data, revolutionising the ways in which they can gain insights

EH News Bureau

UAE Exchange conducts eye testing camp

into the biology of certain diseases. Ultimately, the goal is to develop new treatments for autism and cardiovascular disease, conditions that have a profound impact on the health of millions and add tremendous costs to the healthcare system. Outside the US, SAP is collaborating with the National Center for Tumor Diseases in Heidelberg, Germany, to pilot analysis and collaboration tools based on SAP HANA. These tools are designed to enable physicians and researchers to securely analyse clinical and genomic data in real time to help dramatically improve cancer diagnostics, identify personalised treatment options and facilitate matching patients with the best clinical trials.

UAE Exchange, in association with Vasan Eye Care Hospital, conducted a free eye testing camp at UAE Exchange Nagercoil branch in Tamil Nadu. The staff of Nagercoil branch invited their customers and other people to attend the camp. People from all walks of life including those from residential areas in and around the town, shops, taxi and auto drivers, bank staffs, vehicle dealers came to the venue to get their eyes checked by the team from Vasan Eye Care hospital.More than 76 people from the locality utilised this opportunity. "We care for the society, the people, and we try and help them in the best possible way we can. We have a deep bonding with the communities where we serve, beyond business and service, and it has helped in the growth of the company,” said V George Antony, Managing Director and Country Head on the successful completion of the camp.

EH News Bureau

EH News Bureau

It aims to help optimise patient health by personalising prevention, treatment and health maintenance AT A recent event sponsored by the White House, the National Science Foundation and the Networking and Information Technology R&D program, SAP AG was recognised for its collaborative efforts to enable real-time personalised medicine through innovation with Stanford University and the National Center for Tumor Diseases Germany. The Washington, DC-based event, Data to Knowledge to Action, featured public and private organisations that enhance scientific discovery and biomedical research and derive greater value for consumers by innovating Big Data tools and technologies. “Big Data is transforming the ways in which we live and has the potential to accelerate the pace of discovery in almost every science and engineering discipline,” said Farnam Ja-

with a great responsibility to further build on the tradition of excellence that the brand represents, making it the most advanced and admired healthcare institution.” Kamath is also a visiting faculty member at IIM Ranchi, MET and NMITD, Mumbai, and is on the steering committee of Goa Institute of Management. For his outstanding and extraordinary achievements in Healthcare and Education, Kamath was recently awarded the “Bharat Excellence Award” and the “Rashtriya Jewel Award”.


MARKET

Hairline International signs MoU with Merisis Therapeutics To offer genetic testing in Bengaluru HAIRLINE INTERNATIONAL Research and Treatment Center has tied up with Merisis Therapeutics, a division of DiponEd Bio Intelligence LLP, to facilitate genetic testing for their patients in Bengaluru. Dr Dinesh G Gowda, Dermatosurgeon, Hairline International Research and Treatment Center said, “Anyone with hair and skin condition will now be able to get a medical forecast that will tell them with 80 per cent accuracy their risk of going bald or developing particular skin ailments.”

Patients will be able to know with 80 per cent accuracy about the risk of going bald or developing particular skin ailments Speaking on the occasion, Bani Anand, MD and Founder, Hairline International Research and Treatment Center said, “Youngsters in the 25-30 years age group are showing symptoms of balding due to genetic predisposition as well as lifestyle. With such genomic profiling, we are able to ascertain accurately whether a person is prone to excessive loss of hair. This will facilitate us in creating a customised treatment plan that ensures the health of hair and stops progression of balding”. EH News Bureau

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MARKET

India to strengthen R&D of new diagnostics, vaccines and treatments for NTDs Improved diagnostics and medicines a priority for eradicating NTD LEADING THE global fight against Neglected Tropical Diseases (NTDs), India is moving to strengthen efforts to eradicate the neglected tropical diseases such as dengue, visceral leishmaniasis (Kala azar), soil-transmitted Helminths, among others that affect millions of Indians every year, especially children. The recently held meeting of experts on neglected tropical diseases (NTDs) marked a major step towards accelerating progress in controlling and eliminating NTDs in India. Coming together to launch this strategic drive aimed at the ultimate eradication of NTDs in India were Global Health Progress, Organisation of Pharmaceutical Producers of India (OPPI), and International Federation of Pharmaceutical Manufacturers & Associations (IFPMA). The launch of this initiative,

India has the highest burden of NTDs in the world, and the impact of this is to lock these vulnerable and affected groups into a cycle of poverty and disease called “Partnering for Success – Reducing India’s Burden of Neglected Tropical Diseases” was followed up with a landmark report on the current status and action plan to fight NTDs in India. The meeting and subsequent report emphasised on the partnerships between the Government of India, research organisations, pharmaceutical companies, donors, health professionals and civil society that have contributed technical knowledge, delivery of services and drugs as well as research funding for

NTDs in India. Anshu Prakash, Joint Secretary, Ministry of Health & Family Welfare, Government of India said, “India has supported the London Declaration of 2012 and has joined other member nations at the World Health Assembly this year to adopt a resolution for controlling, eliminating and eradicating 17 identified NTDs. The India Government is working with all stakeholders and the community towards meeting these objectives.”

Ranjana Smetacek, Director General for the Organisation of Pharmaceutical Producers of India said, “For India to achieve its ambitious NTD goals, we must work with other sectors to ensure communities have access to clean water, sanitation, improved living conditions, vector control and stronger health systems in endemic areas. Pharma companies are already doing a lot to prevent and treat NTDs in India and it will be crucial to provide ongoing incentives to ensure pro-

duction of new tools for the market. We must support R&D through partnerships and provision of funding to find next generation treatments and interventions for neglected diseases.” Globally, NTDs affect over one billion people, are more prevalent in rural areas and predominantly affect the poorest and most marginalized communities. India has the highest burden of NTDs in the world, and the impact of this is to lock these vulnerable and affected groups into a cycle of poverty and disease. With 58 per cent of leprosy cases, 40 per cent of lymphatic filariasis and 34 per cent of all dengue cases, India shoulders a high burden of several NTDs, which demands sustained attention and action by all stakeholders. EH News Bureau

Off-the-shelf multibranched stents show promise for aneurysm patients The ‘t-Branch’ stents reportedly offer greater resources for treatment of thoracoabdominal aortic aneurysm RESEARCH PUBLISHED in Journal of Endovascular Therapy shows that early results are promising for use of the first offthe-shelf multibranched stent in aneurysm patients. Five months after receiving this treatment, a small group of patients has survived and remained free of rupture. Although custom-made devices have been available for more than a decade, these readily available “t-Branch” stents reportedly offer greater resources for treatment of thoracoabdominal aortic aneurysm. The current issue of the Jour-

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nal of Endovascular Therapy presents a retrospective review of 15 patients who were implanted with the Zenith tBranch stent. The stent has four downward facing branches and can be combined with a number of individual components, such as tapered thoracic endografts and universal distal bodies. Previous study has shown that a standardised endograft would be suitable for nearly 88 percent of patients with thoracoabdominal aortic aneurysms. The aorta delivers blood from the heart to the rest of the

body. A thoracoabdominal aortic aneurysm—a weakness in the wall of the aorta—can rupture, causing uncontrolled bleeding that can be fatal if not treated immediately. A complex surgical procedure, open repair of thoracoabdominal aortic aneurysms, has been associated with high mortality and morbidity. Since their introduction 13 years ago, custom-made multi-branched endografts have been proven to reduce mortality and morbidity among aneurysm patients. However, these customised stents re-

quire manufacturing times of at least eight weeks, making them unavailable when a patient needs urgent treatment. One year ago, the first commercially made off-the-shelf thoracoabdominal t-Branch became available in Europe. Among the 15 patients treated with this t-Branch stent between November 2012 and May 2013, none have died, and no branch occlusion or type I or III endoleaks have occurred. Type II endoleaks were observed in five patients, one patient suffered paraplegia, and

four patients experienced transient paraparesis that was resolved. These short-term results indicate that use of an off-theshelf t-Branch endograft is practicable and safe. An accompanying commentary suggests some improvements or alternate versions of a standardised t-Branch stent that may help resolve certain issues. The author notes that the design is still evolving, and time will tell which stent approach best meets treatment needs. EH News Bureau


MARKET

Apollo Munich Health Insurance introduces ‘ENERGY’ ENERGY covers people currently suffering from Type II diabetes APOLLO MUNICH Health Insurance recently launched ‘ENERGY’ - The Sweetest Thing for individuals living with diabetes mellitus 2 and/or hypertension. Apollo Munich's ENERGY is its third generation product. The product is designed as a complete package that provides insurance cover as well as works with the insured to help them manage their health condition by giving them an array of information, tools and support. ENERGY reportedly unique is that it combines health insurance, wellness, counseling, incentives, technology, and community together in a very holistic and seamless way, keeping the needs ofpeople living with diabetes in mind. Speaking about the ENERGY product, Apollo Munich Health Insurance’s Chief Executive Officer, Antony Jacob said, “We are proud to be able to offer a first-of-its-kind solution to the millions suffering from diabetes in India. Diabetes is a silent killer, and we wanted to create an insurance product to address it. ENERGY is India’s first plan that truly understands diabetes. The insurance and wellness ecosystem we have built will help those with diabetes control it much better, and lead a ‘close-to-normal’ lifestyle. We used the considerable technical and medical know-how of our parents – Apollo Hospitals and Munich Health – to develop this product.” Also present at the launch, Sourav Ganguly, ex Captain, Indian Cricket said, “I feel privileged to be associated with a new revolutionary health insurance product that will combine health management and insurance all in one. I think ENERGY is the solution for the over 65 million diabetics in the country today.” ENERGY will initially be available in eight cities from December 16, before being rolled out nationally next year. EH News Bureau

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MARKET

Health Minister launches Reverse Dot Blot Hybridization (RDB) Thalassemia diagnostic kit The kit will help to simplify the diagnosis of thalassemia in affected children and for prenatal diagnosis in the first trimester itself THE UNION Minister for Health and Family Welfare, Ghulam Nabi Azad launched the Reverse Dot Blot Hybridization (RDB) Thalassemia diagnostic kit, developed by scientists of National Institute of Immunohaematology (NIIH) and the Indian Council for Medical Research (ICMR). It is now being domestically manufactured by IMGENEX. This kit has been developed to simplify the identification of seven common

beta-thalassemia mutations and two common abnormal haemoglobins (Hb S and Hb E) which will cover most of mutations in hemoglobinopathies in India. The role of the molecular kit is to meet the need for affordable and sensitive tests for diagnosis of affected children and prenatal diagnosis in the first trimester itself. Speaking at the launch function, Azad expressed satisfaction that the kit simplifies

the identification of common mutations leading to formation of abnormal haemoglobins which cover around 90 per cent of all the defects seen in Beta-Thalassemia syndromes in India and thus is tailor made for the Indian population, and hence more effective. Since the cost of production of this kit is low, when it is marketed the kit will be cost effective. This kit thus making India self reliant. The newly launched diag-

nostic kit will cater to thalassemia and sickle cell anaemia, stated Dr VM Katoch, DG (ICMR). He stated that the screening needs to be coupled with counselling. The inherited haemoglobin disorders are the commonest single gene disorders in India. Betathalassemia, Hb E – beta-thalassemia and sickle cell disease pose a huge health burden. The overall prevalence of beta- thalassemia carriers in India is three to four

per cent, while in certain ethnic groups like Sindhis, Kutchi Bhanushalis, Punjabis, Jains and Muslims it can vary from 5 to 15 per cent. It has been estimated that there would be 30 to 40 million, carriers of beta-thalassemia in India and 10,000 to 12,000 babies with major thalassemia syndrome along with over 5000 babies with sickle cell disease are born each year. EH News Bureau

Bhojraj Chanrai Sankara Eye Hospital inaugurated in Mumbai suburb 12000 sq feet specialty eye hospital would be equipped with the first Allegreto Wavelight Refractive Surgery Suite BHOJRAJ CHANRAI Sankara Eye Hospital, stateof-the-art facility of Sankara Eye Care Institutions-India, was inaugurated by Sri Jayendra Saraswathi, Sankaracharya of Kanchi in the suburb of Malad. The 12000 sq feet speciality eye hospital would be equipped with the first Allegreto Wavelight Refractive Surgery Suite, the world's fastest refractive platform enabling (Femto) Blade Free Laser procedure. Equipped with lasers and other advanced diagnostic equipment, and full time specialist consultants, the Institute would offer care for a wide range of eye ailments. “Sankara's distinctive character is based on ethical practice, pricing transparency, passionate service,

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inspiration and an extremely high standard of excellence. Integrating best practices across a continuity of services from preventive to tertiary hospital based care is the objective of Sankara,” remarked Sandesh Rane, CEO, Bhojraj Chanrai Sankara Eye Hospital Keeping with the philosophy of the Sankara Eye Care Institutions, the facility would cater to all segments of society. "When you use Sankara's eye care services, proceeds are used to provide subsidised care to the disadvantage sections of the society thus allowing more people to be a part of the Sankara movement,” shared Dr RV Ramani, Founder and Managing Trustee, Sankara Eyecare Institutions. EH News Bureau


MARKET POST EVENTS

HCG Pinkathon held in Mumbai Around 3000 women ran for a cause in the fight against breast cancer HCG PINKATHON, International Women's 10K Run, was held recently in Mumbai, to create awareness on breast cancer as well as promote health and fitness among women. Almost 3000 women from corporates, colleges, nurses, social clubs and doctors participated in the run under various categories. The event was organised by HealthCare Global Enterprises (HCG) and was flagged of by Gul Panag, actor, Milind Soman, actor, model and ultra marathoner, and Dinesh Madhavan, Director HealthCare Services, HCG Group. The money raised out of the event would be used to treat economically challenged cancer patients. In the 10K category, the prize was won by Jayshri Borgi with second runner up being Sunita Wagmode and Sweta Devraj as third runner up. In the 5K category, the prize was won by Jyoti Punjabi and 3K category, the prize was won by Sheetal Chavan. Soman said, "I'm happy to see so many women coming to lend their support. Awareness is the key and events such as these go a long way in creating awareness, early diagnosis and helps in the fight against breast cancer." Nagraj Huilgol, Senior Consultant, Radiation Oncologist, HCG said, "The incidence of breast cancer among urban women is on the rise and women in their early 40s are diagnosed with breast cancer, which is alarming. 90 per cent of the breast cancers can be cured with optimal therapy if diagnosed early and patients can have good quality of life." Dinesh Madhavan, Director, HCG Group said,

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MARKET

"HCG has been at the forefront in the fight against cancer. With increased awareness today most of the cancer cases are diagnosed early. The aim of this event 'HCG Pinkathon' is to educate women of the fact that they can make lifestyle changes today that can reduce the risk of developing breast cancer." Gul Panag, former Miss India and fitness enthusiast and

event ambassador said, "Fitness plays an important role in boosting the immunity of the afflicted and running is a great way to stay fit. I feel so glad that the women of Pune came out to spread this awareness today. I am proud to be sharing the platform with many other incredible women who have shown dedication and concern to fight breast cancer in our country."

Padmashree Dr DYPatil University organises HOSPIEXPRESS The 5th National Conference on Health & Hospital Management created a platform for knowledge exchange on various aspects related to hospital management PADMASHREE DR DY PATIL University’s Dept of Business Management, CBD Belapur, Navi Mumbai recently organised HOSPIEXPRESS – the 5th National Conference on Health & Hospital Management. The conference was backed by Express Healthcare as the Official Media Partner, VASAN Healthcare as the Knowledge Partner, Forbo Flooring as the Partner, Abhyudaya Bank as the Banking Partner, Peaceful Life as the Insurance Partner, etc. Around 155 hospital promoters, doctors, CEO’s, owners of small to medium healthcare providers ranging from polyclinics, nursing homes, labs, radiology centres, etc., participated in the event. Dr Nitin Sippy, National Convener and Organsing Secretary, opined, “The growth of small to medium healthcare providers is expanding by leaps and bounds. This growth must be focused more on the journey rather than just the destination. The fruit of this segment is already ripe and they must be developed as Centres of Excellence providing them with numerous advantages.” Anupam Verma, (Chief Guest), President, Wockhardt Hospitals, touched upon the

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Dr Nitin Sippy delivering the welcome speech

Panel Members in discussion

Panel members with the organising team

many parameters of expansion strategies for small to medium healthcare providers. He shared his experience of working in renowned organisations like Hinduja Hospital, DM Healthcare and Wockhardt, and covered various challenges in healthcare viz HR, quality, operations etc . Dr Sanjay Oak (Guest of Honour), Vice Chancellor – Padmashree Dr DY Patil University, talked about diverse issues including outsourcing, centralisation/decentralisation to marketing, legalities, ethics and insurance. He said, “Machines can be bought but not loyalty. Commitment needs to be built within. Medicine is an art, management is a science and managing medicine is divine.” Dr R Gopal, (Chairman- National Organising Committee), Director, Dean & HOD –DYPDBM spoke to the audience on typical challenges and their varied solutions, focussing on work-life balance. He said, “The healthcare budget is miniscule and needs to be extended tremendously. This can be a reality when all stakeholders viz the government, private players and various funding agencies develop a win–win model.”


EVENT BRIEF JANUARY-- FEBRUARY 23

Front Office Conclave

FRONT OFFICE CONCLAVE Date: January 23, 2014; 2 – 5 pm Venue: Dr LH Hiranandani Hospital, Hiranandani Gardens, Powai, Mumbai Organisers: Dr LH Hiranandani Hospital Summary: To improve operation management by the front office teams of a hospital and enable them to face the day-to-day patient intake efficiently, Dr LH Hiranandani Hospital is organising a half-day event, Front Office Conclave, at its hospital in Powai, Mumbai. An initiative conceptualised and executed by the front office staff of the hospital. The agenda of the

23

67th Annual Conference of IRIA-2014

conclave includes lectures, case study discussions, questions and answers session, panel discussions. It will serve as a model platform for idea exchange of front office issues/cases and experience. A discussion on need to tackle the physical as well as emotional aspects of the patients and their relatives is also included. The ideas shared on this forum will help in hospital setting and results can be measured in terms of the process completion (turnaround time) and customer satisfaction. Contact Dr Shashikant Pawar Tel: 9769875849

1

Green lean six sigma certification training for healthcare

67TH ANNUAL CONFERENCE OF IRIA-2014

will enhance the clinical acumen and imaging skills of radiologists.

Date: January 23-26, 2014 Venue: Hotel JP Palace and Convention Center, Agra Summary: The 67th Annual Conference of Indian Radiological and Imaging Association-2014 (IRIA-2014) will be organised by IRIA Uttar Pradesh state chapter. Scientific deliberations will be the most important facet of this conference. Luminaries in the various sub-specialities of radiology, from India and all over the world, will enlighten the delegates with their work and vast experience. IRIA 2014 promises to be an academic event which

Contact Dr Bhupender Ahuja Organising Chairman Ahuja Ultrasonography Centre Dr Sarkar Market, Delhi Gate Tel: 0562-3092959, 21052605 Fax: 0562-2150296, Mob: +91 98370 44202 Email: drbahuja@gmail.com

GREEN LEAN SIX SIGMA CERTIFICATION TRAINING FOR HEALTHCARE

Last date to register: December 27, 2013 Organisers: AUM MEDITEC Participant profile: Hospital CEOs/ COOs, management executives, hospital operations managers, quality in charge, MHA/ PGDHA/ MBA (Hcm) final year students Summary: This programme module shall focus on Six Sigma methodologies, lean concepts in healthcare systems and service delivery. Contact Meeta Ruparel Email: meeta@meditecindia.com/ meetaruparel@hotmail.com

Date: February 1-9, 2014 Venue: New Delhi

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January, 2014


cover ) Techn vationsfor2014

ARE YOU READY TO CAPITALISE ON DISRUPTIVE HEALTHCARE TECHNOLOGIES? Six disruptive technologies that the healthcare industry should recognise and adopt to succeed in future BY M NEELAM KACHHAP

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FOCUS: TECHNOLOGY

E

ver since, Clayton M Christensen, a Harvard Business School professor, coined the term 'disruptive technology', it has captured the imagination of business and organisations world over. A disruptive technology is one that creates a new market, a new value by disrupting the existing market. These technologies not only improve a product or service in an unexpected way but also create a new set of consumers and a new market by effectively lowering prices in the existing market. Business owners now know that these technologies offer tremendous opportunity to capture new markets. On the other hand, they are the single largest threat to the existence of a com-

pany. However, today we see new technologies evolve every day. Each promising to be better, a breakthrough that will radically alter our existence. But all technological advances do not live up to the initial hype. Only a few truly have the potential to alter our reality. Recently, a McKinsey Global Institute report listed 12 technologies that could alter our business and social landscape and drive massive economic transformations and disruptions in the coming years. Based on this list we highlight the technologies that will impact Indian healthcare and bring a drastic change in the way we experience healthcare. These disruptive technologies are: Q the Mobile Internet Q the Internet of things Q advanced robotics Q next-generation genomics Q 3-D printing Q advanced materials

MOBILE INTERNET MOBILE INTERNET technology is changing the way we browse. Today, mobile phones are as common as house sparrows were in India in the 1950s. Everywhere you look people are using Internet-enabled mobile computing devices which have apps for almost any task, to understand, perceive, and interact with the world. India is one of the largest global markets for mobile devices and associated apps. One study (Mary Meeker report) claims that more people in India access the Internet via mobile devices than with PCs. Mobile Internet use is driven by increasingly inexpensive and powerful mobile computing devices and pervasive connectivity which has great potential to improve delivery and raise productivity in healthcare. Healthcare is one of the most promising services that stand to benefit from mobile Internet technology. Apart from mobile apps to track health related parameters sensors attached to mobiles could also monitor chronic diseases patients like heart disease and diabetes. Another opportunity to be explored is to provide training and education to healthcare workers, including professionals, administrative

support staff, and others whose jobs require person-to-person interaction and independent judgement. The ‘Ananya’ programme, run by BBC Media Action in collaboration with the Bill and Melinda Gates Foundation in eight districts of Bihar, aims to reduce child mortality and improve maternal health in the state. The programme uses mobile Internet to provide training via 'mobile academy' and an interactive health related guide to community healthcare workers who look out for 27 million child-bearing age women in the state.

