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VOL.12 NO 3 PAGES 60

Market Centre consults states on NHPS Policy Watch Sir Malcolm Grant, Chairman of National Health Service (NHS), UK www.expresshealthcare.in MARCH 2018, `50


Canon Medical Systems formerly Toshiba Medical


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CONTENTS Vol 12. No 3, March 2018

Chairman of the Board Viveck Goenka Sr Vice President-BPD Neil Viegas Editor Viveka Roychowdhury* Chief of Product Harit Mohanty BUREAUS Mumbai Usha Sharma, Raelene Kambli, Lakshmipriya Nair, Sanjiv Das, Mansha Gagneja Swati Rana Delhi Prathiba Raju Design National Design Editor Bivash Barua Asst. Art Director Pravin Temble Chief Designer Prasad Tate Senior Designer Rekha Bisht Graphics Designer Gauri Deorukhkar Artists Rakesh Sharma

The Union Minister’s announcements for healthcare has made the public health sector and private healthcare players very optimistic of the coming times. According to the Finance Minister,the ambitious plan to roll out healthcare coverage for 10 crore families will make it the world’s largest government funded healthcare programme.The private sector looks at this as a great opportunity to partner with the government and expand their businesses. Express Healthcare looks at the real impact of the Union Budget on the healthcare sector | P-12

MARKET

THIS DAY THIS MONTH

Digital Team Viraj Mehta (Head of Internet) Dhaval Das (Web Developer)

STRATEGY

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INVESTMENT PLANNING: THE HOLY GRAIL FOR HEALTHCARE ORGANISATIONS

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‘GAPS IN PUBLIC HEALTH FACILITIES MUST BE ADDRESSED TO ENSURE EFFECTIVE IMPLEMENTATION’

Photo Editor Sandeep Patil MARKETING Regional Heads Prabhas Jha - North Harit Mohanty - West Kailash Purohit – South Debnarayan Dutta - East Marketing Team Ajanta Sengupta, Ambuj Kumar, Douglas Menezes, E.Mujahid, Nirav Mistry, Rajesh Bhatkal, Sunil Kumar PRODUCTION General Manager BR Tipnis Manager Bhadresh Valia Scheduling & Coordination Santosh Lokare CIRCULATION Circulation Team Mohan Varadkar

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CENTRE CONSULTS STATES ON NHPS

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HEALTHCARE SABHA TO BE HELD IN PUNE FROM MARCH 8-10, 2018

EXPRESS HEALTHCARE AND BAYER COLLABORATE TO RAISE AWARENESS ON WOMEN’S HEALTH

POLICY WATCH

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DON’T IMAGINE THAT A NEW MODEL OF HEALTHCARE WILL SOLVE MOST PROBLEMS OF THE POPULATION

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‘INDIAN HEALTHCARE CAN TRANSFORM IF THE ONE NATION ONE PUBLIC INSURANCE SYSTEM, DELIVERED AS PROMISED’

OPINION

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CHASING SDG GOALS Express Healthcare®

Regd. With RNI No.MAHENG/2007/22045. Postal Regd.No.MCS/162/2016-18. Printed and Published by Vaidehi Thakar on behalf of The Indian Express (P) Limited and Printed at The Indian Express Press, Plot No.EL-208, TTC Industrial Area, Mahape, Navi Mumbai-400710 and Published at Express Towers, Nariman Point, Mumbai 400021. Editor: Viveka Roychowdhury.* (Editorial & Administrative Offices: Express Towers, 1st floor, Nariman Point, Mumbai 400021) * Responsible for selection of news under the PRB Act. Copyright © 2017. The Indian Express (P) 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

Is the NMC Bill 2017 jinxed?