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cover ) INTERNET OF THINGS THE INTERNET OF THINGS—sensors and actuators embedded in machines and other physical objects to bring them into the connected world—is spreading rapidly. Low-cost sensors and actuators that enable networks for data collection, monitoring, and decision making and process optimisation have the potential to spur productivity across key industries such as healthcare, manufacturing and mining, according to the McKinsey report. Internet of Things technology has given wings to the Quantified Self concept, which allows an individual to monitor his own health and well being. An increasingly popular trend powered by Internet of Things technologies allow consumers to track the number of miles they

run, their heart rate, and other data generated during exercise, which can then be used to manage health. In fact, doctors now perform ‘capsule endoscopy’ using a pill-shaped micro-camera with wireless data communication capabilities that travels through a patient’s digestive system and transmits images to a computer. This allows a doctor to make informed decisions for the treatment of the patient. Additionally, Internet of Things technology will revolutionise the real-time patient monitoring at hospitals. Experts believe that a nurse could gain 30-60 minutes per day by using this technology for patient monitoring and thus be more efficient. Additional value from use of Internet of Things systems in healthcare would include coun-

terfeit drugs. Experts believe that currently, more than $75 billion worth of counterfeit drugs are sold per year, and that amount is growing by around 20

per cent annually. By using sensors on bottles and packages which could be checked by consumers one could avoid buying counterfeit drugs. The re-

port estimates that this technique could apply to 30 to 50 per cent of drugs sold and could be successful 80 to 100 per cent of the time.

NEXT-GENERATION GENOMICS GENOMICS HAS CHANGED the way we look at things. But what is gaining immense popularity these days is the next wave in genomics. Nextgeneration genomics can be described as the combination of next generation sequencing technologies, big data analytics and technologies with the ability to modify organisms, which include both recombinant techniques and DNA synthesis i.e. synthetic biology. It took 13 years to complete human genome project, but today with the help of advanced computational and analytic capabilities genome sequencing has not only become quick but cheap as well. Experts believe that low-cost desktop sequencing machines could be used for rapid diagnostics and customised treatments. In the next phase, the technology could be used to write DNA sequences and build custom organisms. These advances in genetic science could have a profound

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Advances in genetic science could have a profound impact on medicine, especially in drug discovery impact on medicine, notably by speeding up the drug-discovery process. Cancer has been the main focus of geneticists apart from genetic disorders; but now researchers are focussing on mutations linked to other diseases and finding out how mutations and environmental factors coerce a disease. Personalised medicine are now in the pipeline. Studies have shown how specific

cancer-causing mutations correlate with responses to different cancer treatments and there is a healthy pipeline of bio treatment and diagnostic drugs. According to the report, given the rate at which drugs fail during testing, it is not likely that the number of drugs used with companion diagnostics over the next five years will rise rapidly. Personalised treatments for cardiovascular disease is in the horizon. Every patient responds differently to the mix of medicines they are exposed to, and today high-risk patients are often treated using preventive medications with dosages adjusted on a trial and error basis, creating high risks. While the technology is still in the early stages, genetic testing could help doctors determine dosages and mixes of substances more precisely. Also, screening can enable customised preventive routines (lifestyle changes, for example), as well as tailored treatments.


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FOCUS: TECHNOLOGY

ADVANCED NANOMATERIALS

ADVANCED ROBOTICS

THE DISCOVERY of nanomaterials has opened a new and strange world for us. Any use or manipulation of materials with features at a scale of less than 100 nanometers (roughly molecular scale) can qualify as nanotechnology. Nanomaterials are known to have remarkable properties, for example, nanoparticles have far greater surface area per unit of volume (upto 2,000 sq m per gram) than other materials and are thus highly reactive (and bio-reactive), making them useful in medicine. Pharmaceutical companies are already making progress in the use of nanoparticles for targeted drug treatments for diseases such as cancer. Experts believe that the large surface area and high reactivity of many nanomaterials could make them powerful diagnostic tools for many diseases, including cancer. Nanoparticles can also be used to create potentially lifesaving medicines that can target specific tissues or cells. This can create therapies that are more effective and reduce harmful side effects. For ex-

ADVANCED ROBOTICS refers to robots or robotic tools with enhanced sensory capabilities, dexterity and intelligence to automate tasks once thought to be too delicate or not economically viable for robotic intervention. This means that a human limitation could be overcome to save lives. This technology will have a major impact on surgical robotics that make procedures less invasive and robotic prosthetics and exoskeletons. Today robotic surgical ‘platforms’ are already being used for minimally invasive procedures such as laparoscopic surgery. It is possible that with advances in robotic technology, by 2025 robotic surgery could be widely used for these and other procedures. Likewise, new age prosthetics and exoskeletons are able to take precise directions and make increasingly accurate and delicate movements. Today, new interfaces have been developed that can operate robotic limbs using small electrical signals produced when muscles contract or signals from nerve endings or even brain waves. The day is not far when these prosthetics will be equal to or better than the natural limbs and people start using them for intricate or dangerous

ample, researchers are working on ways to use gold and silver nanoparticles, as well as liposomes (nano-sized bubbles made from the material of cell membranes) for targeted drug delivery. Nanomaterials can be combined with cancerkilling substances and then delivered to a tumour in a more precise way than current options, reducing the damage to healthy cells and other side effects of conventional chemotherapy. As per the McKinsey report, in late 2012 AstraZeneca announced that it is developing a treatment that uses gold nanoparticles to convey the cancer-killing drug TNF (tumour necrosis factor) to specific cancer sites. TNF is normally highly toxic but might

be safely delivered using nanoparticles because it would be targeted directly to tumours. Nanoparticles can be used to target cancer cells passively (by taking advantage of these cells’ increased tendency to absorb such particles relative to normal cells) or actively (by attaching molecules designed to specifically seek out or bind to cancer cells, such as peptides). The application of advanced nanomaterials for medical purposes has relatively high potential by 2025 given the types of advanced nanomaterials likely to be used, the limited quantities needed, the maturity of the production processes for these materials, and the high willingness of consumers.

WHEN DR ANTHONY Atala from Wake Forest Institute for Regenerative Medicine, US demonstrated a technique to print kidney using a 3D printer, two years ago, he gave new hope to patients waiting for organ transplant. Proposing a new possibility in regenerative medicine, Dr Atala believes that 3D printing could solve the organ donor problem and save lives. 3D printing technology is known as additive manufacturing. As the name suggests,

in this process objects are build by adding material layerby-layer rather than through molding or subtractive techniques (such as machining). Today, 3D printing can create objects from a variety of materials, including plastic, metal, ceramics, glass, paper, and even living cells. Organ on demand is no longer science fiction. Organs, tissue and medical implants can very well take shape in laboratories. From custom implants to tissues for degenera-

Image courtesy: Wake Forest Institute for Regenerative Medicine

3-D PRINTING

Wake Forest research fellow, Jaehyun Kim demonstrates skin printing technology on a mock hand

tive diseases, the possibilities are fascinating. Taking the design from a CT scan the 3D printer converts a 3D image to a finished part or product.

3D printing is expected to have a broad impact on consumer products and industrial tooling, but its most dramatic impact could be in healthcare.

work. Who can forget the amplified mobility platform (AMP suit) worn by Avatar’s villian or the Iron Monger worn by Iron Man . Currently, robotic surgery in India is in its infancy. There are only 13 robots for a country with a population of over one billion. India is ideally suited for robotic surgery as the surgeons are skilled, the patient volume is high and a full spectrum of complex diseases are encountered. In India particularly, multispeciality robotic surgery has a great future. The study indicates that by 2025 there could be more than 50 million people with impaired mobility in the developed world, including amputees and elderly people, for whom robotic devices could restore mobility, improve quality of life, and increase lifespan.

The market for complex, lowvolume, highly customisable parts, such as medical implants would be very large in future. Also these products could cost 40 to 55 per cent less due to the elimination of tooling costs, reduction in wasted material, and reduced handling costs.

References Disruptive technologies: Advances that will transform life, business, and the global economy http://www.mckinsey.com/i nsights/business_technology/disruptive_technologies

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KNOWLEDGE

Ushering mHealth revolution in public health Atanu Garai, Associate Consultant – IT, IPE Global, Bhubaneswar, expounds on effectively utilising the potential of mobile phone technology to improve public health facilities in India

Techn vationfor2014

O

F LATE, health industry is going mobile. Consumers in urban India are already using mobile devices and apps to measure blood pressure, glucose, and even to report their health data to doctors. Use of Internet to get tips from an expert is a common practice among the urban youth. Private providers have also started using mobile devices to advise patients. However, for public health programmes, the scene is quite different. Programmes like National Rural Health Mission (NRHM) are having a hard time trying to catch up with the mobile health or 'mHealth' revolution. Despite the growth in mobile telephony, a sizeable section among the poor and women living in rural India is yet to gain access to mobile phones. Lack of direct access to mobile phones among hundreds of thousands of women means that providers cannot communicate to the primary beneficiaries under the NRHM programme. Health workers, even with secondary education, use their mobile phones to record the services they deliver to the beneficiaries. For hundreds of thousands of health workers across India, mobile phones can simplify reporting delivery of care. It can reduce the cost to the exchequer in the longer run, with additional gains on timeliness, and accuracy in data reporting. For more than a year now, some 582 accredited social

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health activists (ASHAs), community health workers under NRHM in Saharsa district of Bihar, have been reporting on the maternal, child health and nutritional services they are deliver using a mobile application called CCS . In this project, CARE, an NGO working for social issues, has imparted training to ASHAs and their supervisors in using CCS application. When ASHAs delay, or even default healthcare to the beneficiaries, their supervisors will be able to quickly identify them. Through mobile reporting, the supervising ANM in village health centres or medical officers in health centres in blocks quickly find those delays. In Dhamtari district of Jharkhand, Virtuous Solutions, an IT company based in Delhi, implemented a mobile reporting sys-

tem for mother and child tracking system (MCTS). The mobile MCTS project generates alerts for supervisors when ANMs delay in attending beneficiaries in their catchment area. Like the providers, patients often tend to forget taking medicines as prescribed by their doctors. Till now, families

used to prompt the patients to take their dosage on time. When providers record patient data in an electronic health record system, the system can generate an SMS or a call to remind the patients on their dosages. BBC Media Action, the development arm of the broadcasting agency BBC, sends such prompts in the form of calls to the pregnant women across eight districts in Bihar. Known as Mobile Kilkari, women subscribers get one call every week according to their maternity stages during the entire period of subscription. Available as 7, 12, and 16 months subscription packs, the call automatically deducts Re 1 from the talk time. In the last few months, more than 7000 women opted to get

Mobile Kilkari calls. These calls prompt the women to take their iron supplements on time, or visit the village health centre for antenatal check-up. Some calls also tell them the nutritional values in the regular foods. More importantly, each weekly call takes into account the current stage of maternity. When India is grappling with the challenge of poor maternal and child health, these messages help in empowering our women, children, and families. There can be little doubt that the use of mobile phones can help providers and beneficiaries improve delivery and adoption of healthy practices. But there are several bottlenecks in implementing these solutions at scale. Soon after the launch of NRHM in 2005, it recruited ASHAs without even prudent screening. Mobile users familiar with English numbers and alphabets can enter data using their phones with minimal training and practice. However, ASHAs with low literacy can find it difficult to type data in their phones. For health workers, it can be fairly easy to tick a check box to record delivery of service. However, even advanced mobile users can find it difficult registering a beneficiary, along with her demographic details, using small phone keypads. More importantly, there is little possibility to know whether health workers are enumerating all the eligible beneficiaries in the system. This problem could have largely been overcome with the electronic National Population Register. It could provide the

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KNOWLEDGE

Healthcare and the Internet of Things Ravi Ramaswamy, Head Healthcare, Philips Innovation Campus gives an insight on the Internet of Things and extols the benefits it can have in improving healthcare delivery

Techn vationfor2014

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MAGINE YOU are in a café when you get a Facebook notification on your mobile handset about a friend posting photos from a party — and you log in to put a ‘Like’ mark on it. Now, imagine you are a cardiologist sitting in a café when a notification tells you of a critical patient — and you receive an ECG chart and patient parameters on a mobile software application and quickly issue instructions. The former is fun. The latter saves lives. The technology is similar. Using the same technologies that let people worldwide share friendly updates and banter, doctors, paramedics and diagnosticians are coming together to bring ‘cloud computing’ — the business of using Internet-based applications to store, retrieve and intelligently use data — to the world of medicine. That’s the power of the Internet. It has changed the way we live. Even if the Internet appears ubiquitous, the number of objects or devices connected to the Internet is still greatly inferior to those that are not connected. The coming revolution will result from the need of replacing disconnected objects with connected ones, and making these objects ever more intelligent, and aware of their surroundings (using sensors). The resulting network promises to create disruptive business models.

We call this new step: The Internet of Things In 2008 the number of devices connected to the Internet exceeded the number of people on earth, and we foresee 50 billion ‘Connected

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Things’ in 2020. There are research studies which tell us that remote patient monitoring is growing with a CAGR of 25 per cent. This will change the way medicine is practiced and dispensed. The starting point for the convergence of healthcare and Internet of Things is represented by our smartphones which are not only connected to the net, but are also going to be ever more enriched with applications and sensors, and used by people as valuable tools for our health. These early adopters armed with devices or even pen and paper, decided to improve their life or performance starting studying and measuring it: every day. The organisation’s 'weightwatchers' is a classic representation of this phenomenon. You are the first one to monitor your performance/ conditions. Self-tracking leverage on consumer technologies instead of complex PRO

medical device, makes you the protagonist sharing on the web, giving you the possibility to be aware of the feedback that your ‘stories’ are receiving. Some traditionalists could be afraid of this alternative approach to medication, but there is no need for fear. First of all because this is not a medication, but second - and most relevant - because self-monitoring makes people aware of

how important prevention is. If just an email/sms makes people 30 per cent more likely for a patient to go to the doctor for an already scheduled meeting, imagine how effective could be a pills reminder (like iPhone Apps already are doing) and how big is the opportunity to extend the space of healthcare through a real one-to-one interaction. Dutch multinational Philips, which has 10,000 people working in India, has developed an ‘eICU’ — an electronic intensive care unit that brings together an array of diagnostic equipment, software, computers and handheld devices to provide an ambulance-to patient bed link that its executives describe as an ‘Intellihospital.’ “Like the monitoring process in a traffic control room, an eICU can monitor patients in different hospitals 24x7 and makes key interventions at the right time,” Philips says.

India has more than 900 million mobile phone connections, while 740 million people live on less than R100 a day. Philips is connecting the two numbers through a system under which it plans to sell its eICU solutions to hospitals, so that semi-skilled health workers can feed back key data at low costs to monitor patients. Such technologies can dramatically improve healthcare because it takes two hours on an average for Indian hospitals to decide to which department a patient has to be taken. Philips recently demonstrated an ambulance device that can take an ECG chart, monitor blood pressure and transmit it over mobile handsets to hospitals, where doctors can be ready with the right solution before the patient arrives and proactively plan for their treatment. Let’s look at the mother and child care segment. As per UN MDGs 4&5, the aim is to reduce maternal mortality by a third as also neonatal deaths. Mobility has a great role to play. 'Mobility Sanjivini', an innovative software of Manipal University, is all set to make rural health services more accessible, eco-friendly and paperless. To provide better health services to poor pregnant women and children in rural areas, Manipal University, in association with Philips, has developed 'Mobility Sanjivini', a software for healthcare data collection that is compatible with mobile phones. Kasturba Medical College and Hospital (KMC) of Manipal University has been providing free healthcare services to pregnant women and children at its seven Rural Maternity and Child Welfare Homes (RMCWH) in different villages of Udupi district. This

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KNOWLEDGE

Empowering healthcare with genomics Dr Kaushik D Deb, Director & CEO, Merisis Therapeutics, DiponEd BioIntelligence LLP elucidates on the various applications of genomics in healthcare

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ENOMICS IS going to play an important role in all the areas of healthcare, namely Prediction, Prevention and Cure.

Genomics in prediction and diagnostics Prediction is the forecast or possibility of a normal person acquiring a disease or medical condition and diagnostics is a method to confirm what a patient might be suffering from. Current age genomics has interesting tools and roles to revolutionise both these areas of healthcare. Genetics is the study of inheritance or the way traits are passed down from one generation to another. Genes have the information to make proteins which direct cell activities and functions as well as influence traits like hair and eye colour. Approximately, there are 30,000 genes in the human DNA. Genomics is a newer term describing the study of all of a person’s genes and the interactions of those genes with each other and the environment. Genomics plays a role in nine of 10 leading causes of death, including: Q Heart disease Q Cancer Q Stroke Q Diabetes Q Alzheimer’s disease For people who are at increased risk for hereditary breast and ovarian cancer, or hereditary colorectal cancer, genetic tests may reduce their risk by guiding evidence-based interventions. Genome studies are rapidly unravelling the role of genetic factors in the pathogeneses of

common diseases in which preventive and therapeutic interventions for complex diseases are related to individuals based on their genetic profiles. Personalised medicine already exists for disorders such as Huntington disease, phenylketonuria (PKU) and hereditary forms of cancer, in which genetic testing is the basis for informing individuals about their future health status and for deciding upon specific, often radical interventions such as lifetime dietary restrictions and preventive surgery. An essential prerequisite for personalised medicine to become feasible is a predictive test or prediction model that can discriminate between individuals who will develop the disease of interest and those who will not. The level of discrimination that is required in clinical care and public health applications depends, among other things, on the goal of testing, the burden of disease, the costs of disease, availability of (preventive) treatment and the adverse effects of false-positive and false-negative test results. Today, more than 900 genetic prediction tests are available. There are also susceptibility tests which can determine an estimated risk for developing the disease. Some of them are: Carrier screening: Identifies unaffected individuals who carry one copy of the gene that needs two to express the disease. This helps in making the right choice of partners before marriage, so that defective genes are not inherited by the children. One example could be the thalassemia trait. Preimplantation genetic diagnosis: Embryo from in vitro fertilisation is tested before it is implanted in the uterus. Timely diagnosis could help in medical elected termination of the pregnancy.

Parental diagnostic testing and newborn screening: Point-of-care genetic testing incorporates the newest most sophisticated techniques to identify variations in the genetic sequence at the bedside – enabling clinicians to react and alter therapy based upon the results. Traditional genetic testing involves the analysis of DNA in order to detect genotypes related to a heritable disease or phenotype of interest for clinical purposes. Point-of-care

Genome studies are rapidly unravelling the role of genetic factors in the pathogeneses of common diseases

tests (POCT) are designed to be used at or near the site where the patient is located. They do not require permanent dedicated space, and are performed outside the physical facilities of the clinical laboratories. POCT can be used for diagnosis and also find the stage of different diseases. Single nucleotide polymorphisms, frequently called SNPs (pronounced 'snips'), are the most common type of genetic variation among people. SNPs occur normally throughout a person’s DNA. Researchers have found SNPs that may help predict an individual’s response to certain drugs, susceptibility to environmental factors such as toxins, and risk of developing particular diseases. SNPs can also be used to track the inheritance of disease genes within families. Future studies will work to identify SNPs associated with complex diseases such as heart disease, diabetes, and cancer. These also help in detection of occupational hazards, inheritable genetic disorders. Reduced costs and increased speed and accuracy of sequencing can bring the genome-based evaluation of individual disease risk to the bedside. Parental conflicts: Conflicts among fathers, mothers to know their offspring can be detected by genomic detection. The data on genomic configuration of an individual would be important to maintain in the coming years to solve disputed parenting issues. This will be particularly important in issues related to same sex marriages, improvement and empowerment in IVF/ARTs for infertility and surrogacy related affairs.