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he National Medical Commission Bill, 2017 seeks to replace the Medical Council of India (MCI), an association tainted by corruption charges. But are we exchanging one flawed system for another? If there are complaints that the election process at MCI was rigged, the selection process proposed in the NMC Bill 2017 is vulnerable to the same pressure. If medicos were in complete control of MCI, the NMC Bill 2017 swings to the other extreme. The proposed NMC Bill has a 25-member commission appointed by the central government, of which 20 will be appointed by the search committee chaired by Cabinet Secretary, leaving only five members to be elected by and from the medico community. Various associations have submitted representations to the standing committee on health tasked with seeking public opinion on the NMC Bill 2017. It is hoped that each objection is debated and the Bill fine-tuned if necessary. As expected, this exercise is turning out to be a turf war between medicos and ministry mandarins. The Alliance of Doctors for Ethical Healthcare (ADEH) say that a “technocratic, bureaucratic NMC is no solution to the ailment of the outdated, degenerate Medical Council of India.” It warns that the Bill will result in further privatisation of medical education as it seeks to allow for-profit organisations to open up medical colleges as well as regulating fees for just 40 per cent of the seats, instead of mandating that 40 per cent seats should match the fees in government hospitals and even the remaining seats should have marginal increases. This suggestion is ideal but unrealistic as for-profit organisations will seek profits. If our objective is to increase supply (of doctors and therefore medical colleges and seats) then there has to be sufficient but reasonable incentive for organisations to put in the resources to meet this demand. Who decides the range of fees, is the crux of the matter. Dr KK Aggarwal, National President, IMA, finds fault with the NMC’s proposed composition, structure, and alleges that it aims to hand over power to administrators rather than medicos. There is no doubt that the Bill seeks to plug the gaps in India’s healthcare ecosystem. For instance, it seeks to address India’s poor doctor: patient ratio by introducing bridge courses for practitioners of homeopathy and other systems of medicine, so

Are we exchanging one flawed system for another? If there are complaints that the election process at MCI was rigged,the selection process proposed in the NMC Bill 2017 is vulnerable to the same pressure

that they can step in to fill the gaps. The intention may be noble, but the manner in which it has been proposed has raised the hackles of even the homeopathic community. It is tucked away under the Miscellaneous section, as Clause no 49, which provides for joint sittings of the Commission, Central Councils of Homeopathy and Indian Medicine to enhance interface between their respective systems of medicine. Such meeting shall be held at least once a year. The joint sitting may reside on approving educational modules to develop bridges across the various systems of medicine and promote medical pluralism.” The Indian Institute of Homeopathic Physicians (IIHP) opposes the proposed bridge course for AYUSH doctors in the NMC, 2017 saying it would encourage back door entry of quacks and that they would prefer to maintain the ‘purity’ of homeopathic practice. But it is a reality that with the dearth of doctors and nurses from the allopathic field, especially in the rural areas, AYUSH practitioners step in and fill the gap. Although this is refuted by the IIHP and other AYUSH associations, the proposed bridge course would bring this practice out in the open, and this cadre can be utilised in a more regulated and efficient manner. The NMC Bill has thus succeeded in uniting practitioners of different systems of medicine, though their criticism varies. While the Central Council of Indian Medicine (CCIM) supports the proposal, it does so because it hopes that the bridge course will allow AYUSH practitioners to address the gaps as they are not allowed to use anaesthesia, radiology, ultrasound, MRI and so on. CCIM representatives feel that if they are allowed to do this, they would “remain an ancient medicine but with modern advances.” But, this does not seem to be the intention of the bridge course as described by in the proposed NMC Bill 2017. The call for reform of the MCI was first voiced by former Prime Minister Manmohan Singh in his 2009 Independence Day speech. It has taken almost a decade to have a replacement, but observers say that the same flaws remain. Do we go back to the drawing board for (yet another) fresh Bill? Or go ahead with the NMC Bill 2017, and work on fixing the flaws via various amendments? After all, some regulation is better than none.

VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com

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MARKET

Centre consults states on NHPS State governments have started contemplating on the recently launched National Health Protection Scheme (NHPS), touted as Modicare, as the Centre seeks information from each state over its implementation. Prathiba Raju reveals more

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he Ministry of Health and Family Welfare (MoH&FW) along with Niti Aayog have consulted all the state governments to set up a mechanism and discuss details about implementation of NHPS. This is to assess their preparedness and learn from the states which have had a good experience in implementing their own health insurance and assurance schemes. According to MoH&FW, the background notes and concept paper of the scheme was shared in advance with all the states. 31 states and Union Territories participated in the two-day deliberations along with representatives from MoH&FW, Ministry of Finance, NITI Aayog and other stakeholders. According to a statement issued by MoH&FW, most of the states were represented by officials at the level of Additional Chief Secretary, Principal Secretary, Secretary of Health. The two-day consultations were attended by more than 200 participants. The programme was to engage with states to finalise the contours of the scheme. Six working groups were formed. Informing that the working groups had detailed deliberations based on the experiences of implementing Rashtra Swasthya Bima Yojana (RSBY), implementation of the states’ own schemes and global experiences, the MoH&FW informed that the best practices for each of the process related to beneficiary identification, hospital empanelment, hospitalisation services, grievance redressal mechanisms, IEC activities etc., were identified from each state and recommendations were presented by each work-