Genomics in preventive healthcare Gene tests look for signs of

a disease or disorder in DNA or RNA taken from a person's blood, other body fluids like saliva, or tissues. These tests can look for large changes, such as a gene that has a section missing or added, or small changes, such as a missing, added, or altered chemical base (subunit) within the DNA strand. Gene tests may also detect genes with too many copies, individual genes that are too active, genes that are turned off, or genes that are lost entirely. Prevention genetics performs genotyping of human DNA polymorphisms in support of biomedical research. We type Single Nucleotide Polymorphisms (SNPs), Diallelic Insertion/Deletion Polymorphisms (INDELS) and Short Tandem Repeat Polymorphisms (STRPs) (also called microsatellites). A powerful panel of Ancestry Informative Markers (AIMs), based on SNPs is excellent for determining geoancestry. In addition, whole genome scans and fine mapping can also be done for disease prevention and prediction.

Genomics in dry screening Spots of blood are routinely collected from patient onto filter paper called Guthrie cards and used to screen for metabolic and genetic disorders. The archived dried blood spots are an important and precious resource for genomic research. Whole genome amplification of dried blood spot DNA has been used to provide DNA for genome-wide SNP genotyping. This procedure can be used for genome-wide association studies and other large-scale genomic analyses that require robust, high-accuracy genotyping of dried blood spot DNA. Overall interest in having future newborns undergo whole-genome sequencing was

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KNOWLEDGE

generally high among parents. If whole-genome sequencing were offered through a state’s newborn-screening programme, 74 per cent of parents were either definitely or somewhat interested in utilising this technology. If offered in a paediatrician’s office, 70 per cent of parents were either definitely or somewhat interested. Parents in both groups most frequently identified test accuracy and the ability to prevent a child from developing a disease as “very important” in making a decision to have a newborn’s whole genome sequenced.

Genomics in treatment and drug development Regenerative medicine is a new and expanding area that aims to replace lost or damaged tissues in the human body through either cellular transplantation or endogenous repair. Adult stem cells infused into the circulation are currently leading the clinical front of regenerative medicine. However, in various genetic diseases like hemophilia, or cardiac diseases, scientists are trying stem cells transplants which have the defective genome corrected with the right genetic sequences. One recent development in regenerative medicine is the genetic reprogramming of adult somatic cells into stem cells, now known as the induced pluripotent stem cells (iPSC). This landmark cellular reprogramming technology was developed by Dr Shinya Yamanaka, at Kyoto University Japan. The findings led to a Nobel prize in physiology and medicine for Dr Yamanaka in 2012. iPSCs are an important advance in stem cell research, as they may allow researchers to obtain pluripotent stem cells, which are important in research and potential therapeutic uses. Human pluripotent cells such as human embryonic stem cells (hESCs) have ethical limitations in their application in therapy or drug discovery research. However, induced pluripotent stem cells (iPSCs)

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created from genetical reprogramming of an individual’s adult skin cells and their in vitro differentiation models (say in creation of disease specific cell lines, or hepatocytes , cardiomyocytes etc) provide effective models for investigating drug toxicity, metabolism and mechanisms underlying human diseases and as potential source of replacement cells in cellular transplantation approaches. For e.g.; with the iPSC technology skin biopsy of a patient who is suffering from metabolic disorders can be collected and converted into the iPSC cells, these cells could be undifferentiated into genetically defective cadiomyocytes and hepatocytes. These cells which carries the inherent genetic defect/mutation can be used to screen drugs or do drug metabolism studies. Personalised drug prescriptions: Pharmacogenomics is the study how a person’s genetic makeup affects their

body’s response to drugs. These are drugs which are designed to work mostly with people who have a particular gene functioning in a particular way. Genetic factors may account for between 20 to 95 per cent of the observed variation in drug response between individuals. One important aspect of personalised medicine is patient-to-patient variation in drug response. Pharmacogenomics addresses this issue by seeking to identify genetic contributors to human variation in drug efficacy and toxicity. Here, we present a summary of the current status of this field, which has evolved from studies of single candidate genes to comprehensive genome-wide analyses.

Examples of using genetic information in the treatment of disease A person's genetic makeup affects how their body breaks

down certain medicines. Genetic testing can examine certain liver enzymes in a person to find out how their body breaks down and removes medicines from the body. Because these liver enzymes are less active in some people, they are less able to break down and get rid of some medicines. This can lead to serious side effects. This type of testing is being used to find the right dose of certain medicines, such as antidepressants that are used to treat some mental illnesses. There is now a test to find out whether a medicine called Herceptin will be an effective treatment in breast cancer. This test looks for ‘estrogen receptors’ in tumours. Children with a common type of leukaemia can be tested to find the right doses of chemotherapy treatment. Today, family history is the best genomic tool available, and compared with other genetic tests, it can be relatively

inexpensively collected. A genetic analyses of the genome of a person can tell a doctor if the patient will respond well to some of the following blockbuster drugs Simvastatin, Atrovastatin, Pravastatin, Warfarin, Clopidogrel, Carbamazepine, 5 Fluorouracil, Metfromin, Abacavir, Floxacillin etc. Gene therapy involves changing or replacing faulty genes by inserting a normal gene into the body of a person with a serious illness. The approach is used either to disrupt the function of a gene or to replace it with a new one. To replace the gene, we must also add a DNA template for the new gene, which would be copied into the genome after the DNA is cut. The various ways to achieve this includes nanoparticle-based gene deliveries, and other viral vector based genomic integrations. Techniques are being developed to edit the genome with high precision. Complexes known as transcription activator-like effector nucleases (TALENs) can also cut the genome in specific locations, but these complexes can also be expensive and difficult to assemble. Other more precise and user friendly technologies are also being developed. Among other possible applications, these systems can be employed in designing new therapies for diseases such as Huntington’s disease, which appears to be caused by a single abnormal gene. Clinical trials, in which zinc finger nucleases to disable genes, are now under way in the Western countries and may offer a more efficient alternative. The technology would be useful for treating HIV by removing patients’ lymphocytes and mutating the CCR5 receptor, through which the virus enters the cells. After being put back in the patient, such cells would resist infection. The genetically modified hematopoietic stem cell transplant to reconstitute the patient with normal blood and immune system is a futuristic application too.


KNOWLEDGE

Recent advances in nanomedicine Dr P Gopinath, Assistant Professor, Centre of Nanotechnology, Indian Institute of Technology Roorkee, talks on the tremendous potential of nanomedicine and its application in personalised medicine

Techn vationfor2014

N

ANOPARTI CLES small things which make bigger effects are not a new phenomenon. It already exists in nature, for example the lotus leaf’s nano-size ridges and wax coated hairs make it difficult to get them wet and nanoscale setules on Geckos' feet help them to stick on smooth surfaces. There are plenty of examples of nanoscience before us in dayto-day life, one such example is milk (colloid) which is a natural nanomaterial. Almost all the cellular events are in the nanoscale. We can acquire the idea from nature and try to mimic the same to solve most of the human problems. According to a recent scientific report, 90 per cent of drugs presently in the market are effective in only ~50 per cent of individuals. This emphasises the need for personalised medicine where the prescription of treatment is best suited for a single patient. The main objective of personalised medicine is to deliver the right drug to the right patient at the right time to increase drug efficiency, and thereby minimise dose side effects, and enable quick patient recovery. With the progression of nanotechnology, personalised medicine can overcome the drawbacks associated with the conventional treatment. The applications of nanotechnology are gaining overwhelming response in almost all the fields. Especially in healthcare sector, tremendous developments have been achieved. For example, cancer

diagnosis and therapy, medical implants, tissue engineering etc. In case of medical implants, materials which shows nanometer topography, resemble native environment which leads to better tissue regeneration and thus such implants are highly biocompatible. By using nanoscale modification we can control the cellular response to materials. In tissue engineering, the success rate mainly depends on the suitable scaffold (support) to grow the cells. By using nanofibers we can mimic the cell's native micro environment where more cells can attach and proliferate. Artificial tissues/skin can be grown on nanofiber based 3-D environment to repair the damaged tissues. At present, we can detect the cancer at the late stage only where we have to mainly depend on surgery, radiation or chemotherapy as the only means of treatment. In the near future due to the advancement of nanotechnology, cancer prognosis or early diagnosis might be possible where we can prevent the cancer invasion at an earlier stage. In the recent years many researchers’ focus have been on developing theranostic nanoparticle where a nanoparticle can simultaneously detect cancer and deliver the anticancer agents. Nanoparticles can be targeted specifically to cancer cells by functionalising it with cancer specific binding antibodies or peptides. Most of the cancer cells express multiple markers; hence multifunctional nanoparticle with multiple cancer specific antibodies/peptides would enhance the targeted therapeutic effect. Another advantage of nanoparticles-based cancer therapy is that, it overcomes the drug resistant nature of cancer cells. Nanotechnology is pro-

gressing towards the development of artificial cells. It is in course with the same kind of success that has been achieved in developing red blood cells (RBCs) substitutes. The major advantages of artificial RBCs are it don’t have any blood group antigen so it can be given to any person irrelevant of his/her blood group. They also have high oxygen carrying capacity, longer half life and one need not worry about the transmission of human immunodeficiency virus (HIV) or any other microbial infections. The artificial RBCs are made through encapsulation of

haemoglobin in a biocompatible polymeric membrane. This RBC substitutes can act as a life saver in many circumstances including surgery, accidents that cause severe bleeding, and hemorrhagic shock. The major advantage of artificial RBCs is that they can be freeze dried and stored as dried powder, which can be reconstituted with the appropriate salt solution just before its use. Another remarkable advancement of nanomedicine is nano-vaccine. The traditional vaccine development process use the whole or modified pathogens which presents many challenges to researchers in terms of personal safety, overall time and cost. Nanoparticle based vaccine is a promising approach for developing low cost nano-vaccine. Biomimetic nanoparticles offer an easy approach to develop multi-functionalised nanoparticles with multiple antigenic parts of various pathogens that act as multivaccine. This nano-vaccine can reduce the production, storage and transportation costs. In the personalised medicine field, 3-D organ printing technology plays a vital role and assures that one day we

will be able to print organs ondemand. Latest breakthrough in 3-D printing technology is printing new bones on patient. Research team at the University of Wollongong in Australia created a BioPen loaded with 'stem cell ink' using which one can make new bone. If someone loses parts of bone in an accident, this BioPen would be a valuable tool to repair the damaged area. Another research team at Wake Forest Institute for Regenerative Medicine developed artificial kidney using 3-D printing technology, once it is functional it will be a boon for patients waiting for organ transplantation. Recent advancement in personalised nanomedicine is nanorobots/nanobots, a tiny machine designed to perform a specific task with precision at nanoscale dimension. In future, nanobots may act similar to or better than our immune response. Lot of research is going on to develop nanobots for breaking blood clots, removing pathogens, breaking kidney stones, and also for cancer and diabetes treatment. In case of diabetes treatment, the nanobots can act as a smart delivery system and release the insulin according to the body’s glucose level. It is a great relief for diabetes patients who have to take insulin injections daily. However, despite ample enthusiasm, nanobots technology is still science fiction and an unfamiliar territory. Nanotechnology is a doubleedged sword. Particular care must be taken in nanomedicine because the novel properties which make nanoparticles so attractive, make them potentially toxic too. The clinical applications of personalised nanomedicine have a long way to go. Hope is that soon, personalised nanomedicine may be available to all at an affordable price.

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KNOWLEDGE

Next revolution: 3d printing Viral Sachde, Founder Director, Cycloid System, speaks on the major advantages of 3D printing in healthcare

3

D PRINTING is a process of making a three-dimensional solid object of virtually any shape from a digital model. 3D printing is achieved using an additive process, where successive layers of material are laid down in different shapes. Major advantages of 3D printing for the healthcare domain are : Q Mass customisation, i.e. each part can be of a different shape/size and one does not need to do any tooling work. This reduces turnaround time for production of the custom part. Q 3D printing is a fully automatic method of manufacturing. Thus it offers clean and accurate parts without manual intervention. General offering of 3D printing in healthcare domain: Q Model of patients' body part Q Prosthetic body part Q Custom support part such as teeth cap or ear phone holder Q Custom test setup or low quantity tool production Q Implatable part Q Scaffolds for tissue engineering Model of patient's body part: Using mass customisation through 3D printing in the healthcare domain can open up many new avenues. This starts with making simple model of effected body part of patient for better understanding. This model can be generated from 3D scanner, X-ray or CT scan of patient. Next is building supporting or duplicate part to help patient.

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Custom support part such teeth cap or ear phone holder: Teeth cap and ear phone needs customised size. There are several example where both of these things are made using 3D printing methodology and supplied in thousands. Custom test setup or low quantity surgical tool pro-

3D printing in the healthcare domain can open up many new avenues. This starts with making simple model of effected body part of patient for better understanding

duction: Mass customisation also helps in building custom or low quantity surgical tools and test setup as per research requirement. While developing new test setup or surgical tools, 3D printing offers quick and economical turn around time. Implatable part: Parts from material such as Polyetherketoneketone (PEKK) can be used in 3D printer which provide offering equivalent or better than stainless steel or titanium for medical applications.

PEKK material is available in medical and implatable grade for using in Health care domain. Further more, by 3D printing with implatable grade PEKK, custom implatable parts can be made. Models for printing these part can be generated from taking X-Ray of patient. In case patient has broken body part, X-ray can be taken of such body part and later it can modified in CAD tools to provide perfect shape to body part. This newly generated design can be feed to 3D Printer to get proper implatable body parts. Scaffolds for tissue engineering: More advance opportunities are in using tissue engineering with combination of 3D printing. Cells are often implanted or 'seeded' into an artificial structure capable of supporting three-dimensional tissue formation. These structures, typically called scaffolds. Each patient may require cus-

tomised scaffolds. By 3D printing biocompatible material, surgeons can generate support structures. Once support structure is built, cells taken from other body area of patients are included on it and kept in growth environment. This can help to reconstruct live section of patient. Separate 3D printers which can deposit cells at right locations are also underdevelopment. Research, experiments and trials on all above solutions are happening in various parts of India. The expected impact is high. Although Indian medical industry is price sensitive but will not pass such large opportunity. Few jaw replacement by 3D printed parts are already conducted successfully in India. Many doctors in orthopaedic and dentist have started regularly using 3D printed parts. While experiments in tissue has just began, it will take some to see fruitful results.

Image courtesy: Cycloid System

Techn vationfor2014

Prosthetic body part: 3D printing offers reduction in turn around time in making custom size prosthetics and increases offering. RoboHand project uses 3D printer to make custom size prosthetic hands for kids. One of most commonly used biocompatible material is polylactic acid (PLA). Post degradation in human body, it becomes lactic acid, which naturally gets removed from body. Thus, parts made using PLA as well as polyglycolic acid (PGA) and polycaprolactone (PCL) works with human body.


KNOWLEDGE

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Ushering mHealth revolution in public health state health departments with demographic data by the communities. Health departments could crosscheck the data reported by providers with Aadhar service, the flagship national identification scheme promoted by the Central Government. However, both Aadhar and NPR are yet to be made available on a large scale. In the absence of beneficiary data, state governments should engage community health workers, government machinery, and private resources for enrolling beneficiary data. India provides cash benefits to pregnant women for deliver-

ing babies in health facilities. Pregnant women find it difficult to go to the nearest bank branches to withdraw these amounts, which are often disbursed in two to three instalments. IPE Global, a development consulting firm based in Delhi, is supporting the Panchayati Raj Department to disburse wages to workers under Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) through engagement of mobile operators and their network of mobile retailers. In this method, the MGNREGA workers will use their mobile phones to autho-

rise withdrawal of wages credited in their bank accounts. Then the mobile retailers who are selling phone recharge coupons in and around villages

shall provide the workers with cash. Pregnant women can also withdraw cash in and around their communities in this way. Once the data about the patients is available electronically, doctors and trained staffs can screen them to detect risk profiles. In Sky Health Centres, now operational in several districts of Bihar and Uttar Pradesh by the World Health Partners, doctors screen the patient profiles sitting in remote locations before prescribing over the Internet. Electronic screen has the potential to save valuable time for experts

and doctors in rural areas. There is little doubt that mobile communication can empower the public health system in India in a big way. However, there appears to be little awareness and ownership of promoting mHealth across the political and bureaucratic hierarchies. Most mHealth projects fail to get necessary resources and support from public and private quarters on time. Both central and state health department should designate nodal persons to expedite the approval and engagement processes for such project implementation.

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Healthcare and the Internet of Things new software will be helpful for auxiliary nurses and midwives attached to RMCWH. The software has been developed by students and teaching faculties of the Manipal Centre for Information Science (MCIS) and Manipal Institute of Technology with the support of Philips. Dr Veena G Kamath, head of the department of community medicine, KMC, opines that earlier, nurses of RMCWH used to visit houses in villages and collect healthcare data, including weight of babies, vaccinations for babies, blood pressure of mothers and other health status of mothers and babies. "During their visits, nurses used to note down the data on paper and later upload to the server of KMC via internet-enabled computers from RMCWH. The new software will save time and help nurses in collecting accurate data using mobiles. Nurses can collect healthcare data from houses in remote villages and upload it directly to the server within minutes through Internet-enabled mobile phones," says Dr Kamath. "This application is very

helpful. For instance, if a pregnant or baby requires immediate healthcare, doctors sitting in hospital can guide nurses to provide emergency health services using the healthcare data uploaded to the server by nurses," she added. Another advantage is that this technology makes the entire procedure paperless. And folds into Internet of Things !!! If the Internet of Things is the upcoming scenario, healthcare has already generated more fitness and personal health oriented devices than in any other area. The whole process of taking care of patients, have to be 'inclusive' and designed in a completely new way, based on user experience

Internet of Things will change the way medicine is practised and dispensed

and cutting edge design approach. Appropriate analysis and visualisations, typical of Web 2.0, should be a constant in the solution provided to any kind of users. Data and information generated by medical appliances - personal, wearable or geographically distant from major hospitals - carry with them the need to establish remote services which are secure, but also open and interoperable if necessary. A 'health cloud' is an asset that will be a primary need for hospitals as well as for medical device manufacturers (and a service for patients). At the beginning of the Web, no one believed that Amazon was set to have 5 to 10 times more revenue (online) than Walmart. In 2010 the brick and mortar retail giant, invested more than $100 million for the acquisition of new technologies, and it is only a small amount given the gap they have to fill now. The race has definitively started and a slice of this evolution is already on the store shelf.

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Techn vationsfor2014

TOP 10 HEALTHCARE

innovations to look out for in 2014 Here is a list of up-and-coming technologies which will have great impact in 2014 and help shape healthcare over the next 12 months. The list was developed by Cleveland Clinic, US and presented at its annual Medical Innovation Summit. In reverse order:

INNOVATION

[10]

B-cell receptor pathway inhibitors

C

hemotherapy is a blunt instrument designed to indiscriminately kill rapidly dividing cells in the hope that the cancer cells die more and grow back less than healthy cells. That normal cells are routinely damaged in this destructive procedure accounts for the side effects and toxicity of traditional chemotherapy. The B-cell receptor

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pathway tightly controls the growth of the infectionfighting cells that are known as B-cells. When B-cells become cancerous, this pathway becomes unregulated and contributes to the malignant nature of the cells. However, this overactive pathway can be inhibited by novel drugs. In the last year, the results of clinical trials in humans conclusively showed that these new drugs are extremely effective at treating

low-grade B-cell lymphomas and leukaemia for a long time and with very few side effects. Ibrutinib targets Bruton’s tyrosine kinase (BTK), a protein essential for B-cell survival and proliferation. While it kills malignant B cells, ibrutinib has little effect on healthy T cells—unlike other lymphoma therapies. This leaves an important arm of the immune system largely intact, enabling patients to remain healthier during treatment.


Many patients respond well to this novel B-cell receptor pathway inhibitor, which lacks many of the side effects of chemotherapy, and it frequently produces longlasting remissions even in patients with high-risk genetic lesions. Results from a study published in The New England Journal of Medicine in 2013 reported an overall response rate of 71 per cent for patients with chronic lymphocytic leukaemia (CLL) who were treated with ibrutinib tablets. At 26 months, the estimated progression-free survival

rate was 75 per cent and overall survival was 83 per cent. Ibrutinib has also shown very promising results in the treatment of patients with other B-cell malignancies, including mantle cell lymphoma (MCL), a rare and aggressive B-cell

subtype of non-Hodgkin lymphoma. With approval from the U.S. Food and Drug Administration (FDA) expected at the end of 2013, ibrutinib would be the first in a class of oral BTK inhibitors and one of the first medicines to file for FDA approval via

the new ‘Breakthrough Therapy Designation’ pathway, which is intended to expedite the development and review of drugs for serious or life threatening conditions. To follow soon after will be other much anticipated B-cell

pathway inhibitors for leukaemia, including spleen tyrosine kinase (Syk) inhibitors, like fostamatinib, and phosphoinositide-3 kinase (PI3K) inhibitors, like idelalisib. The B-cell receptor pathway inhibitors are innovative because they help fulfill the initial promise of imatinib. They will help patients who are no longer responsive to chemotherapy live longer, provide an alternative to chemotherapy in the future, and will stimulate additional research to find similar advances for other cancers.

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KNOWLEDGE INNOVATION

[9]

TMAO ASSAY: Novel biomarker for the Microbiome

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here is a global hunt in progress using a variety of cardiovascular fingerprints— scientists call them biomarkers—that have been discovered or created to help identify the initiation, development, and ongoing cascade of damage caused by heart disease. Everyone is familiar with the most common biomarker for heart disease, the blood test for cholesterol levels. In the search for additional ways to predict the risk of heart disease, considerable evidence indicates that a molecule called C-reactive protein (CRP)—a protein made by the blood in response to inflammation of any kind—tends to be elevated in people who go on to develop heart disease and suffer a heart attack. Scientists have now discovered what may be an important new biomarker for heart disease that serves as an

INNOVATION

accurate screening tool for predicting future risks of heart attack, stroke, and death in persons not otherwise identified by traditional risk factors and blood tests. The novel biomarker is called TMAO, or trimethylamine N-oxide, and it’s a microbial byproduct of intestinal bacteria. TMAO is produced when intestinal bacteria digest the nutrient phosphatidylcholine, which is more commonly known as choline. This metabolite is thought to promote atherosclerosis by contributing to cholesterol metabolism in heart artery walls as well as in the liver and intestines. Major dietary sources of choline include egg yolks, red meat and dairy products. Recently, tests conducted on more than 4,000 adults undergoing angiography over a three-year period revealed that TMAO levels are good indicators of who is at risk for

serious heart disease—and can also serve as a possible future treatment target. As reported in The New England Journal of Medicine (NEJM) in 2013, people with the highest levels of TMAO had double the risk of death, nonfatal heart attack, or stroke compared to those with the lowest levels. Heart experts now believe that by testing the gut biome for cardiovascular risk, doctors soon will be able to personalise nutritional recommendations for their patients on how to best prevent cardiovascular disease based on the production of TMAO. This advice could include modifying the diet to limit the intake of choline-rich food, using bacteriotherapy to alter the gut microbiota with the use of probiotics or suppressing TMAO synthesis with medication. A laboratory test for TMAO research studies is now commercially available.

[8]

Computer-assisted personalised sedation station

A

colonoscopy is an exam that lets a gastroenterologist look closely at the inside of the entire colon and rectum for polyps, the small growths that over time can become cancerous. Using a colonoscope, a thin, flexible, hollow, lighted tube that has a tiny video camera on the end, the doctor sends pictures to a TV screen. The exam itself takes about 30 minutes. Patients are usually given light sedation to help them relax and sleep while the procedure is performed. In order to deliver minimal-to-moderate sedation during a colonoscopy procedure without using the services of an anaesthesiologist, a new

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computer-assisted personalised sedation device that delivers the prescription drug propofol for sedation via intravenous (IV) infusion was given premarket approval by the FDA in 2013. The novel technology is expected to empower healthcare facilities to more effectively use their limited resources for delivering greater value in the increasingly resourceconstrained US healthcare environment. The new sedation system is a first-of-a-kind device in the world that allows non-anaesthesia professionals to administer the drug propofol during colonoscopy procedures as long as they have professional training and use the machine where there is immediate availability of an

anaesthesia professional. The device can also be used for an esophagogastro duodenoscopy (EGD) procedure, which is an in-office test to examine the lining of the oesophagus, stomach, and first part of the small intestine. A physicianled team performs the EGD with a small camera that is inserted through the mouth and down the oesophagus while the patient is sedated. The pivotal study for the computerised sedation device demonstrated that healthy patients who were sedated using the device had lower occurrences of low blood oxygen levels (hypoxemia) compared to similarly healthy patients who were sedated with midazolam or a similar medication during elective

colonoscopy and upper endoscopy procedures. According to the American Society of Gastrointestinal Endoscopy, the innovative computer-assisted sedation system can reshape the world of endoscopic procedures, because it can administer propofol without a trained anaesthesiologist on hand. Having an anaesthe siologist for certain routine endoscopic procedures is expensive and this has limited the use of propofol, which is regarded as a superior sedative because it gets to work quickly and has a short half-life, which leads to faster recovery. The new sedation system is expected to be introduced into clinical practice on a limited basis beginning in 2014.


KNOWLEDGE INNOVATION

[7]

INNOVATION

[6]

Relaxin for acute heart Faecal microbiota transplantation failure

M

H

eart failure is a debilitating and potentially lifethreatening condition in which the heart is unable to pump enough blood to supply the body. Heart failure affects both quality of life and life-span. Although it’s a diagnosis that carries a poor prognosis, it’s one that is improved and enhanced by medical and device therapy and, in limited cases, heart transplantation. Serelaxin, a synthetic version of the naturally occurring hormone human relaxin-2, which is associated with pregnancy, has proven that it can help treat patients with acute, decompensated heart failure episodes after being infused over a 48-hour period in the hospital. Serelaxin is a drug called a vasodilator. In people with heart failure, the chemically engineered form of relaxin increases blood flow throughout the body, which helps a poorly functioning heart to be more effective. Relaxin is also anti-inflammatory. Inflammation associated with heart failure can damage the kidneys, liver, and heart, but serelaxin appears to help prevent this from occurring.

Currently, 25 per cent of all patients admitted to the hospital with acute heart failure die within a year of their admission. Phase III study results from an international, double-blind, placebo-controlled trial reported a reduction in death rates by 37 per cent in patients with acute heart failure following six months of treatment for an acute episode compared to those who received standard therapy. The FDA gave the investigational heart drug “breakthrough status” in 2013. This increases its prospect for faster FDA approval. Once approved, serelaxin, the first in a new class of drugs that acts through a mechanism in the heart and kidneys, will become the first treatment breakthrough for acute heart failure in two decades. In clinical trials of patients hospitalised with acute onset of heart failure, serelaxin significantly improved shortness of breath, one of the most frightening and persistent symptoms of the disease. It also reduced organ damage caused by reduced blood flow, protected the kidneys and liver, and helped resolve fluid build up in the lungs more quickly than other therapies.

any hospitalised patients develop hospitalacquired infections, often times due, paradoxically, to broad-spectrum and fluoroquinolone antibiotic therapy used for medical treatment. Antibiotics, which are supposed to kill bacteria, can also increase the odds of some people developing a dangerous and potentially lethal infection from rod-shaped bacteria called Clostridium difficile, or C. diff. C.diff infections—and the infectious diarrhoea that they cause—are a major reason for sickness and increased healthcare costs for hospitalised patients. Gut microbiota, previously known as gut flora, is the name given today to the microbe population living in the human intestine. C. diff is just one of the hundreds of different microbial species found there, and, like the other intestinal bacteria, it is typically harmless. However, when antibiotics are used, aggressive and friendly bacteria in the gut are often killed together by the drugs. This can cause a gastrointestinal imbalance, which then allows for abnormal C. diff growth. Once passed through the faeces, C. diff is tough and persistent and can survive on dry surfaces for months. C.diff spores can inadvertently be transmitted to hands, food, utensils, sheets, counter-tops, and curtains. When transferred and swallowed by another person, these spores multiply and produce toxins that lead to inflammation of the lining of the intestine, diarrhoea, nausea, vomiting, and abdominal pain. Symptoms range from moderate to severe, and some patients are at serious risk of death when they don’t respond to standard therapy. C. diff is typically combated with one of two antibiotics, vancomycin

or metronidazole. However, many gastroenterologists are now employing faecal microbiota transplantation—the use of human stool transplants—to battle C.diff in those patients who do not respond to standard drug therapy. This novel bacteriotherapy typically entails a colonoscopy or enema to transfer a liquid suspension made from a healthy person’s faecal matter into a sick person’s colon in order to restore bacterial balance and cure a specific disease. The clinical study results to date have been extraordinary, with the stool proving to be a safe and effective treatment that alters the faecal microbiota to resemble that of their donors with no more than two transplantations. Some people who have had multiple episodes of C.diff have realised benefits from the therapy hours later, have been cured of their symptoms within 24 hours, and have had no recurrences. As more research about microbiota and how bacteria can actually make people healthier continues, it’s expected that faecal microbiota transplants could become a primary mode of therapy, not only for patients with multiple recurrences of C.diff but also for treating inflammatory bowel disease and non gastrointestinal medical conditions such as rheumatoid arthritis and Parkinson’s disease. A recent Dutch pilot study reported that obese patients with symptoms known as metabolic syndrome improved their insulin sensitivity and lowered triglyceride levels six weeks after receiving a faecal transplant from thin, healthy relatives. A 2013 study involving the transfer of gut bacteria from obese and lean human twins to mice reported that mice receiving the bacteria from fat twins grew 15 per cent fatter while those with the bacteria from lean twins remained lean.

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KNOWLEDGE INNOVATION

[5]

Perioperative decision support system

A

naesthesia is given to patients to inhibit pain, sedate the body, and also regulate various bodily functions in surgery. In the hospital surgical suite, there is tremendous activity among the medical personnel in attendance, so it’s critical that the anaesthesiologist appropriately recognise all of the patient’s known medical conditions, the surgical procedure being performed, and the anaesthesia work-flow, which includes knowledge of all the anaesthetic agents, fluids, and therapies that will be administered at specific times during the surgery. Understandably, the anaesthetic record is now one of the most detailed physiological and pharmacological accounts in medicine. In order to meet

INNOVATION

the demands of modern surgery and improve the standard of care, a new anaesthesia management system that combines the latest in computer technology and microelectronics is now available. This innovative system electronically documents the care provided by an anaesthesiologist, from pre-op to intra-op and recovery, producing a complete anaesthesia record of events, drugs and procedures. It’s this real-time patient data acquisition that elevates the quality of clinical decisionmaking, patient surveillance, and physician oversight. Designed by anaesthesiologists for anaesthesiologists, this electronic anaesthesia record and clinical guidance system

enables anaesthesia best practices to be carried out and helps to reduce the risk of anaesthetic errors. The ability of this anaesthesia information management system to collect data automatically enables

anaesthesiologists to reliably and continuously create an accurate record, regardless of other demands during surgery. In addition, it also builds a compliant, billable electronic anaesthesia record while also

supporting the clinical team managing the needs of the patient, whether a centenarian with multiple health issues or an infant who is eight weeks premature and struggling to thrive. Having ready access to physiologic trends is essential, because it allows anaesthesiologists to make proper diagnoses and treatment decisions during surgery. Some complex surgeries last as long as 16 hours and clinicians need to be replaced. With this anaesthesia management technology system running, however, everything during the surgery has been documented, providing the next clinician with all the critical information needed to allow continuity of care.

[4]

New era in hepatitis C treatment

H

epatitis C infection, a common liver disease that affects an estimated four million people in the US, is transmitted through exposure to infected blood (blood was not screened effectively for hepatitis C until 1992) or sexual contact with an infected person. The majority of people with the ailment don’t realise that they have the disease because of a lack of symptoms. Hepatitis C is typically diagnosed when abnormal liver enzymes are identified through a routine blood test or if the infection becomes severe. 70 per cent of patients with hepatitis C develop chronic disease and 30 per cent may develop scarring of the liver and cirrhosis of the liver within 20 years of exposure to the virus. An additional 20 per

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cent of these patients eventually develop liver cancer. About 15,000 deaths are linked to the disease in the US each year. While hepatitis C treatment has improved considerably, especially when compared to the 1990s, the news is even better now. Sofosbuvir, the first all-oral hepatitis C treatment, is moving through the final stages of FDA approval. What this direct-acting antiviral (DAA) drug has is the potential to improve what for many has been a very difficult treatment regimen that can take up to 48 weeks and requires injections of interferon, a drug that is difficult to tolerate. More important, the drug can improve treatment response rates to 90 per cent or higher in certain groups of patients. In addition to significantly higher cure rates,

sofosbuvir—and others now in the pipeline—has better tolerability, safety,and a 12week treatment duration. In the FISSION trial, treatment-naïve genotype 2 patients treated with an oral DAA (1 pill daily) and ribavirin (2-3 pills twice daily) had a 67 per cent cure rate, which was just as good as standard therapy, but without the use of interferon. In the FUSION trial, a study with patients with genotype 2 disease who did not respond to standard 24-week therapy or who had relapsed, those who completed 12 weeks of therapy with the oral DAA and ribavirin had an 86 per cent cure rate. An additional four weeks of the therapy increased the cure rate to 94 per cent. An oral drug with the highest cure rates ever and few side effects: There is finally real hope on the horizon for people with chronic hepatitis C.


KNOWLEDGE INNOVATION

[3]

INNOVATION

Responsive neurostimulator for intractable epilepsy

Genome-guided solid tumour diagnostics

G

E

pilepsy is a neurological condition that produces seizures—brief disturbances in the normal electrical activity of the brain—that affect various mental and physical functions. Seizures happen when clusters of nerve cells in the brain signal abnormally, which may briefly alter a person’s consciousness or movements. When a person has two or more unprovoked seizures, he or she is considered to have epilepsy. Medications and other treatments help many people of all ages who live with epilepsy, but in spite of their medication regimen more than one million people continue to have seizures that can severely limit or curtail many of their life’s experiences. Sudden unexpected death in epilepsy, or SUDEP, is a serious concern. It is a non-accidental death in a person with epilepsy, who was otherwise in a usual state of health. Epilepsy surgery is a possibility for some with intractable epilepsy, but many cannot have it due to the risks involved or because it’s unlikely to be helpful. There is now another option. An implanted neurological device that can significantly reduce the frequency of epileptic seizures gained the unanimous backing of an FDA neurological device advisory panel in 2013.

Surgically implanted under the skin, the small device records electrocorticographic (ECog) patterns through leads containing electrodes that are placed at the patient’s seizure focus within the brain or else they rest on the brain. surface where seizures are known to start. When detection thresholds are met, the device delivers short electrical pulses to interrupt the triggers before any seizure symptoms can occur. After reviewing ECoG recordings, physicians can assess the relationship between the detections of the device and reported seizures and then, non-invasively, customise the system’s electrical impulses as needed for that patient. At long last, there appears to be a workable solution for people who suffer out-of-control bursts of electrical energy in the brain. With more than 15 years of development, testing and three clinical trials, the pivotal clinical study reported a 40 per cent reduction in seizure frequency among the treatment group compared to a 17 per cent reduction in the sham-stimulation control group. Long term results demonstrated sustained improvements in seizure frequency, with average frequency reductions of 44 per cent and 53 per cent at one and two years postimplant, respectively.

[2]

enomics is the study of groups of genes, how they interact in cells and the role that they play in health and disease. A variety of genomic-based cancer tests are currently available that, without surgery, can analyse the genes in a person’s tumour and predict both the biology and the aggressiveness of the cancer. What each of these novel genomic tests offers is the potential to reduce unnecessary cancer treatments and avoid their attendant side effects. For prostate cancer, the new tests can predict whether a patient truly has a low-risk form of the disease and— based on the biology of the tumour—help a man decide if he is a good candidate for active surveillance rather than initial therapy. Women with oestrogen receptorpositive breast cancer can find out if they need chemotherapy in addition to hormonal therapy in their treatment regimen, or whether they can benefit from hormonal therapy alone. If a person has early-stage colorectal cancer, there is also a multi-gene expression test that looks at the gene activity with a person’s lymph node-negative tumour sample, assesses the risk and provides valuable information to the patient and doctor that traditional technologies do not capture. To create their novel prostate test,

scientists evaluated more than 700 patients and 288 candidate genes that predict clinical recurrence expressed in common by both the primary and highest Gleason patterns, which are indicators of prostate cancer aggressiveness. They then honed the genes down to 17 and asked whether the expression of these 17 genes could predict the presence of high-grade cancer or cancer outside the prostate in men who underwent prostate surgery. In these studies there was a substantial increase in the number of patients who could more confidently consider active surveillance. This treatment plan entails monitoring cancer closely with blood tests, digital rectal exams, and biopsies at regular intervals to see if the cancer is growing. The protocol avoids unnecessary treatment and its potential side effects, which can include erectile dysfunction and incontinence. The genomic test also identified a smaller number of patients who, despite seemingly low-risk clinical factors, had more aggressive disease that might require more immediate treatment. We are now in a new age of cancer diagnosis. Thanks to the development of a variety of genomic tests for various cancers, what we are now witnessing is the beginning of an era of true precision medicine that has its basis in biology.

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KNOWLEDGE INNOVATION

[1]

Retinal prosthesis

R

etinitis pigmentosa, or RP, is a group of rare inherited diseases that damage these light-sensitive cells. People with RP experience a gradual decline in their vision because photoreceptor cells—the rods and cones—of the retina slowly degenerate, causing a gradual loss of side and night vision and, eventually, central vision and colour. Many patients become totally blind in both eyes. There has been no effective treatment for RP—until now. After two decades of development and testing and more than $200 million in funding, the FDA approved a new technology for severe RP in 2013. It combined a surgically implanted 60electrode retinal prosthesis that receives signals from a pair of external video cameraenabled glasses with a video processing unit that is worn at the waist or carried. This approval follows European agreement in 2011 and a unanimous recommendation by the FDA’s Ophthalmic Devices Advisory Panel in 2012 that this revolutionary product be made available to treat the RP patient population in the US.

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The retinal system works when the video unit transforms images from the miniature camera into electronic data that is wirelessly transmitted to the retinal prosthesis, which contains an antenna and

electrodes that replace the degenerated cells in the retina. Here, the data are transformed into small electrical impulses that stimulate the retina’s remaining inner neurons, resulting in the corresponding

perceptions of light and images in the brain. People then learn to interpret these patterns of light and thereby regain some visual function. Given the profound vision loss that occurs with late-stage RP, the retinal implant will not

restore complete vision, but it does allow people to detect light and dark in the environment as well as identify the location or movement of people and objects. The retinal prosthesis system is approved for people of 25 years and older and have severe to profound RP with bare light perception—they can perceive light, but not the direction it comes from—or no light perception in both eyes. What this novel retinal implant system does is allow people to reclaim their independence by being able to perform day-to-day activities. Results from a clinical study of 30 participants who received the ‘bionic eyes’ reported that most were able to perform basic activities better with the prosthesis than without it, including walking on a sidewalk without stepping off the curb; matching black, grey, and white socks; and recognising large letters, words, and sentences. The retinal prosthesis is certainly a game changer in sight-affecting diseases and it represents a huge step forward for the thousands of people who had been without any available options for treating their blindness.


KNOWLEDGE I N T E R V I E W

‘Huge numbers of Indian people are exposed to dangerous noise levels everyday’ India is said to be a leading nation in various types of auditory impairment. Dr Ingeborg Hochmair, CEO, MED-EL explains to Raelene Kambli about the number of people at risk, the effect of noise pollution and need for awareness on this subject

How many Indians suffer from auditory impairments as compared to the rest of the world. Can you give us some statistics on the current situation and the reasons behind this? Less than 10 per cent of people who have severe hearing loss receive a hearing implant across the world. In India, we estimate that figure is significantly lower, maybe even less than one per cent. This is due to a number of reasons. Historically, there has been a lack of funding, but the Government is now aware and sees this as an important issue. This should result in more Indians receiving cochlear implants. The health screening procedures of children is not at the level it should be and a high number of home births mean many children with hearing problems go undetected. On top of this, the population growth in India, with around 50,000 births every day, means that even if a small proportion of these are born profoundly deaf it is still a huge number of children (and

then adults) have hearing problems. Do you think that excessive speaking over mobile phones or constant listening to MP3 players (I-pods) or any kind of extensive exposure to noise can induce hearing loss? How many young people in India are at risk? How can this situation be tackled or managed? It certainly is a growing problem, and not just with electronic devices. Huge number of Indian people are exposed to dangerous noise levels everyday. We seek to raise awareness of the importance of hearing and it must be supported broadly by governments and other authorities across the world. How can people living with hearing disabilities lead a better life? Awareness is a key part to help this, clarification about hearing loss reduces anxieties and prejudices. Hearing loss isn't a fate that you have to resign yourself to. Being unable to hear separates you from people and for children it

◗ An implant as early as possible is crucially important, especially for children,- children learn to speak and understand a language only if they hear properly. Obviously this then has a strong link to their education and future career

restricts their opportunities in life. We have solutions that can make someone suffering from hearing loss or even complete deafness to hear again – the change this brings to one's life is truly remarkable.