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NHPS WORKING GROUPS The working group are set up to recommend on the details of various processes related to NHPS which will be incorporated in the broad operational guidelines proposed to be issued for implementing NHPS. Working group on information technology The working group was set up to recommend on the on Information Technology System/ Platform that will be used for effective implementation of NHPS. Working group on fraud detection and grievances The working was set up to recommend strategies to prevent and control potential frauds and abuse that may happen under the scheme.The group will also recommend mechanism for complaint and grievance redressal at each level under the scheme.

Working group on awareness generation The working group was set up to recommend on the IEC and awareness generation activities that will need to be carried out for implementation of NHPS. Working group on institutional arrangement The working group will need to recommend on the institutional arrangement that will need to be carried out for implementation of NHPS. Working group on continuum of care The working group was set up to define the scope and range of the continuum of care approach such that when NHPS evolves over the years, the direction of this growth is pre-defined.


ing group to the ministry. The States had shared the current challenges being faced and potential solutions were shared with them. The statement added that on the second day of national consultations, five groups of states were formed based on the implementation status of health insurance schemes: States with only RSBY, states with RSBY and their own schemes, states with only their own schemes in insurance mode, states with only their own schemes in trust

mode and states with no health insurance/assurance schemes. Each of these five categories of states identified the issues and likely solutions. Bilateral meeting was held by Secretary Health and Member Health NITI on the preparedness of the states to integrate and operationalise the scheme. Concurrently, the state government representatives were uncertain about the pattern of NHPS. While several state health officials informed that the state's budget allocations

for the financial year is already done, with the NHPS they are asked to provide extra budgetary allocations for the scheme. Speaking to Express Healthcare, a Principal Secretary, representing a southern state, pleading anonymity informed, “The Centre and Niti Aayog has given two options to decide on the trust or insurance mode of implementing the scheme. We have been asked to give Aadhaar-seeding socio-economic caste census (SECC) data for targeted families and organising gram sabhas, finalise insur-

ance companies and empanelling hospitals in and around three to four months.” Many state government have raised question on why they should switch to NHPS. Speaking at a public meeting recently, Mamta Banerjee, Chief Minister, West Bengal, informed that the state has already made hospitalisation and medical treatment free for its citizens and sees no point in spending health plan and it will not waste its hard-earned resources in contributing to the programme.

Giving his opinion, Ramesh Kumar, Health Minister, Karnataka informed that the state would focus on its own universal health assurance scheme that would be launched at the end of the month. Under the NHPS, the central government will contribute `2,000 crores to the scheme out of a total cost of ` 5,500-6,000 crores – the remaining amount is to be paid by the state governments. prathiba.raju@expressindia.com

PRE EVENT

Healthcare Sabha to be held in Pune from March 8-10,2018 THE INDIAN EXPRESS Group and Express Healthcare will organise the third edition of Healthcare Sabha in Pune from March 8-10, 2018. Healthcare Sabha 2018 will bring together policy makers, thought leaders, national and international health organisations, social entrepreneurs, and technology and ancillary healthcare service providers. The first two editions of Healthcare Sabha held in Hyderabad and Vizag provided an excellent platform for researchers, policy makers, healthcare practitioners,

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public health advocates to share and exchange evidence

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drawn from research and experiences in health develop-

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ment programmes in India. Over the past two editions, public health experts came together to share their insights on public health policy and its implementation. The first edition was ”Universal Access to Equitable, Affordable and Quality Healthcare Services to All’ while the second edition focused on “Co-creating a Manifesto for a Healthy India.” As India’s public health ecosystem continues to evolve, the third edition of Healthcare Sabha invites public health leaders to work to-