We (MED-EL) have been in India for around 20 years and continue to introduce the latest products to provide more solutions for a wide range of auditory impairments

Which are the technologies introduced by you in India that can be utilised by people suffering from auditory impairments? We have been in India for around 20 years and continue to introduce the latest products to provide more solutions for a wide range of auditory impairments. In November (2013) in India we introduced Bonebridge, world’s first active bone conduction implant. It transmits sound directly to the inner ear by bone conduction and is designed for people where sound cannot be transferred to the inner ear via the outer and the middle ear. It also works for some types of single-sided hearing loss. We also have Rondo, the world’s first single unit processor that is placed discretely behind the ear. Other options include Electric Acoustic Stimulation (EAS) for partial deafness, and Soundbridge for middle ear hearing loss. There really are a wide range of products available for providing a

number of solutions. How do cochlear implants function? Are these cost effective? The cochlear implant is the first and only replacement of a human sense, the sense of hearing. MED-EL offers the widest range of implantable solutions to treat the various causes and degrees of hearing loss. Put simply, cochlear implants are solutions for people with severe to profound hearing loss where hearing aids provide little or no benefit. An implant is surgically placed under the skin behind the ear. Externally, there is a microphone, a speech processor and a transmitter. Internally, electrodes travel through the cochlear and sending impulses to the brain. Cochlear implants do require a financial investment but the benefits both socially and economically are repaid very quickly. An implant as early as possible is crucially important, especially for children,- children learn to speak and understand a language only if they hear properly. Obviously this then has a strong link to their education and future career. raelene.kambli@gmail.com

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STRATEGY

POLICIES FOR CHANGE Experts share their views on healthcare policies in India and their role in driving progress, with Express Healthcare

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ROUND TABLE DR DEEP GOEL DR MUKESH BATRA ZAHABIYA KHORAKIWALA AMOL NAIKAWADI VIKRAM ANAND

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RAJENDRA PRATAP GUPTA

DR RAJEEV BOUDHANKAR

DR ARAVEETI RAMAYOGAIAH

DR MUKESH BATRA

National Health Policy: Nailing it right!

Rooting for medical devices regulation

BSc Community Health vs MBBS in India’s rural healthcare system

Government health schemes: Challenges and the road ahead


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PROF ANIL GUPTA ‘We need linkage between people's knowledge and practitioner’s knowledge and researcher's expertise’

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STRATEGY

Healthcare policies for progress The Indian healthcare industry is undergoing a transformation, be it on the delivery front or on the policy front. In its 12th five year plan, the Government of India has planned some significant policy changes and intends to introduce new regulations to make healthcare not only more accessible and affordable but also more transparent and ethical. How far will these regulations and policies help better healthcare access and improve healthcare delivery within our country? Express Healthcare talks to industry players on how policies can play a role in improving healthcare delivery Excerpts…

‘The healthcare delivery model of India in its current form is an excellent idea about how a system should be’

H

ealthcare in India is heading towards a major makeover, thanks to the liberalisation and globalisation of the economy. Like every other field, such a change starts from the class room. Involvement of private players in education has set the bar high; now it has to be followed by government institutions as well. Health education in India is comparable to anywhere in the world. Policy change from MCI had ensured relaxation of stringent criteria required for operating medical colleges. Currently there are around 300 medical colleges all over India; around 30,000 to 35,000 students graduate every year. Yet there is room for improvement. Insurance in healthcare has a bright future, as an industry

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it is expected to touch Rs 32,000 crores by 2016-17, public-private partnership is making it happen. Welfare schemes for employees by ESI, CGHS, ECHS etc, have made world class tertiary level healthcare accessible to poorest of patients. But there are discrepancies in the financial compensation offered by government and that of private sectors, which put pressure on patients. The healthcare delivery model of India in its current form is an excellent idea about how a system should be. The biggest challenge is translating it into providing basic healthcare to rural areas. Talent migration due to poor working conditions is at best stopped or reversed only by allowing private players to enter the arena of primary healthcare. But then who will go to rural areas without expecting good return? Political and bureaucratic hurdles make the process more painful. One solution to this problem is public private partnership creating

The biggest challenge is translating it into providing basic healthcare to rural areas. But who will go to rural areas without expecting good return? competition which ultimately leads to improved healthcare delivery at primary care level. No doubt that the healthcare facilities in urban areas of India are not less than anywhere in the world. We have hospitals providing best facili-

DR DEEP GOEL, Director, Department of Minimal Access & Bariatric Surgery and Surgical Gastroenterology, BLK Super Speciality Hospital, New Delhi

ties, performing advanced procedures, with world class equipments. India has one of the largest clusters of Joint Commission International (JCI) approved hospitals. This

enormous concentration of tertiary or quaternary care centres in the urban area makes us to ignore basic healthcare, leading to pressure on urban centres to handle high patient load. The Government of India had recognised this problem and taken initiatives to address it through National Rural Health Mission launched in 2005 to extend healthcare to all. The Rashtriya Swasthya Bima Yojana works towards providing health insurance to the lower strata of community. However, the problem lies in implementing these policies at the grass root level. Improving the GDP allotment to healthcare by 4-5 per cent would help in providing basic facilities and better pay grades to health workers would attract more employees. Need to translate the phenomenon of globalisation of healthcare at the level of villages would require involvement of both private and public sectors.


STRATEGY

‘The biggest obstacle in the healthcare sector today is lack of access to medicines’

G

overnment policies and regulations play an important role in developing efficient and sustainable healthcare delivery model in any country. Especially in India, where medical sector is still unorganised, regulations play an important role in achieving standardisation in processes and healthcare delivery. However, the key to success of any regulations and schemes run by the government is implementation. In India, where there are several states and diverse health schemes for each state, efficacy of any scheme depends on how successfully it is implemented by different states’

authorities. For example, Rashtriya Swasthya Bima Yojna (RSBY) may have been exceptionally successful in other states but it seems to have fallen flat on its face in Maharashtra. The ministry of labour is contemplating whether to continue the national health insurance scheme in its present form in the state. Thus, implementation plays an important role in the success of any scheme. To ensure maximum outcome, policies and regulations should be developed on the basis of the learning of all available systems, the strengths as well as lacunae in existing schemes and needs of individual states. Also, people need to be properly directed towards taking benefit of health schemes. The best example of stringent implementation of regula-

DR MUKESH BATRA Founder and Chairman, Dr Batra’s Healthcare

tions is Dubai where we are present since the last four and a half years. There the emphasis is on quality of services and safety of patients based on the local and federal laws in addition to international accredita-

tion standards. There are strict regulations governing licensing of any healthcare facility in Dubai. Audits are done at regular basis to ensure the quality of service in healthcare facilities. For example, it took us one year to get a license for our clinic in Jumeirah. Moreover, the license needs to be renewed regularly for ensuring proper implementation of guidelines. India should follow such discipline in implementing the guidelines set for quality in healthcare delivery. The biggest obstacle in the healthcare sector today is lack of access to medicines. It is the common denominator in all the nations of the world, regardless of whether their healthcare systems are public or private. Healthcare regulations must begin with reform in the way in

which medicines are created and, accordingly priced, which requires a series of improvements at Research & Development (R&D) level. They further need to focus on availability of these medicines to people even in remote areas. Indian healthcare today is urban centric. It needs to be reformed through regulations that emphasise on providing good medical facilities in rural areas. They must provide impetus to lift the population, which is at the bottom of the pyramid. Conclusively, at the core of every regulation should be the safety of patient. Everyone should have access to quality healthcare at affordable rate. Moreover, the state authorities should take the responsibility of implementing regulatory guidelines for success of policies and health schemes.

‘India needs increased penetration of insurance throughout the country’

W

here the Indian healthcare sector is concerned, there are a couple of things that are needed to be put in place in terms of bringing new policies. Firstly, we will have to create more access to healthcare without compromising on quality of care. We need to see to it that we provide good standards of healthcare facilities to more people, especially in the Tier II and III cities and towns of India. Secondly, we need to make healthcare affordable.

This can be made possible by way of partnerships between the government and the private players; where the government plays the role of a payer and the private players provides the service. We have initiatives like the Rajiv Gandhi Arogya Yojana in this sphere which is indeed a good scheme but needs to improve its mechanism. The systems followed under the scheme are fairly ad hoc. A health insurance co-ops is a good alternative. Apart from this what India needs is increased penetration of insurance throughout the country. Well, speaking of the policies and regulations introduced by the government in recent times, I

would like to point out a commendable move by the government of India- the PCPNDT Act. This is one act that will help us curb sex detection and abortion of girl child. Another good move is the CSR Act which makes all companies give two per cent of their net profit towards the society.

Rajiv Gandhi Arogya Yojana is good but needs to improve its mechanism

This culminates to a significant amount of funds been ing raised for many social and healthcare causes. On one hand we have policies like PCPNDT and CSR Acts that have helped us bring in some transformation but on the other, we have the Clinical Trial Act which was brought with the right intent but has some adverse effects. Regulations brought under this Act for monitoring and compensation has made companies reluctant to conduct clinical trials in India. This serves as a drawback to India. Finally one area that the government needs to focus on is opening avenues for private players to enter into medical

ZAHABIYA KHORAKIWALA MD, Wockhardt Hospitals

education space. This will also help in increasing the number of doctors, nurses and other healthcare professional within the country.

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STRATEGY

‘New regulations and policies introduced would be of much larger use if well organised, improvised and facilitated’

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mproving public health for all is documented in the Constitution of India as one of the primary duties of the state. To achieve this, the planning process of the country provides a broad framework to the states to develop their health services infrastructure, as well as facilities for medical education and research. It is very difficult to ascertain whether the presence of private healthcare pro-

vision has made any impact on health outcomes and whether the states having higher availability of private healthcare provision do really exhibit significant differences. It would require observing health status and utilisation patterns over a long period of time. The laws pertaining to healthcare in India are effective in protecting the interests of the patients; but the main area of concern is about their proper enforcement. Issues with regard to public and private health infrastructure are different and both of them need attention but in different ways. Rural public infra-

AMOL NAIKAWADI, Joint Managing Director Indus Health Plus

structure must remain in mainstay for wider access to health care for all without imposing undue burden on them. Side by side the existing set of public hospitals at district and subdistrict levels must be supported by good engagement and with adequate funding and user fees and out contracting services. This demands better routines, more accountable staff and attention to promote quality. These, attempts must persist without any wavering or policy changes or periodic denigration of their past working. New regulations and policies introduced would be of

much larger use if well organised, improvised and facilitated. These regulations would surely be beneficial for the Indian healthcare industry but the concern still remains that whether the designated body or authority utilises the opportunity justly. In a market economy, healthcare is subject to three links, none of which should become out of balance with the other - the link between state and citizens' entitlement for health, the link between the consumer and provider of health services and the link between the physician and patient.

‘Mere legislation doesn’t bring significant change’

I

ntroduction of numerous healthcare bills in the cabinet in the last two years is in itself a testimony to the growing importance accorded to this sector by the Government of India. Recent regulations and amendments include almost all areas of healthcare ecosystem, from medical technology, medical education, insurance, to healthcare delivery and medical tourism. They are a critical and much needed steps in setting off on a path of long-term reforms in a country where healthcare services are still marred by issues of poor physical access, high cost, under-

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insurance, and unregulated quality of care. Amendments to the Medical Council of India Act will empower the central government to ensure proper development of medical education, and keep corrupt practices under check. The bill to regulate medical devices is a long-due initiative which is likely to strengthen the domestic manufacturing industry and make medical equipment more accessible and affordable to the masses. It will also benefit hospitals as they will have more high-quality indigenous products to choose from. With more than 80 per cent of the providers being in the unorganised space, there is barely any quality control over this segment at present. A regulation that can go a long way in improving quality of care deliv-

ery is the Clinical Establishments Act, which emphasises on adherence to standard practices. The utility of this Act can be further enhanced if the registered facilities are mandated to periodically share critical operational and clinical data with the state and national councils. This database can be leveraged to design performance benchmarks for Indian healthcare providers and analyse their performance on a continuous basis. While these regulations have many positive features, it is important to not lose sight of the fact that mere legislation doesn’t bring significant change if it is not followed by effective enforcement and monitoring. We have a long history of drafting strong laws which remain mostly on paper. Therefore, the important as-

pect is the speed of enactment, management of stakeholders including doctors and healthcare administrators, and monitoring of adherence. This is a mammoth task which requires an army of officials, and continuous investment in financial and technological resources. It also requires serious commitment from private healthcare players, as self-regulation is the first step.

VIKRAM ANAND, Head, Head, Healthcare Practice, IMS Health, India

We have a long history of drafting strong laws which remain mostly on paper. Speed of enactment, management of stakeholders and monitoring of adherence is important


STRATEGY

‘It is imperative to evolve a robust long term policy for healthcare’ DR KRISHNA REDDY, CEO, Care Hospitals

I

t is imperative to evolve long term policies and regulations for healthcare, as the developed world witnesses the perils of galloping healthcare costs. While the intent is visible, the way these are approached and framed, there is a growing concern among various stakeholders in healthcare. There is not enough research data on various issues to frame these policies and thus there is an inherent risk of framing wrong policies. The core issues that need to be addressed together are: Q Who pays for the costs? Q Who provides care? Q Who regulates safety and quality of medical services? Q How do we meet the human resource need? Q How do we design medical education for future? Q How do we address the rising costs in terms drugs, devices and diagnostics? Is there a national policy to support indigenous industry to contain costs? Hence, in conclusion, it is imperative to evolve a robust long term policy for healthcare. However, it needs to be addressed professionally taking all stakeholders into confidence and should be based on robust national data.

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STRATEGY

National Health Policy: Nailing it right! Rajendra Pratap Gupta, President, Disease Management Association of India speaks on the need for an effective National Health Policy and the aspects to be considered while framing it

Policiesf rchange THE NEED for planning and policy in health was felt about seven decades ago in British India, when a committee was appointed under Sir Joseph Bhore. The Bhore committee recommended the formation and execution of a ‘National Health Policy’ (NHP) in 1946 (Health Survey & Development Committee, Vol II - Bhore Committee, 1946, p. 410) . India has had only two National Health Policies till date; i.e. the National Health Policy 1983 and the National Health Policy 2002 - the first healthcare policy came after a gap of 37 years from Bhore committee recommendation. Also, there are some learning from the past National Health Policies. The ‘National Health Policy’ did not adequately reflect ground realities. Despite the fact that the National Population Policy (NPP) 2000, the National Health Policy 2002, the Eleventh Five Year plan (2007-12 ) and the National Rural Health Mision (2007-12)- having laid down the goals for child health, the number of children dying < 5 years in 2000 was 2294000 and had reduced to 1696000 in 2010. But still, it is way too high. ‘Universal comprehensive primary healthcare services which was the goal of the National Health policy is far from being realised’……..NHP recommended the formulation of the medical education and a population policy , but this has not been done till today . (Voluntary Health Association of India, 1997, pp. 39,40) Also, the earlier National

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Health Policies did not even have the word ‘chronic diseases’, and so clearly, the older policy documents are not relevant today . The National Health Policy document of 1983 aimed at achieving ‘Health for all by the year 2000’ and emphasised universal provision of comprehensive primary care, community participation, decentralisation, increase in outreach services through domiciliary care and field camps, seek involvement of voluntary organisations, according priority to tribal, hilly and backward areas, promotion of family planning, supply of drinking water and sanitation, over hauling health manpower development, phasing out private practice amongst government doctors , integration of indigenous system of medicine in healthcare delivery, besides other issues. NHP 2002 came out after 19 years of the first National Health Policy in 1983. The policy document accepted that some areas of NHP 1983 have yielded results, but in several other areas, the outcome has not been as expected! NHP 2002 accepted that the mortality and morbidity were unacceptability high and such indices are an indication of the limited success of the public health system in meeting the preventive and curative needs of the general population. The document dwells on problems like stagnancy of the public health funding, inequity in healthcare, health being the responsibility of states, shortfall in health infrastructure (as high as 58 per cent when disaggregated for CHCs) and ac-

cepted that the public health infrastructure was far from satisfactory. NHP 2002 looked into the deficiency of health personnel, healthcare education, specialists in public health and family welfare, shortage of nursing personnel, use of generics, urban health, mental health, IEC, health research, enhancing the role of private sector, role of civil society, national disease surveillance network, scientific health statistics database, women’s health, medical ethics, quality standards for health foods, standards for paramedics, medical tourism, inter sectoral issues in health, population growth, increase in use of traditional/alternative systems of medicine, controlling the irrational use of drugs etc. NHP 2002 recommended the increase in allocations for healthcare, reversed the 1983 policy of decentralisation in a sense by recommending key

role of central government in designing national programmes and technical support, monitoring and evaluation at the national level by the centre. NHP 2002 recommended the gradual convergence of all health programmes under a single field administration, vertical programmes for major diseases like TB, malaria, HIV/AIDS, RCH and Universal Immunisation programmes. The NHP 2002 did not talk about child health, chronic disease, the role of technology besides a host of other important issues. In the summary section, NHP 2002 stated ‘NHP 2002 does not claim to be a road map for meeting all the health needs of the populace of the country’. Clearly, if one reads any of the NHP documents, it looks like more money in the kitty and more doctors and allied health professionals are the only solution to the healthcare problems of this country. But the experience in the US and UK have not been able to demonstrate the positive impacts of reckless increase in health budgets or professionals. Policy makers have to go beyond the confines of Nirman Bhawan (HQs of Ministry of Health & Family Welfare) and Yojna Bhawan (Planning Commission). Earlier approaches have led to over dozen committees in health since 1947 and all have failed time and again. If we continue with the same approach, we are bound to fail in our goal of Universal Health Coverage. It is time we rethink our entire approach. One also needs to look at the Public Accounts Committee report on

NRHM and its recommendations Also, it is important to note that the last National Health Policy was drafted more than 10 years ago in 2002, since then a lot of things have changed, like; Q NRHM was launched in 2005 as a flagship programme focused on rural health Q Rashtriya Swasthya Bima Yojna (RSBY) was launched for BPL families, and as of October 31, 2013, it had 37,506,938 active smart cards and 6,215, 293 registered hospitalisation cases Q Rise in use of broadband and mobile phones. As on date, the number of internet users in the country are more than 200 million, and the number of mobile phones far exceed the land lines and India has more than 900 million users according to the Press Information Bureau (PIB, Govt. of India, 2013) Q Pandemic outbreaks like H1N1 (swine flu) have been a surprise and have shaken the world Q Rise of MDR – TB Q Increase in the incidence of chronic diseases and the issues related to child health Q Occupational hazards Q High IMR/MMR and MDGs deadline approaching in 2015 Q Besides, a lot of other developments have taken place, like; Q UID –Aadhaar number for the entire population have been initiated . UIDAI plans to issue 60 crore Aadhaar cards till 2014 . Q Emergence of mHealth and telemedicine Q Newer technological interventions for diagnostics


STRATEGY

and treatment Q Emergence of Big Data Analytics Q Also that, India is focusing on transitioning the healthcare system to Universal Coverage Q Emergence of innovative concepts, like Disease Management, Accountable Care Organisations (ACOs), Health Management Organisations (HMOs) and meaningful use. Q Emergence of the prominent role of civil society organisations in healthcare delivery Q Role of social media To me, the most important aspect to look at, is the increased sectoral allocations. The health sector allocations have increased from Rs 65.3 crores in the first plan to Rs 3.84 lakh crores in the 12 th Plan. If we compare this to the 11th five year plan , this is a jump of 174 per cent. I some times shudder to think how can the ministry spend so much money without a policy in place? Even the Ministry of IT has a National Policy for IT ( NPIT), for the country. Health has been getting the focus at the highest levels and the Prime Minister in his independence day speech (2011), highlighted that health would be accorded the highest priority. Also that, the 12th Five Year Plan has often been referred to as the ‘plan for health’, and it is the right time to set up a committee to draft the new National Health Policy for 2015-2025. We should not lose any time in doing so, as drafting the policy is a time consuming process and it involves a lot of research and consultation. Even if the committee is set up in early 2014, it will take at least a year to do the survey and complete the policy and so, most likely, the NHP would be tabled by 2015 and would cover a period of next 10 years (2015-2025). Key areas to consider in the National Health Policy Q Rural Urban Divide –

The health sector allocations have increased from Rs 65.3 crores in the first plan to Rs 3.84 lakh crores in the 12th Plan. If we compare this to the 11th five year plan , this is a jump of 174 per cent. I some times shudder to think how can the ministry spend so much money without a policy in place? despite decades of planning, we are failing Q Social Media Policy – This is a new development and India can leverage this, considering that 65 per cent of the population is less than 35

years in age Q Affordable and accessible medicines – Despite referring to the use of generics in Hathi Committee report in 1975 and in NHP 1983, we have not succeeded

Q Nutrition policy – 50 per

cent of Indian children are malnourished, according to the CRY report Q NCD policy – NHP 2002 made a passing reference to diabetes, CVD and cancer and

now, we have a full blown problem of chronic diseases. Q Communicable disease/epidemic outbreak policy – Dengue, malaria are still around, and 100s of people die. Q Health Technology Policy – It is time we leveraged technology for providing some form of healthcare information and advice through technology driven care and also for surveillance and reporting Q Medical Devices policy – A lot needs to be done besides the MDRA Q Epidemiology policy – We are making ad hoc policies if we do not have an annual epidemiological survey. In fact, with the right usage of IT, we can have live data that can be used for effective and relevant policies Q Medical education and CME policy – Big gaps remain Q School health policy – school health programmes started in Baroda in 1909. We still could not make it a universal programme despite the idea being over 100 years old Q Innovations in health –This needs to be the focus area. Q Occupational health – Another big challenge that India has to be prepared for Q MCH – We continuously face flak for missing out of MDGs Q PPP – Time to clear our thoughts on how and what we wish to do with the private sector Q Sanitation and hygiene – Too much to do Q Implementation plan – All the NHP documents have been high level policy papers which never touched the implementation part and the new NHP must go in detail to ‘professionalise’ the public healthcare delivery system It is time we started work on the NHP 2015-2025, before parliament questions the ministry on how they can use Rs 3.84 lakh crores without even having a policy in place! As we say prepare and prevent is better than repair and repent!

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Rooting for medical devices regulation Dr Rajeev Boudhankar, VP, Kohinoor Hospitals talks on the need and benefits of a medical devices regulatory body in India

Policiesf rchange THE MEDICAL devices market is the most unregulated market in the country vis-à-vis the healthcare sector. There are no prescribed 'gold standards' for manufacturing in India, no data on Indian studies for 'safety standards', no studies showing efficacy and even indications of use in India, no MRP is ever fixed and even the variations in cost prices is very wide. This scenario is made worse by unscrupulous vendors and manufacturers offering incentives to doctors for use of their products. Medical tourism too, is now looking to boom in India, which will bring in patients from across the world; to maintain international standards of healthcare and earn our healthcare industry an international reputation. We need to follow international standards in use of medical devices. Hence to consolidate laws related to medical devices and for establishing and maintaining a national system of controls relating to quality, safety, efficacy and availability of medical devices that are used in India, whether produced in India or elsewhere, a regulatory body under the regulatory law is a must. Having considered paramount the safety of the public in the use of medical devices, and the fact that the content and scope of the present laws of the country including the regulations and administrative

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provisions in force do not extend to and cover adequately the safety, health protection and performance characteristics of medical devices, the regulatory body is essential. Also, even in the amendments to the Drugs and Cosmetics Act, 1940, the scope of the definition of the expression ‘drugs’ has not been extended to cover the entire spectrum of ‘devices’ fully and does not adequately cover all the products which are covered by the current internationally accepted definition of ‘medical devices’. Thus, the regulatory body will cover the aspects of medical devices broadly covering the design, manufacture, packaging, labelling, import, sale, usage and even disposal of medical devices in India. Along with the regulatory body it is essential that a law should be in place for regulating medical devices to give teeth to the body. The following aspects also show the need of the regulatory body: It is clear from international experience in the regulation and use of medical devices, that the optimum assurance of medical device safety has several essential elements, viz.:  Absolute safety cannot be guaranteed  It is a risk management issue  It is closely aligned with device effectiveness/ performance  It must be considered throughout the life span of the device  It requires shared responsibility among the

stakeholders A diverse range and multitude of medical devices are in use, which are manufactured using a wide variety of technologies with the result that for ensuring the safety of the public in the use of medical devices an entirely different system and method of regulation from the current national and international practices that are being applied for the regulation of drugs and cosmetics is required. Also, the national provisions for the safety and health protection of patients, users and, where appropriate, other persons, with regard to the use of medical devices should be harmonized with global provisions in order to guarantee the free movement of such devices within the country and into the global market. There is a need to ensure that medical devices should provide patients, users and third parties with a high level of protection and attain the performance levels attributed

to them by the manufacturer; it is necessary to improve, the level of regulation, supervision and control over medical devices manufactured in or imported into the country. Therefore, it is found expedient in the larger public interest, that the Parliament should enact a law to bring under its control the safety and performance of all medical devices which will be administered through the regulatory body. The objective of the regulatory body should be to regulate and monitor the design, testing and evaluation, manufacture, packaging, labelling, import, sale, usage and disposal of medical devices, to ensure availability of safe medical devices for human use in the country. With a view to the implementation of the objects specified above, the regulatory body should:  Provide for notification of essential principles of safety and performance of a medical device and the requirements for design and manufacturing  Provide for risk-based classification of medical devices  Notify the standards and guidelines in relation to medical devices and specify an appropriate system for enforcing various standards notified under this Act;  Provide for a mechanism for conformity assessment using direct or third party notified bodies  Notify the method of

conformity identification by assigning marks or other means  Specify the requirements pertaining to conformity assessment of imported medical devices, refurbished devices, date expired devices, custom made devices and other special cases  Stipulate the procedure and guidelines for testing laboratories and referral testing laboratories and notification of the same;  Provide for the exchange of information among the notified bodies and other enforcement authorities;  Prescribe methodology for implementing and operating a vigilance and post-market surveillance system and taking preventive and pro-active measures  Provide for enforcement of the various provisions stipulated in the law and those relating to offences  Stipulate the manner and procedures for risk management and risk benefit analysis. The duty of the regulatory body should also be to:  Provide scientific advice and technical support to the Central Government and the State Governments in matters of policy and principles in areas which have a direct or indirect bearing on medical device safety and efficacy;  Search, collect, collate and analyse relevant scientific and technical data


STRATEGY particularly relating to:  hazards with the use of

medical devices  the exposure of individuals

to risks related to the use of medical devices;  incidence and prevalence of risks associated with medical devices;  identification of emerging risks; and  introduction of effective alert system;  Promote, co-ordinate and issue guidelines for the development of risk assessment methodologies and monitor, conduct and forward messages on the risks associated with medical devices to the Central Government, State Governments and other enforcement agencies;  Provide scientific and technical advice and assistance to the Central Government and the State Governments in implementation of crisis management procedures

To consolidate laws related to medical devices and for establishing and maintaining a national system of controls relating to quality, safety, efficacy and availability of medical devices that are used in India, whether produced in India or elsewhere, a regulatory body under the regulatory law is a must with regard to medical device safety and to draw up a general plan for crisis management and work in close co-operation with the crisis units set up by the Central Government in this regard;  Promote networking of national and international organisations within and outside India with the aim of facilitating scientific cooperation, co-ordination of activities, exchange of information,

implementation of joint projects and exchange of expertise;  Provide scientific and technical assistance to the Central Government and the State Governments for improving co-operation with international organisations;  Take all such steps to ensure that the public, medical professionals and interested parties receive rapid, reliable, objective and comprehensive information through appropriate

methods and means;  Provide, whether within or

outside their area, training in medical device safety and standards for persons who are or intending to become involved in medical device businesses, whether as entrepreneurs or employees or otherwise;  Contribute to the development of national/international technical standards for medical devices;  Contribute, where relevant

and appropriate, to the development of agreements, national or international, aimed towards standardisation of metrology relating to medical devices;  Support international efforts to improve and harmonise standards relating to medical devices and regulatory practices;  Promote consistency between international technical standards and national medical device standards while ensuring that the level of protection adopted in the country is not reduced; and  Promote general awareness as to medical device safety and medical device standards.  Provide guidance and support to industry to understand and comply with the regulatory requirements To sum up, a regulation in this area of healthcare will help patients and the doctors alike.

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BSc Community Health vs MBBS in India’s rural healthcare system A medical officer, an auxiliary nurse midwife and an accredited social health activist form the backbone of India’s rural healthcare system: B.Sc. (Community Health) graduates have no place and they are a cure worse than a disease, opines Dr Araveeti Ramayogaiah, FounderOrganization for Promotion of Social Dimensions of Health (OPSDH) and Former Additional Director of Health, Andhra Pradesh

Policiesf rchange INDIA LIVES in villages. India’s MBBS doctors are averse to step in there! India thinks in terms of alternative professionals to its rural population and that is the reason why a B.Sc. Community Health course was approved by the UnionCabinet. According to census 2011, of the 121 crore population in India, 83.3 crore people live in the villages. India’s public sector rural healthcare (RHC) consists of a sub centre (SC) for every 3000 to 5000 population and a primary health centre (PHC) for every 20,000 to 30,000 population and an Accredited Social Health Activist (ASHA) for every 1000 population. A SC is the peripheral out post. It is an interface with the community at the grassroot level. It is manned by two female multipurpose health assistants (MPHAs) and one male MPHA. Before launching of MPHW programme, the designation of female MPHA was Auxiliary Nurse Mid Wife (ANM). They are called as Front line Health Workers. Most of the curative, preventive and promotive services are provided at the SC level. A PHC is the corner stone of Rural Health Services, the first port of call to a qualified public sector doctor in the rural areas. The model emerged as the outcome of the 1946 Bhore committee, 1962 Mudaliar Committee, 1973 Kartar Sing Committee, 1975 Vastav Com-

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mittee, 1983 National Health Plan and 2005 National Rural Health Mission (NRHM). A PHC is manned by a Medical Officer (MO) with a team of nursing and paramedical personnel. MO is the custodian of health for 30000 and odd population and is the leader of a team comprising about 40 to 50 staff. MO can make or mar the PHC. An ASHA is an addition from NRHM. An ASHA is the replication of China’s Barefoot doctor and the WHO’s Community Health Worker (CHW) programme implemented by several nations in the 80s. MO, ANM and ASHA form the backbone of Rural Health Care. A MO at cephalic end leads, an ANM at the middle delivers and an ASHA at caudal end liaisons with the community. This is the best model in the world and envy of many nations. If this model is failing to deliver, there is something wrong in the implementation. Tinkering in any form and adding new cadres is not a remedy and is a disaster. As per the Rural Health Statistics (RHS) 2011, we have 1,48,124 SCs and 23,887 PHCs and are short by 35,762 SCs and 7048 PHCs for 83.3 crores of rural population (68 per cent of total population as per census 2011). The sanctioned medical officer posts are 30051 and 26329 are in position. India produces about 45,000 MBBS doctors annually. 70 per cent of one year output is more than enough to man all the PHCs. India’s Medical Council register has about seven lakh registered MBBS doctors!

Aspiration of young MBBS grads in the 70s “After how many years of graduation in MBBS, do you get the job?” was the usually question faced by every MBBS student when I joined medical school in 1968. The stock answer by every student used to be – “After five to six years!” Doctors with five to six years of standing practice used to jump to work as a Medical Officer of PHC despite earning twice or thrice as much as a MO. A MO is a born Gazetted Officer and is a very glamorous post. It is a prestigious position in society. The aspiration of 80 per cent of MBBS students during the 70s was to settle as general practitioners in their native vil-

lages. The leading politicians of Andhra Pradesh, late Dr YS Rajasekhara Reddy, Dr DL Ravindra Reddy and Dr MV Mysora Reddy practised in their villages before joining politics. Distinction students and gold medallists also settled at MBBS. Students who could have easily got a PG seat also used to settle for basic qualification. Alas, now no where in the country an MBBS is starting a clinic for general practice. The irony is that policy makers of our country think in terms of starting new speciality courses in general practice. In that scenario what is the role of a MBBS doctor?

The need of the hour In India, health is always talked in terms of medical colleges, GDP, doctor population ratios etc. India does not talk health in terms of infant mortality rates (IMR), maternal mortality ratios (MMR) and life expectancies. In India health means medical care. The word ‘health’ very often misused for the word ‘medical’. India thinks in terms of expanding medical colleges to meet the demands of rural areas for doctors. In our country, it is easy to get a medical college than a functional sub centre. Two years back, a leading English weekly asked a famous, highly revered

India does not talk health in terms of IMR, MMR and life expectancies. In India health means medical care.

doctor to write an article on health needs of the country for its New Year issue! The core content of his article was the need to create more opportunities for MBBS for becoming specialists! My curiosity on the content of the article dried down immediately after reading! I actually looked for solutions to reduce IMR and MMR from the article! A south Indian state in India brought an NRI and appointed him as a Chairman to study and recommend changes needed for improvement in healthcare. Isn’t an Indian medical professional with wide exposure and success behind him/her the right person to do that job? Paramedical staff play a crucial role in rural health and medical care. However, the state does not take them into confidence during policy making. Small pox eradication is due to their committed work and sacrifices. Due to their hard work, India is free from the endemic of poliomyelitis. An ASHA is capable of diagnosing deadly falciform malaria and initiating treatment within 15 minutes, a great public health revolution. But, as the medical officers do not lead them, they do not work adequately. They don’t have a role model to follow and the net result is all round dysfunction. It is not at all difficult to position a MBBS at PHC. Without changing the model of medical education, we can’t improve medical care. We should have proper policy on creating MBBS and their deployment. “Make up your mind how many doctors the community


STRATEGY needs to keep it well. Do not register more or less than this number; and let registration constitute the doctor a civil servant with a dignified living wage paid out of public funds,” said George Bernard Shaw in ‘The Doctor’s Dilemma’. Is it not relevant to Indian situation for policy making on today? Alas, hundred years after ‘The Doctors Dilemma’, we could not grasp what Shaw said.

Recommended measures A single window policy of recruitment with a fixed tenure at remote PHC, plain area PHC, upgraded PHC, PG opportunity, career advancement to every MBBS is the right policy to tide over the crisis. Compulsion or coercion to work in rural areas as a student is unethical and irrational. In no other profession, students are insisted to work in rural areas. Rural people also require experienced doctors. Their lives can’t be left to raw, inexperienced doctors who are continuously replaced by a new batch every year. Doctor patient relationship is not one of short term but is one of sufficiently long term. MBBS belongs to the nation. MBBS is the outcome of blood and sweat of people of the nation. They are not sacrosanct and people are not untouchables! The irony is that people are also getting alienated from the PHCs by themselves and resorting to their own solutions! State is a myth for them!

B.Sc Community Health MBBS can’t be substituted with any other cadre. After brooding over Bachelor of Rural Medicine and Surgery (BRMS) ad Bachelor of Rural Health Care (BRHC), the union cabinet settled on B.Sc. community health much against the wishes of ‘The Parliamentary standing committee on Health’. Any alternative to MBBS is a cure worse than disease. Alas, many elitists are supporting this! It is discriminatory. The early reports suggest that the proposed graduates will be positioned at SCs. The reports also indicate that they form an intermediary cadre between MO and ANM. It is also given to understand that they

play a role in promotion of and protection of health. The proposed graduates can’t be a substitute for MBBS at PHC. The SCs are already manned by two female MPHAs and one male MPHA. This is foolproof and working well. There is no role for these new graduates at SC level. There are several intermediary cadres already in the system between MO and ANM viz.,

Multipurpose Health Supervisors (MPHSs), Multipurpose Health Extension Officers (MPHEOs), Public Health Nurses (PHNs), Health Educators (HEs) and Community Health Officers (CHOs). There are already other cadre of professionals existing with 3 to 3 ½ years formal training. They are B.Sc nurses and general nursing midwifery trained nurses. The proposed graduates face

career advancement problems with existing cadres. The new graduates can’t be designated as CHOs as such a cadre already exists and is a Gazetted Post. India’s private and corporate sector doesn’t employ them. Every health functionary is an inherent promoter and protector of health and there is no role for the proposed new cadre to play such a role. The new cadre definitely do not opt

to settle in private practice and even if they want they are not eligible. In this country everyone except modern medicine doctors visualise a career in a government service. The new cadre is an economic burden without tangible results in commensuration with the efforts and investments. This may lead to a new brand of unemployed graduates who will be an organised pressure group on the state. Traditional practioners in India is a reality as along as professionally trained persons do not go to the community. Quackery or glorified quackery or quackery by scientifically trained persons or quackery to benefit corporates continues to exist and survive in this country as along as the present economic model exists. Let wisdom dawn over the state so that it does not burden people of this country with another cadre! What we think as unacceptable today are summation effects of at least three decades of misdeeds committed by most of us. Trying to tinker without going into roots is escaping from truth and avoiding reality. Tinkering at best gives minimal transient and apparent results and at worst destroys or reverse already achieved progress. In a running kleptocracy, morbid individualism and crony capitalism, many refuse to agree and even listen to this. Indeed it is an unfortunate phase of our times! “Build healthcare systems based on principles of equity, disease prevention and health promotion. Strengthen public sector leadership in equitable health care systems financing, ensuring universal access to care regardless of ability to pay. Invest in national health work forces, balancing rural and urban health workers density” are some of the key recommendations of WHO report on closing the gap in a generation. Let our policymakers rise to the report! The author was also Former Medical Consultant - Indian Institute of Health and Family Welfare- Hyderabad and Former State Coordinator, Breastfeeding-Promotion Network of India, Andhra Pradesh

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Government health schemes: Challenges and the road ahead Dr Mukesh Batra, Founder & Chairman, Dr Batra’s Healthcare, says that the challenges faced by the healthcare sector, from the need to improve infrastructure to ensuring the availability of trained medical professionals, are substantial

Policiesf rchange DESPITE AN incredible growth in recent times, the Indian healthcare sector can be described as a paradoxical one. On the one hand, the country boasts of ‘best in class’ healthcare delivery attracting medical tourists from across the world, while on the other, there is a near absence of accessible and affordable quality healthcare for a large part of its population, especially in the rural areas. The challenges the sector faces are substantial, from the need to improve infrastructure to ensuring the availability of trained medical professionals and from the necessity of providing health insurance to increasing health awareness amongst people. Let us analyse these challenges first to understand the future roadmap for better healthcare.

Low spending on health: a major reason for severe health consequences India’s health system failures can be majorly attributed to low levels of health spending. Despite increased spending in recent years, according to the statistics of the World Health Organization (WHO), in 2011, India has spent only 3.9 per cent of gross domestic product (GDP) on the health sector which is the lowest amongst the BRICS (Brazil, Russia, India, China, South Africa) member countries. Even countries like Pakistan and Bangladesh spend more on healthcare than India. Moreover, amongst the BRIC nations, in 2011, Russia’s out-ofpocket expenses stood highest at

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87.9 per cent closely followed by India (86 per cent), China (78.8 per cent), Brazil (57.8 per cent), and South Africa (13.8 per cent). On the other hand, these expenses in developed economies like the US and the UK were comfortably poised at 20.9 per cent and 53.1 per cent respectively. Low spending on health is the major reason for severe consequences in India where majority of the population lives below the international poverty line and an even greater proportion of the population rely on public health facilities.

Shortage of trained manpower and quality infrastructure According to a report by the United Nations, 75 per cent of the infrastructure and manpower in India is concentrated in urban areas where only 27 per cent of India’s population lives. The rural population of India is around 716 million people (72 per cent) and yet there is a chronic lack of proper medical facilities for them. Shortage of doctors and specialists and other support staff is one major reason for poor healthcare delivery in rural India. There is only one doctor per 1,700 citizens in India. The World Health Organization (WHO) stipulates a minimum ratio of 1:1,000. While the Union Health Ministry figures claim that there are about 6-6.5 lakhs doctors available, India would need about four lakhs more by 2020. While shortage of doctors, nurses and support staff is one problem, their unwillingness to work in the rural areas is another. Though government takes initiative in posting doc-

are not equipped to handle critical cases and several hospitals lack even basic facilities. For example, more than half of the primary healthcare centres (PHCs) across the country have less than four beds or a functional operation theatre. Very few PHCs (12 per cent) have an electricity connection and even fewer are equipped to provide emergency obstetric care.