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wards formulating a change strategy, built on three principles: Prioritise, Plan and Practise. The central theme of the two day event aims to explore and debate how India can bring in a multi-disciplinary and holistic approach across the spectrum of public health. As in past editions the deliberations of the speakers, panelists and delegates will be compiled into an OUTCOMES REPORT . For more details check: http://healthcaresabha. financialexpress.com/

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cover )

The Union Minister’s announcements for healthcare has made the public health sector and private healthcare players very optimistic of the coming times. According to the Finance Minister, the ambitious plan to roll out healthcare coverage for 10 crore families will make it the world’s largest government funded healthcare programme. The private sector looks at this as a great opportunity to partner with the government and expand their businesses. Express Healthcare looks at the real impact of the Union Budget on the healthcare sector

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BUDGET REACTION

Aconcrete push on UHC,but foundations needs to be strong enough

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ecades of low public investment in the healthcare space has resulted in two health systems co-existing under one flagworld class care for those with ample monetary backing and connections to access it, and for the rest, a stark choice between poor quality services or financial ruin – or very often both. Now, under the proposed Ayushman Bharat Programme, the government has taken a major step towards a solution to this crisis for hundreds of citizens. Properly designed, funded and implemented, the scheme represents a once-ina-generation opportunity to improve the health and wealth of India’s under-privileged. Under the programme, the National Health Protection Scheme (NHPS) will cover 10 crore families with an annual coverage of 5 lakh per family. The same is expected to boost demand for medical services and also provide an opportunity to healthcare providers and insurance companies to partner with the government. Further, it will reduce out of pocket healthcare spending, leading to increased disposable income, thereby laying the foundation for a strong economy in a long run. The proposal also includes an allocation of ` 1200 crore for setting up 1.5 lakh health and wellness centres which will specialise in managing non-communicable diseases. The policy is big on ambition, but faces a difficult road ahead. India is a new addition in the series of high growth economies to launch a national health insurance schemes over the last decade, and not all have worked. Looking around the globe, as well as to the lessons of the Rashtriya Swasthya Bima Yojana (RSBY) it is clear that the future of NHPS will in large part be determined by the foundations that it is built on.

How well its design can respond to the four tests for success: First, would NHPS be a big enough player to really change the shape of healthcare in India? Health is a $100 billion annual market nationally, and to meaningfully move the sector towards ‘health for all’, the scheme is going to need to be seen as a serious, ideally dominant, payer. The initial amount allocated in the Union Budget 2018 will be sufficient to fund implementation, but will stand short of the full requirement. Second, would NHPS be an active or a passive payer? The least effective national health insurance schemes perform a largely administrative function – enrolling citizens, accrediting providers and processing claims. They pay money out but give little attention to how it could be used to raise quality or lower costs.

NILAYAVARMA PARTNER & HEAD, GOVERNMENT & HEALTHCARE, KPMG IN INDIA

This passive approach is changing as more and more countries become actively involved in the services they are buying – contracting with new kinds of providers, creating new kinds of services and setting quality standards below which they won’t reimburse. Third, would NHPS be governed in a way that people can trust? In choosing what will and won’t be reimbursed NHPS would be making controversial life and death decisions that affect almost 500 million citizens. The only response to this is to rely on transparency and evidence. A good example of this is the UK’s value-for-money agency, National Institute of Care and Heath Excellence (NICE), which determines what drugs and procedures will be funded by the tax payer based on clear thresholds of costs and benefits. Fourth, would it have the digital infrastructure needed to cope with such massive volumes of data on citizens, records and payments? The US Government remembers well how the launch of Obamacare was undermined by the frequent delays and crashes to its benefit exchanges, causing huge embarrassment to the President personally. There is a huge variation in technical capabilities across India’s many states, and the IT aspects of NHPS will have to be managed carefully. These four tests will be at the centre of the policy discussions ahead over how to operationalise NHPS the best. To sum up it may be some years until we understand the full impact of the scheme, but what that impact is will likely be determined by the foundations created over the next few months.

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cover ) Astep in the right direction

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he government has made the health of its citizens an important priority in this year's budget. India has traditionally been behind the developed world in its focus on the state’s role in the healthcare sector. The budgetary announcements are a step in the right direction but further measures need to be taken to address the challenges in healthcare. If implemented, these measures will result in substantial benefits to the marginalised and underprivileged sections of society. Access to healthcare is a fundamental right and these announcements are a nascent step in that direction. The announcements are likely to result in greater enrollment in health insurance schemes across the country. As health is a state subject, it may be difficult for the centre to get every state government on board within this financial year, given the significant burden the scheme is likely to pose on states finances.

DR RAMEN GOEL SENIOR BARIATRIC AND METABOLIC SURGEON & DIRECTOR, CENTER OF BARIATRIC & METABOLIC SURGERY,WOCKHARDT HOSPITALS

A national health policy which facilitates the participation of the private sec-

tor in increasing access to healthcare would be an important step in the success of this scheme. We need to create a national NHPS authority on the lines of UIDAI to structure and implement the scheme, otherwise it is likely to be a nonstarter. The government should look to leverage the private sector's resources and expertise in implementing this plan. The National Health Policy 2017 envisages the strategic purchase of services from secondary and tertiary hospitals for a fee so that people can go to both public and private healthcare providers for treatment. The government must partner the private sector to clearly define the procedures and cost of treatment under this scheme. There is no denying that India’s rural areas suffer from a shortage of skilled medical professionals. The addition of PG seats is desirable but the major problem is an uneven distribution of manpower between rural and urban areas.

Only a concerted effort to provide medical professionals with security, infrastructure and adequate financial compensation will result in the nationwide presence of healthcare professionals. Many experienced people understand that in a diverse country, a robust public sector plays an essential role in healthcare provision. Alternative solutions like government coupons or payments can't act as substitutes in the basic provision of primary healthcare centres. The government’s focus must eventually shift towards improved governance and better quality of existing public healthcare services. According to a 2017 report by the World Bank, roughly five crore Indians are pushed into poverty because they have to pay for healthcare costs out of their own pockets. Therefore the NHPS should be broadly viewed as an attempt to tackle the drivers of poverty in addition to its role in providing essential health services for citizens.

We have to come up with creative ways to ensure coverage for all

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or the first time in years, healthcare sector has been given prominence in the Union Budget. Considering the role of the healthcare sector in assuring the nation’s health, the government has placed a strong emphasis on covering underprivileged and elderly. The National Healthcare Protection Scheme outlines providing up to ` 5 lakh cover per family per year for secondary and tertiary care hospitalisation. It will benefit nearly 50 crore (500 million) citizens. The biggest declaration by the Finance Minister is the health protection scheme where 10 crore poor families for secondary and tertiary treatment will get ` 5 lakhs per family. This announcement will steer the move towards universal healthcare in India. It is encouraging to note that the government has allowed senior citizens to claims benefits of ` 50,000 as part of medical insurance, earlier this was ` 30,000. The allocation of ` 1200 crore towards health and wellness centres and ` 600 crore towards nutrition for patients suffering from tuberculosis are positive steps. All these initiatives are expected to boost healthcare services demand at every

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DR RAMAKANTA PANDA VICE CHAIRMAN AND MD, ASIAN HEART INSTITUTE

level. For example, pharma sector will also get an impetus as more than 30 per cent of the healthcare cost is through purchase of medicines. Covering 50-crore citizens under a healthcare scheme is a humongous task.

A well-coordinated effort both at the central and state level is required to successfully roll out this type of a scheme. To make it a success, all the stakeholders including private and public healthcare, insurance as well as pharma companies will have to work in tandem. India is under-served in the healthcare sector, both in terms of number of doctors and hospital beds. Public hospitals are overburdened and are not able to cope with the flow of patients seeking treatment. We have to come up with creative ways to ensure coverage for all and therefore need to look at ways in which private healthcare can support and accommodate a significant share of the patient load. It's imperative that the entire population receive healthcare and not just pockets of it. As I said earlier, to achieve this the country has to come up with creative ways to ensure coverage for all. In India, private healthcare providers can play a key role in supporting government healthcare initiatives. However, it is vital that they are able to break-even and remain profitable to be able to contribute towards making the

partnership successful. We must also address the need for providing health insurance solutions that will work in favour of all the stakeholders and focus on affordability, ease of transactions, accessibility and overall security to the citizens. The Finance Minister spoke of 24 new government medical colleges to be set-up and this could be a big incentive for medical education in the country. India has just one doctor per 2000 people, according to Ministry of Health and Family Welfare estimates. There is a desperate need to increase the number of doctors in various specialities and therefore starting new medical colleges is a step in the right direction. Hopefully, every year India will be able to add more medical colleges. We need a paradigm shift in our approach to make the most of the available resources and infrastructure. Implementation of information technology is crucial to run the systems more efficiently. Likewise, training AYUSH practitioners to fill the gaps in healthcare delivery at primary level can improve the doctor-patient ratio.