Lack of insurance cover

tors in rural areas, where it fails is in getting it implemented, as doctors take least interest in working in rural conditions. Furthermore, while China has 30 hospital beds for every 10,000 people, India has only 12. The figures are even more alarming when looking at nurses: there are 98 nurses per 10,000 people in the US, and in India there are only 13. In fact, to reach the WHO’s prescribed standard of 35 beds per 10,000 people, India would need to add six million beds by 2028. One of the major reasons cited for failure of various government schemes for better healthcare is that to take benefit of government schemes, the beneficiaries have to opt for government hospitals or health centres. However, many hospitals

A widespread lack of health insurance compounds the healthcare challenges that India faces. It has been estimated that only 11 per cent of the population has any form of health insurance coverage. Although some form of health protection is provided by government, the health insurance schemes available to the Indian public are generally basic and inaccessible to most people.

Poor implementation of policies and regulations The key to success of any regulations and schemes run by the government is implementation. In India, state governments possess primary responsibility for public health and sanitation. As there are several states and diverse health schemes for each state, efficacy of any scheme depends on how successfully it is implemented by different states’ authorities. For eg. Rashtriya Swasthya Bima Yojna

The key to success of any regulations and schemes run by the government is implementation

(RSBY) may have been exceptionally successful in other states but it seems to have fallen flat on its face in Maharashtra. The Ministry of Labour is contemplating whether to continue the national health insurance scheme in its present form in the state. Thus, implementation plays an important role in success of any scheme.

Poor sanitation and hygiene According to a survey conducted by Dasra, a strategic philanthropy foundation, over 50 million people in urban India defecate in the open every day. 66 per cent of the women in Delhi slums are verbally abused, 46 per cent are stalked and more than 30 per cent are physically assaulted while accessing toilets. 80 per cent of India’s surface water pollution is on account of sewage alone. Around 4,861 of 5,161 cities across the country do not have even a partial sewerage network. There is an adverse impact of poor sanitation and hygiene on various aspects including the environment, economics, education and more importantly health. Diarrhoeal diseases are the primary causes of early childhood mortality. These diseases and several others can be attributed to poor sanitation and inadequate safe drinking water in the country. Diseases such as dengue fever, hepatitis, tuberculosis, malaria and pneumonia continue to plague India due to increased resistance to drugs. In 2011, India developed a totally drug-resistant form of tuberculosis. India is ranked third highest among countries with the amount of HIV-infected patients.


STRATEGY Lack of awareness and health education In 2012, India was polio-free for the first time in its history. This was achieved because of the Pulse Polio Programme started in 1995-96 by the government of India with support from Rotary International. A lot of credit for this success can be attributed to awareness created amongst people regarding polio through various promotional and educational campaigns. Thus education plays an important role in spreading awareness regarding health, wellness and sanitation. Educating woman in particular is extremely important, as an educated woman can take care of hygiene and sanitary issues of her family. People also need to be educated enough and aware of the benefits of health services, like institutional delivery and immunisation programmes. Lack of education and awareness has resulted in epidemic of HIV/AIDS which has become one of the greatest social challenges. The Government has mapped out a number of remedial measures for its prevention and treatment, but its outreach and effect has been limited. Sex education and awareness is extremely important in controlling HIV and other related disorders. India needs to spend more on educational and awareness campaigns. UK spends an estimated two million pounds on its no-smoking campaigns, whereas India spends a dismal amount on such campaigns, which play an important role in health education.

Poor access to medicines A recent market research showed that only 25 per cent of the Indian population has access to conventional medicine, which is practised mainly in urban areas, where two-thirds of Indiaâ&#x20AC;&#x2122;s hospitals and health centres are located. Many of the rural population rely on alternative forms of treatment and several do not have access to even basic health amenities. With so many challenges impeding the growth of Indian healthcare sector, it is evident that though a huge amount of money was spent by the government on various health

schemes, they did not perform as expected. To some extent they did help make healthcare accessible to the rural population and eradicate some threatening medical conditions, they failed to deliver intended results, the proof of which is poor physical infrastructure, rising health concerns and inadequate human resources in rural India.

Why did the health schemes fail? The Government of India launched several programmes to improve the healthcare in the country. Amongst several schemes launched some noteworthy are National Health Mission (NHM), Central Government Health Scheme, National Health Insurance Program and National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke. Most of the schemes related to alternative medicine systems had been initiated during the 9th Five year Plan, a majority of which relate to strengthening essential central institutions in medical education, healthcare, quality of medicine and research in complementary medicine. The failure of many such schemes can be attributed to Indiaâ&#x20AC;&#x2122;s health policy failures because whatever little is spent on health is not used effectively. It is equally clear that awareness and understanding is a significant challenge when it comes to rolling out large flagship

schemes in a manner that the benefits of the scheme reaches those it is meant to. Over and time again it has been proved that non-transparency; no accountability and bureaucratic failures plague health service delivery in India, particularly in the poor states. Continuous monitoring and audit of health schemes implementation is imperative for better healthcare delivery. Tough laws on health are required and they need to be effectively implemented. For example, a strong no alcohol and no tobacco policy can help in eradicating health and social concerns due to alcohol abuse and smoking.

Road ahead for better healthcare Looking at health in its holistic form is important to achieve healthcare objectives. Health problems cannot be addressed in isolation, as they are related to several other factors. At the individual as well as

Looking at health in its holistic form is important to achieve healthcare objectives

the national level, it is important to control environment as well as water pollution, as it leads to spread of several threatening health disorders. Mental health awareness can lead to decline in number of suicides due to depression and other reasons. Similarly, physical health awareness and education regarding hygiene and sanitation can help prevent several diseases. Furthermore, to ensure maximum outcome, policies and regulations should be developed on the basis of the learning of all available systems, the strengths as well as lacunae in existing schemes and needs of individual states. Also, people need to be properly directed towards taking benefit of health schemes. The policymakers might also analyse how other emerging countries, such as Brazil, have addressed their healthcare needs. Transforming a healthcare system needs to be driven by consistent political leadership over a sustained period. Creating universal access to medicine has to be the primary focus, with a secondary focus on efficiency or quality. Government also needs to balance between focusing on increasing funding for programmes such as national insurance, and concentrating on providing better infrastructure, such as more hospitals and clinics, and increasing recruitment. There should be an increased

and a far closer partnership between the public and private sectors. Last but definitely not the least, I would like to suggest adoption of alternative medicine, in particular homoeopathy by the government as a means to reach reliable and cost effective healthcare to rural India. Urban India too needs homoeopathy. Rather than running to separate specialists for each separate part of the body, what we need is holistic healthcare. What homoeopathy offers is safe, sensible and, cost effective healthcare. For eg., Union Cabinet recently sanctioned Rs 4000 crores for the treatment of Japanese encephalitis in Bihar and UP. On the other hand, during an outbreak of viral encephalitis few years back in Andhra Pradesh, one million people were given doses of the homoeopathy remedy Belladona and not a single person died in the epidemic. Moreover, the cost of treating them was just under Rs 10 lakhs. A little known fact is that homoeopathic medicine developed its popularity in the US as well as in Europe because of its success in treating the infectious epidemics that raged during the 19th century, much before antibiotics were developed. In 1849, the homoeopaths of Cincinnati claimed that in over a 1000 cases of cholera treated with homoeopathy, only three per cent of the patients died. To substantiate their results they even printed in a newspaper the names and addresses of patients who died or who survived. The success of treating yellow fever with homoeopathy was so impressive that a report from the US Government's Board of Experts included several homoeopathic medicines, despite the fact that the Board of Experts had many conventional physicians who despised homoeopathy. Conclusively, the objective of medical practitioners must not be to profit from disease. Ultimately our attitude towards medicine is defined by what we consider our goal â&#x20AC;&#x201C; do we want more doctors, more medicines and more hospitals or simply less disease? In my opinion, this is one case where less is definitely more.

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STRATEGY I N T E R V I E W

‘We need linkage between people's knowledge, practitioner’s knowledge and researcher's expertise’ It is a known fact that India needs innovative strategies and technologies to make healthcare affordable and accessible to every citizen. However, the question that arises is how far have we reached in this journey? Raelene Kambli quizzes Prof Anil Gupta, Founder of Honey Bee Network and Executive Vice Chair, National Innovation Foundation, Government of India to understand the kind of innovation that Indian healthcare currently requires Excerpts...

According to you, is India on the path of innovation in healthcare? No, it’s a definite no! If it was, then so many innovators would be developing diagnostic or palliative devices or surgical devices. New therapeutic approaches would not have been struggling for support for science validation, value addition, testing, clinical trials etc. There are three inadequacies in the innovation ecosystem for healthcare:  Existing innovations which are rising, inspired out of the system, are not being leveraged and supported both from a policy and institutional perspective except to some extent in the biotechnology space, thanks to Biotechnology Industry Research Assistance Council (BIRAC);  We are yet to start using distributed knowledge platforms like techpedia.in for collaborative, open, and modular technology development and dialogue,  Extremely affordable

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service delivery models that have been developed in eye care, heart care are not being replicated due to lack of sufficient policy and institutional support. Healthcare innovations are extremely crucial for those whose entire savings of last few years may evaporate in a single adverse episode. The preventive and synergistic healthcare streams combining AYUSH and allopathic systems are not on the radar of the policymakers. Whatis the kind of innovation that India currently needs? India needs innovations that meet three criteria: affordability, accessibility and availability. It is possible to do so. We have extremely cost effective mocks like:  dialhealth.com  Gandhian Young Technological Innovation Awards’ winner “Chetna” - a device developed for tracking pregnancy developed at IIT Guwahati,  Non invasive haemoglobin measuring device by

myshkin,  Threenethra that diagnose

The triggers for innovation exists all around and many doctors do innovate. But many are busy treating patients and don't get time to document their creative experiences

more than five ailments of eye at a very low cost,  Other winners include qualitative diagnostic test for Vitamin B12 within fifteen minutes, etc. Many of the examples, I have mentioned above (like techpedia.in/GYTI award winner) are at the proof of concept stage. They need to be taken to the prototype, product and utility stages. There is no funding for these fledgling entrepreneurs and innovators. We can expand the innovation spectrum in healthcare very soon by throwing challenges to young technology and management students to harness their vitality and irreverent attitude toward change. Everyone talks about inclusive healthcare in India, however there are umpteen challenges involved. Do you think that these challenges call for a rethink about every link in the healthcare chain? Yes, we need to learn to make tradeoffs sometimes between accuracy and

affordability. Let us take a hypothetical case where there are two drugs available for a particular illness. One of them costs Rs 100 a month and gives 80 per cent relief without any significant adverse side effect and another drug for the same ailment gives 95 per cent relief but costs Rs 1000 per month. Should only the first drug be developed and allowed to be released? The whole regulatory system is designed on a Western model where the healthcare system is broken. We need to develop our own healthcare goals and approaches for solving national problems. Many times, we don't realise that when we bring a disease or disorder under 80 per cent control, say a threshold value, then remaining control may be achieved by the autoimmune system. We must work with nature and not against it. Likewise, the role of functional foods grown in mineral rich soils in rain fed regions must be looked at afresh. Food and nutrition


STRATEGY

are getting attention but cooking in a cast iron vessel is not popularised still to overcome iron deficiency. Knowledge networks among doctors are yet to be developed as are disciplines and super specialties. Every medical intern during rural service or urban slum service must be asked to make an inventory of unmet healthcare needs as well as grassroots innovations. This will help in reorienting the medical education as well as practice. How else can we explain wide prevalence of horizontal posture delivery tables when squatting position is known to be far more convenient for mothers and a fact that has been known in Indian tradition for ages. There has to be a complete rethink across all links in the healthcare value chain. What else is important to

We need open innovation platforms, challenge awards like X-prize, reforms in curricula to increase awareness about innovation, intellectual property rights as well as open source solutions, collaborative learning, linkage between formal and informal grassroots sector, engagements with patients who can contribute towards innovations and a regulatory system which stimulates innovation and not stifle it understand in this regard? The triggers for innovations exist all around and many doctors do innovate. But many are busy treating patients and don't get time to document their creative experiences. Same is true of many hospitals. We need open innovation platforms, challenge awards like X-prize, reforms in curricula to increase

awareness about innovation, intellectual property rights as well as open source solutions, collaborative learning, linkage between formal and informal grassroots sector, engaging with patients who can also contribute towards innovations and above all, a regulatory system which stimulates innovation and not stifle it. Holistic medicine, systems

biology approach and blending different pathologies are also essential. What innovative strategies are needed to make inclusive healthcare ; especially in the primary care sector? We need linkage between people's knowledge, practitioner’s knowledge and researcher's expertise without too many barriers and

with considerable mutual respect. We also need risk funds to encourage young inventors and innovators. Overall context of health, hygiene, food, nutrition, lifestyle and socio-cultural context of happiness needs redefinition. How can we make this possible? Well, we need to expand the usage of techpedia.in, upload all medical thesis abstracts on it, and encourage dialogue on that site. Culture specific challenges are then open to practitioners and youth. The curriculum should incorporate indigenous examples of innovations and corporations should contribute towards creation of creative, collaborative, compassionate and caring ecosystems. raelene.kambli@expresshealthcare.com

CONTRIBUTOR’S CHECKLIST ●

Express Healthcare accepts editorial material for the regular columns and from pre-approved contributors/ columnists. Express Healthcare has a strict non-tolerance policy towards plagiarism and will blacklist all authors found to have used/referred to previously published material in any form, without giving due credit in the industryaccepted format. As per our organisation’s guidelines, we need to keep on record a signed and dated declaration from the author that the article is authored by him/her/them, that it is his/her/their original work, and that all references have been quoted in full where necessary or due acknowledgement has been given. The declaration also needs to state that the article has not been published before and there exist no impediment to our publication. Without this declaration we cannot proceed. If the article/column is not an original piece of work, the author/s will bear the onus of taking permission for re-publishing in Express Healthcare. The final decision to carry such republished articles rests with the Editor.

Express Healthcare’s prime audience is senior management and professionals in the hospital industry. Editorial material addressing this audience would be given preference. The articles should cover technology and policy trends and business related discussions. Articles by columnists should talk about concepts or trends without being too company or product specific. Article length for regular columns: Between 1300 - 1500 words. These should be accompanied by diagrams, illustrations, tables and photographs, wherever relevant. We welcome information on new products and services introduced by your organisation for our Products sections. Related photographs and brochures must accompany the information. Besides the regular columns, each issue will have a special focus on a specific topic of relevance to the Indian market. You may write to the Editor for more details of the schedule. In e-mail communications, avoid large document attachments (above 1MB) as far as possible.

Articles may be edited for brevity, style, relevance. Do specify name, designation, company name, department and e-mail address for feedback, in the article. We encourage authors to send a short profile of professional achievements and a recent photograph, preferably in colour, high resolution with a good contrast.

Email your contribution to: viveka.r@expressindia.com Editor, Express Healthcare

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IT@HEALTHCARE

Effective IT policies to save lives Rahul Mattoo, GM & Head, HLS, Wipro, elucidates on effectively implementing IT to ensure universal healthcare and opines that the Centre should formally legislate healthcare-IT/e-Health policies

Policiesf rchange THE OPENING up of the Indian economy by what is popularly known as LPG (Liberalisation - Privatisation and Globalisation) during the early nineties heralded a spell of unprecedented economic growth in India. The growth rates witnessed tallied and often exceeded those of the fastest growing economies, the result of which was a confident and resurgent Indian industry making forays into almost all the sectors of economy. Healthcare has also witnessed a steady growth in investment, budgetary spending, employment and proportionate improvements in outcome, including clinical outcomes. Technology in the last two decades has revolutionised the way healthcare is delivered worldwide. It has greatly aided patients and providers alike by enhancing the quality of delivery, reduction in turnaround time of work-flows and thus the overall cost, besides bringing in higher accountability into the system. Advancements in medical science and technology are playing a positive role in saving lives. The influence of medical technology is all pervasive - its positive impact is not only limited to the upper crust of society but has also helped the not so privileged sections. A quantum jump is being planned during the 12th five year plan period, with sizeable increase in budget and a slew of policy and programme initiatives. 12th five year plan has

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recognised health as the top priority sector with the High Level Expert Group (HLEG) recommending universal healthcare (UHC) for all citizens through budgetary support (as a means of healthcare financing) – by increasing the current support level of ~ 1.2 per cent to 2.4 per cent by the end of 12th plan and to three per cent by 2022. The ten guiding prinicples for the formulation of these recommendations

for introducing a system of UHC in India: (i) universality; (ii) equity; (iii) non-exclusion and non-discrimination; (iv) comprehensive care that is rational and of good quality; (v) financial protection;(vi) protection of patients’ rights that guarantee appropriateness of care, patient choice, portability and continuity of care; (vii) consolidated and strengthened public health provisioning; (viii) accountability and trans-

parency; (ix) community participation; and (x) putting health in people’s hands. Each of these principles can be leapfrogged to achieve their respective goals with assistance of IT systems. Centrally funded agencies like Employees' State Insurance Corporation (ESIC), armed forces and state governments have implemented solutions around healthcare and this is the very reason to believe


IT@HEALTHCARE

that what is happening in a few of these initiatives can be replicated for a seamless, integrated state-wide and nation-wide e-Health, as is being attempted by a large number of countries worldwide. It is possible for India too to move in that direction, if measured and implementable steps are initiated. Some of the core policies which government has already set their eyes on or on the path of the same are the following:-

Digital signature Digital signature enables the subscriber to authenticate the electronic record created by the person. It is bound cryptographically to an electronic identity, to an electronic document and the digital signature cannot be copied to another document. Digital signature can be a good replacement for traditional system of ink signature and can be used widely specifically in healthcare where acceptance of the same should be legalised as per section 13-14 and 15 of the Information Technology Act, 2002. This would enable widespread use of IT applications/EMR across the hospital for clinical usage by clinicians and nurses. This would make the legally required case sheets-flow sheets redundant and hence a giant leap towards acceptance of patient centric EMR.

Standards Despite healthcare innovation we are falling dangerously short of providing and accessing consistent quality healthcare due to our inability to get data spread across varied island of information systems, spread across care system ranging from sub centres, PHCs, tertiary care to private hospitals. This information loss is extremely costly, both economically as well as loss of life. The Ministry of Health has recognised this and set up a committee to recommend standards around data security and privacy-disclosure standards, interoperability standards and data ownership standard. Unfortunately it

The government should formally legislate healthcare-IT/e-Health policies as a central subject with delivery of care still being a state subject has no real teeth to implement the same across the country; hence these gaps or shortcomings have to be filled up byrequired legislation and guidelines for implementations of the same. One of the easiest ways to is achieve this is by enacting regulations and certifications of software products dealing with hospital information system /EMRs. This will ensure the usage of these standards in vendor products and services.

Direct Benefit Transfer for healthcare While Aadhar is getting to

be the most viable option of authenticating and validating the direct benefit transfer (DBT) and currently covers three areas of work â&#x20AC;&#x201C;student scholarship, LPG subsidy and national child labour, it should be extended to healthcare as well. One such well known example is Brazils-Bolsa Familia, families below a particular income threshold are provided grants on fulfilling certain conditions like attendance at government clinics and 85 per cent school attendance. This would bring in a paradigm shift from hospital-based care to preventive care empow-

ered for the patient and by the patients assisted outcomebased DBT. While the responsibility for the delivery of healthcare services rests largely with the State Governments, the Central Government sets policies, provides resources and oversees overall progress in the sector as a whole, including that of nationally formulated programmes. Instead the government should formally legislate healthcareIT/e-Health policies as a central subject and should be the driving force for the same across the state, with delivery of care still being a state subject.

Wipro syndicated a study with Dun and Bradstreet (D&B) titled Future Thought of Business (FTOB): Healthcare. It identifies key drivers that reinforces the future imperatives of this business: Q Increasing penetration of both private insurance and Government health insurance schemes will bring more people under the healthcare net and will drive demand for preventive healthcare services Q The demand for healthcare services will be driven by both urban and rural markets in the coming decade with a distinct shift towards life styles and chronic diseases. Q The attractiveness of the Indian market will entice more foreign players through capital investments and technology tie-ups across various segments such as hospitals, diagnostics, medical equipment etc. Q High operating costs in the metro cities and fear of oversupply will drive more healthcare companies to increase their focus on the untapped smaller towns Q The growing medical travel sector in India will benefit from rising cost burden of national healthcare system in the developed economies. Q Large number of single speciality hospitals will come up especially in Indiaâ&#x20AC;&#x2122;s tier II and tier III cities driven by rise in local incomes and awareness level, in areas of heart, cancer, ophthalmology, maternal â&#x20AC;&#x201C;child care, and cosmetology. Q The need to optimise costs and increase efficiencies will make IT an integral part of hospital management.

References 1:- Planning Commission Report:-planningcommission. nic.in/reports/genrep/rep_uhc2111.pd 2. Department of Telecommunications-Government of Indiawww.dot.gov.in/act-rules/information-technology-act-2000? 3. Standards CommitteeMinistry of Health and Family Welfare

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IT@HEALTHCARE I N T E R V I E W

‘Emerging markets continue to move the needle for innovative ways to decrease costs, improve quality’ Dell is looking to leverage its leading position in the global healthcare provider space, to maximise its potential in the India healthcare market says Dr Cliff Bleustein, Managing Director and Global Head - Healthcare Consulting, Dell Services. In conversation with Viveka Roychowdhury, Dr Bleustein explains how innovation will continue to help drive costs down as organisations look to change the current care delivery system and also highlights how systems like Dell’s new cloud-based Hospital Information System (HIS) solution, will create an inclusive model for healthcare solutions within India

According to a report by Frost and Sullivan, India's healthcare information technology (HIT) market is expected to hit $1.45 billion in 2018, more than three times the $381.3 million reached in 2012. India's corporate healthcare chains may well be on the way to adopting state-of-the-art HIT systems but does Dell have any IT solutions for Tier II & III cities? Dell is actively investing to create healthcare solutions that are aligned with the macroeconomic dynamics of it key target markets. With over 70 per cent of India’s population living in rural areas, Dell’s objective is to create accessible solutions that support organisations in their IT and business goals. An example of this is Dell’s new cloud-based Hospital Information System (HIS) solution that delivers seamlessly integrated clinical and financial systems for hospitals and health providers in India. The solution will support core clinical tasks and back-end needs of providers

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and ensure smooth access and instant information availability. It is scalable, cost effective, widely accessible and flexible to suit the unique needs of Indian healthcare providers. How are Dell's solutions built to enable an inclusive rather than exclusive model of healthcare in India? For more than 25 years, Dell has played a critical role in transforming computing, enabling more affordable and more pervasive access to technology around the world. When it comes to healthcare this overarching strategy remains the same and Dell is applying the same principles to ensure we create an inclusive model for healthcare solutions within India. What is Dell's current market share in the global HIT sector? And specific to India? What is the target growth rate for the next couple of years? How is Dell positioned to become the HIT vendor of choice for India's healthcare sector

Handling healthcare in the second most populous country is not an easy task for anyone.Yet, India has been successful in eliminating diseases such as small pox and leprosy

vis-a-vis other competitors? Dell was ranked No.1 in Worldwide Healthcare Provider IT Services, based on revenue by Gartner in 2013. This represents the third year in a row in which Dell bagged this rating. With over 14,000 resources dedicated to healthcare worldwide, many of whom are based in India, Dell is looking to leverage its leading position in the healthcare provider space with its global reach, to maximise it potential in the Indian healthcare market. Like other nations, India's healthcare/hospital sector has lagged other sectors when it comes to adoption of IT. The Frost & Sullivan report mentions ease of integration with existing IT systems and time spent by doctors and employees during the implementation phase as the main concern/challenge. How is Dell responding to these potential legacy and downtime issues? Dell has invested heavily in its implementation

methodology called ADOPTS and processes to decrease the downtown associated with implementation of IT systems. We also use teams composed of both clinicians and technicians to allow for individuals with similar backgrounds and skill sets to assist in the various phases. As the Affordable Care Act, commonly known as Obamacare, rolls out in the US, what has been Dell's learnings from helping US physicians, hospital administrations and other stakeholders cope with these changes? This is the largest change to the healthcare market in the last 40 years. At a highlevel, Obamacare has accelerated the shift from feefor-service to account-able care. We also see cost pressures, market consolidation, and new payment models. Each of these impacts provider IT departments. We have seen clients increasing look to consolidate and rationalise their current applications,


IT@HEALTHCARE

upgrade their infrastructure to decrease total cost of ownership, increasingly outsource business processes and functions within their IT department, move more IT into the cloud, and seek out external guidance to improve operations, work flows, and processes. It took Obamacare to push the HIT implementation forward in the US but India has no such political/policy pushes for HIT. What will be/are the drivers for implementation of HIT in India? On the other hand, in spite of a stupendous growth of healthcare industry in India (with a CAGR of nearly 16 per cent over the last few years), the average IT adoption rate stands at a dismal five per

cent. Private healthcare in India plays a dominant role in delivery and has approximately 80 per cent share of healthcare spend. The drive for IT adoption will initially be fuelled by private organisations that want a competitive advantage for attracting patients to their facilities. Leading private organisations will want to differentiate themselves with higher quality, improved value, increased efficiency, and improved physician satisfaction which are all facilitated by enhance IT platforms. Lately, the Indian government has also realised the value of IT adoption for healthcare delivery, and stepped forward in developing standards for Indian HIT in 2013. Indiaâ&#x20AC;&#x2122;s Ministry of

Health and Family Welfare has developed an initiative to draft national EHR standards which created a guideline in August 2013 to encourage interoperability, HL7 and ISO standard adoption to capture a minimum standard for patient records. The objective of this initiative is to create a single record for a patient which will have patientcentric information, in chronological order, and can be shared at the national level with different providers. Like many emerging economies, India's healthcare sector struggles to cope with the huge disease burden, funding as well as infrastructure issues. Will cost be a barrier in India? Handling healthcare in the

second most populous country is not an easy task for anyone. Yet, India has been successful in eliminating or controlling certain diseases such as small pox, leprosy, polio, and TB. Indiaâ&#x20AC;&#x2122;s public health expenditure, as a percentage of GDP, is the lowest among BRIC countries. The latest Five-Year Plan (2012-17) has increased focus on public healthcare and increased the spending provision to 2.5 per cent. There are encouraging steps such as the national health insurance scheme, improving health access in rural areas, where close to 70 per cent population lives, and mid-day meal scheme in schools for improvement in public health. Innovation will also

continue to help drive the costs down as organisations increasing look to ways to change the current care delivery system. These changes have typically occurred in those areas that have the biggest need. While cost pressures occur in all economies, emerging markets continue to move the needle for innovative ways to decrease costs and improve quality. Has stakeholder mindset been an issue so far in India? All economies face challenges related to a diverse group of individuals who hold different perspectives around the delivery and financing of care. viveka.r@expressindia.com

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HOSPITAL INFRA FAQs ON HOSPITAL PLANNING AND DESIGN | MEDICAL EQUIPMENT PLANNING | MARKETING | HR | FINANCE | QUALITY CONTROL | BEST PRACTICE

ASK A QUESTION Is ‘healthcare management’ different from ‘healthcare administration’? SHELLY, Mumbai

Healthcare management and administration deals with the same tasks such as budgeting, marketing, meeting with stake holders, and dealing with several of hospitals in your given area, organising and managing the staffs that are through various departments. They also are in charge of orchestrating different rules and regulations in the processes of discipline, hiring, firing etc. through various hospital areas. Describe the evacuation tasks for ICU-based staff? DR PRAHLAAD, Allahabad

A disorganised evacuation can result in confusion, injury, and property damage. When developing your emergency action plan, it is important to determine the following: Q Clinical engineering Q Facilities management Q Hospital volunteers Q Housekeeping Q Pharmacy Q Patient transporters/escorts [intra-facility] Q Transport team if available on site [inter-facility] Q Social work How are standard operating procedures important in hospitals? DR REENA, Raipur

Standard operating procedure, if realised and materialised as a component of an effective management system, helps cultivate transparent functions, implement error prevention measures and facilitate corrective actions and transfer

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knowledge and skill. When it comes to the practice of medicine and pharma care, its relevance and importance becomes critical to ensure safety. SOP helps provide an efficient and quality service and having an efficient SOP in place minimises errors, clears the way forward by avoiding uncertainties, and serves as a vital tool to transfer knowledge and skill. How is model of care (MOC) helpful for the hospital, especially the emergency department (ED)? DR TRIPATHI, Pune

The information in each MOC will help the ED and hospital to understand: Q The key principles of the model Q The key requirements to operate the model Q Considerations to help understand why your ED would use the model Q Benefits and challenges of using the model Q The monitoring measures that can be used to assess the model effectiveness and success What are the benefits of forming a patient's flow team? DR PATHAK, Bhopal

The importance of creating multidisciplinary teams to plan quality improvement interventions. One of the benefits of a multidisciplinary team is that members will bring different perspectives and knowledge about problems, their underlying causes, and potential solutions. We recommend that, at a minimum, your team include a team leader (day-to-day leader), senior hospital leader (e.g., the chief quality officer), individuals with technical expertise related to the strategy, ED physicians

and nurses, ED support staff (e.g. clerks, registrars), a research/data analyst, and representatives from inpatient units. What is hospitality marketing? MR NAIR, Thane

Marketing is the activity, set of institutions and processes for creating, communicating, delivering and exchanging offerings that have value for customers, clients, partners and society at large. It’s a process for getting a company’s product or service out to customers. Hospitality marketing is how segments of the hospitality industry promote their products or services. Hospitality marketing management asserts that there are five components in what they call a hospitality marketing mix. Knowledge of all five components of the mix is helpful for managers who are developing marketing strategies. The five component are as follows: Q Product-service mix Q Presentation mix Q Communication mix Q Pricing mix Q Distribution mix

TARUN KATIYAR Principal Consultant, Hospaccx India Systems

Express Healthcare's interactive FAQ section titled – ‘Ask A Question’ addresses reader queries related to hospital planning and management. Industry expert Tarun Katiyar, Principal Consultant, Hospaccx India Systems, through his sound knowledge and experience, shares his insights and provide practical solutions to questions directed by Express Healthcare readers


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v Warm / Cold cycle facility

v Requires less foot print, stand provided to mount the unit.

v Operates on domestic power supply v Built in auto aeration facility v World class unique cartridge puncturing system, Automatic & Manual – both modes provided.

v Ready to use type, no special installation requirements. v Unique, fool proof door locking arrangement. v Manual & Semi Automatic Model available.

Kaustubh Enterprises A-6 Nutan Vaishali, Bhagat Lane, Matunga (West), Mumbai - 400 016. INDIA • Tel.: (022) 2430 9190 • Telefax: (022) 2437 5827 • Mobile: 98204 22783 • E-mail: rujikon@rediffmail.com / rujikon@gmail.com • Website: www.rujikon.com

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v Sterilization / Aeration in same chamber

v Does not need skilled personnel for its operations.

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BASIC OPTIMA & LIFE LINE HOPE

BASIC OPTIMA

LIFE LINE HOPE ANAESTHESIA MACHINE

Manufactured by

G S Health Care Products Pvt Ltd

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Bringing Innovations to Immunoassays

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Medical Grade

SILICONE TRANSPARENT TUBING

1 1

USFDA approved raw material of European origin Imported state of the art machine having the most advanced auto-curing system Excellent heat resistance (-50째C to 250째C) Odourless Completely nontoxic Repeatedly autoclavable

ied Certif om Cleanro

No leaching of particles Does not support bacteria growth Retains elasticity even after prolonged use Blue Heaven

1 1 1 1 1 1 1

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TRADE & TRENDS

Cervical cancer prevention: HPVvirus cannot escape anymore! Dr Dinesh Gupta, CureHealth Diagnostics Laboratory, New Delhi, talks on the ways and means to curb cervical cancer incidence in India

THERE HAS been unprecedented surge in our knowledge and understanding about cervical cancer during the past three decades, enabling us to charter a successful passage for its total prevention within our lifetime. The group of human papilloma viruses (HPVs), essentially transmitted through the sexual route, has been identified with considerably higher oncogenic potential that discounts almost every other critically known risk factor including multiple sex partners or early age for sex or oral contraceptive use or even smoking. This is a leading cancer in Indian women and the second most common worldwide, dubiously contributing over one third of the global burden, both in terms of annual incidence as well as mortality. Documented evidences indicate that almost 80 per cent of sexually active women acquire genital HPV by 50 years of age. Relying upon annual screening with pap test, the Western world was able to curtail the incidence of cervical cancer considerably in the last five decades but India could not draw any advantage owing to the lack of community screening, commensurate technical expertise, health consciousness, inappropriate national health policies and priorities as well as highly commercialised healthcare industry. Thanks to the rising middle class, the trend has been seen changing during the past decade. People are getting more concerned about their sexual health, which in its basic obligation, is

the crux of social health. Of late, going past the conventional pap test, a number of new-gen armaments have been added to deal with the latent phase of cervical precursor disease. This phase, spanning over few to several years, provides a greatest window of opportunity to plan its successful prevention. This is a clinically detectable phase with predictably identifiable characteristics, most commonly involving uterine cervix but also other organs of lower ano-genitalia of women and men alike. Therefore, most state-of-the-modern-care tools of cervical cancer prevention, such as early detection technologies or prophylactic and therapeutic vaccines are continuously being evolved around ceasing disease progression beyond this phase. The most advanced ammunition to this armament is HPV E6/E7 mRNA assay, popularly referred to as OncoTect in global references. This clinical assay combines fluorescence in situ hybridisation (FISH) with molecular diagnostics on the very sensitive flow cytometry technology platform. Going past HPV DNA detection that gives us risk assessment of the disease, identifying individual cells undergoing oncogenic activity due to HPV oncogenes gives us a real time status of the precursor disease. This knowledge is then most accurately verifiable through clinical procedures such as colposcopy or histopathology examinations, and helps to plan a successful disease intervention. The positive reports

HPV mRNA gives us nearly four-fold higher specificity to identify the active disease at an equal sensitivity as that of a DNA test thus indicate a current pre-cancerous disease which would put the woman at increased risk of developing cervical cancer. Conversely, the negative reports may indicate that the woman is healthy and may return to preventive health check-up in next five years, killing the anxiety around cervical cancer! The high-risk HPVs are known to induce chronic infections leading to oncogenesis without any observable viremia. The virus infects

the metaplastic basal keratinocytes of squamous tissue and integrates its DNA with host cell genome. The infected basal cells rapidly divide to carry infection in the upper parabasal layer where viral early oncogenes (E6 and E7) start to express viral particles in low copy numbers, to the order of 50 to 100 copies per cell. Active viral replication to above 1000 viral particles only takes place in the terminally differentiated superficial epithelial layers. Periodically large amounts of infectious virus are either cleared due to the death of terminally differentiated cells or shed for transmission to other naive individuals. Thus there is no viral induced cytolysis or cellular necrosis and no release of pro-inflammatory cytokine which could trigger antigen presenting cells (APC) to become activated. The immunity at this stage is largely reflected by the cytotoxic T cells as a part of host immune defence but is successfully evaded by the virus. Therefore, most HPV infections resolve within 8 to 10 months as a result of a successful cell-mediated immune response directed against early HPV proteins. At the advanced pre-cancer stage (CIN 2 and above) however, the viral clearance is rapidly overtaken by the viral oncogene expressed proteins making the oncogenesis progress in the forward direction irreversibly, leading to cancer development. Although most ano-genital HPV infections get resolved, about 10 per cent of individuals develop persistent infection

who go on develop high-grade cervical intraepithelial (CIN 2 and above). This is essentially characterised by the over-expression of HPV E6 and E7 proteins in dividing cells, exhibited in the form of chromosomal instability and the progressive ability to resist host immunity. Most clinical guidelines developed during 2012 suggest HPV DNA testing together with pap test for women above 30. Given the higher positive prediction of the disease, HPV mRNA testing offers us with a real time choice! While HPV DNA has an excellent sensitivity for detecting HPV infection for women potentially at risk of precancer disease, HPV mRNA gives us nearly four-fold higher specificity to identify the active disease at an equal sensitivity as that of a DNA test. Itâ&#x20AC;&#x2122;s like, leaving no scope for the virus to escape detection! Moving forward, a growing number of clinical researchers are reinventing gene therapy with mRNA and finding success in treating cancer as well as other diseases. Though the DNA forms a basis of genetic code, mRNA offers a platform for the genetic activity taking place in the living cells at all the time. No wonder, then that most future strategies of cancer prevention will be revolving around the mRNA expression, making cervical cancer prevention possible within our lifetime itself. Contact Email: digup100@gmail.com

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TRADE & TRENDS

Strategic partnership in healthcare industry Indus Healthcare gives a rundown on the evolving workable partnerships in healthcare and the company’s strategic partnership projects with the government IN TODAY’S increasingly competitive environment, where hospitals have grown drastically in number and the big groups are still building up each year, it is now an essential element of a company’s growth strategy to form strategic relationships with the best-in-class partners for your expansion needs. The pressure of being top with the best means you must have the best partners in India and around the globe to make this happen. Hence, strategic partnerships exist in nearly all areas of authority, including healthcare business and are evolving partnerships.

Definition To understand what this means let’s have a quick look over the definition of the term strategic partnership. A strategic partnership (definition from Wikipedia) is defined as a formal alliance between two enterprises, usually formalised by one or more business contracts but falls short of forming a legal partnership or, agency, or corporate affiliate relationship. They bring together representatives from the statutory, voluntary, community and private sectors to address problems, allocate funding, discuss strategies and initiatives and aim to encourage joint working. As it is not possible to build hospitals/offices all over country or globally, which is financially also unviable hence from expansion point of view strategic partnerships can be thought of. With a sole purpose to achieve specific business objectives by maximising the effectiveness of each partner participating, such partnerships can go a long way. But yes for sure for strategic partnership to work, there should be good amount of trust between the

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Dr Vandana Sharma Unit Head, Indus Healthcare

parties/partners as distrust can lead to the failure of partnerships.

Strategic partnership projects of Indus Healthcare Indus Healthcare has been fortunate enough to avail the opportunity of partnering the Government, nationally and internationally, on various projects. The major projects in partnership with the government are: Q Surgical camp at Rekangpeo, Himachal Pradesh under National Rural Health Mission in 2012. Indus Healthcare team did its first Partnership Project with Government of Himachal Pradesh under National Rural Health Mission successfully doing 60 total surgeries (including 20 major general surgeries, 20 gynae major surgeries and 20 cataract surgeries) in remotest area of Kinnaur, Himachal Pradesh where the medical facilities though available are not as advanced as in tier one cities. Where super speciality doctors and intensive care is lacking in the area Indus

Healthcare accepted the challenge and with zero mortality completed the project. Q Establishing Mother and Child Hospital Hospital at Fatehgarh Sahib, Punjab on PPP Mode, 2013-2014. We have been shortlisted by Goverment of Punjab for establishment of Mother and Child Hospital (in partnership with Government of Punjab) on Public Private Partnership (again a strategic partnership project). In its first phase with 30 beds and to be taken to 60 beds in next five years. This hospital would be based again in a rural area of Punjab. Fatehgarh Sahib (a historical town) is located 30 km away from the city with one civil hospital and low socioeconomic group of people. The land will be allocated by the government with certain concessions, but hospital will

serve the area and need of the local people, where mortality is high among pregnant women and new borns. Q Gynaecology Backlog Project in Africa in 2011-2012. We also had the opportunity for working internationally in Africa for betterment of HIV related gynaecological diseases. Under this project major gynaecological proicedures were conducted successfully in Africa through a partnership with local health-sector stakeholders and NGOs.

Conclusion Right strategic partnership means: Q Spreading risk and trusting other companies to act in joint best interests Q A match between partners so that objectives match show synergy Q Identify complementary

skills, competencies and resources in partners Q Sharing highly confidential information among the partners. Advantages Partnerships can help an organisation: Q Find an outlet for excess capacity Q Gain quick and low risk access to new emerging markets Q Strengthen technology base Q Achieve economies through high volume, low cost and mass distribution Q Overcome globally geographic, legal and trade barriers Q Speeding up innovation and new product formation and introduction Disadvantages Unsuccessful partnerships may result in the following: Q A lack of strategic fit between partners Q An imbalance in the inter- relationship between the partners Q Implementation problems because of different leadership styles Q A lack of trust and confidence Q Slow decision making Q Key requirements for a market project are concentrated in one of the partners Hence strategic partnership is a modern business strategy even for healthcare business that will prove effective in these times of complexity, network organisations and social system change. Such co-operative relationships can help organisations gain new competencies, increase their commercial reach, and share resources and risks, and to move more quickly to take up new ventures and explore new opportunities.


REGD. WITH RNI NO.MAHENG/2007/22045. REGD.NO.MH/MR/SOUTH-252/2013-15, PUBLISHED ON 8th EVERY MONTH & POSTED ON 9, 10 & 11 EVERY MONTH, POSTED AT MUMBAI PATRIKA CHANNEL SORTING OFFICE.

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