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BUDGET REACTION

Monitoring investments improve qualityof maternal health services

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he decision of the government’s Ayushman Bharat Program of increasing availability of drugs and diagnostics to reach all 1.5 lakh health centres will be of benefit to women. Childbearing women need to often pay out of pocket for these services in case they are not available. With bet-

DR APARAJITA GOGOI EXECUTIVE DIRECTOR, CENTRE FOR CATALYZING CHANGE

ter availability of drugs and diagnostics and general investment of ` 1200 crore to overall healthcare is bound to raise demand for services. It is hoped that these monitoring investments will lead to overall improvement in the quality of maternal and child health services and lower infant mortality rate and maternal mortality rate, so that we meet SDG 3.2 in the near future.

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cover ) Universal healthcare insurance seems to be the onlyremedy

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he Union Budget definitely has given most needed attention to healthcare this time around, by thinking about the reach of affordable healthcare to the masses, by taking first step towards ‘Universal Insurance Coverage’. Also, the mention of additional medical seats would have a far-reaching impact to bridge the gap in the medical talent space. Allocation though seems to be the issue, as there is no clarity as of now about the funds, and keeping in mind the meagre allocation that healthcare has been getting all these years, reaching to the level of 2.5 per cent of the GDP at the earliest is the need of the hour . In the long run, universal healthcare insurance seems to be the only remedy which will try to bridge the gap. If the wishful thinking of the government is implemented in true letter and spirit, there is no doubt that it would change the healthcare scenario in coming years and make affordable healthcare available to the masses . It remains to be seen how and who will contribute towards financing the National Health Protection Scheme

DR BIPIN CHEVALE ZONAL DIRECTOR, SL RAHEJA HOSPITAL, MAHIM – A FORTIS ASSOCIATE

(NHPS), as few state governments are already running these health cover schemes on their own, or through insurance partners. It would be a herculean task to amalgamate all these into one, in a time bound manner. Also, roping in pri-

vate players with reasonable cost structure and outcome based incentive model will be pertinent to cater to all the beneficiaries. India already has a three-tier healthcare delivery system, which has not been leveraged efficiently so far. NHPS can actually revive the same for categorising the cases requiring primary, secondary and tertiary level care, thereby reducing the burden and the cost considerably . The scenario today is that the government hospitals lack infrastructure, talent, etc. but are overflowing with patients while private hospitals are struggling to fill their capacity. By partnering with each other, both the stakeholders can leverage each others strengths. The government has already shown its resolve to contain the healthcare cost by rolling out substantial price control measures through National Pharmaceutical Pricing Authority (NPPA) and Drug Price Control Orders DPCO. In this scenario, low cost - high volume would be the mantra for private healthcare providers. The void in the medical talent space is pretty huge in this country when it

comes to doctor to patient or specialist to patient ratio. The announcement of opening 24 medical colleges, is a welcome step with a far-reaching impact on healthcare delivery as it not only provides sustained infrastructure but enables continuous churn of talent. The number of post graduate seats allotted to these medical colleges will also help in curbing lot of brain drain in times to come. However, maintaining the healthcare education standards would be a tough task herein due to the dearth of recognised teachers and infrastructural limitations. The private sector can again be considered as a partner for post graduate teaching and training. The problem with most of the healthcare facilities run by government, is lack of proper infrastructure and hygiene, bureaucratic apathy, improper resource allocation, non-adherence to quality standards, etc. Taking care of the aforesaid basic good governance practices is essential to sustain in the long run. Employing trained hospital administrators, adhering to basic NABH guidelines would be the way forward.

Acollaborative approach is needed

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he new policy is definitely an indication towards carving a powerful roadmap for healthcare in 2018. But, we are still far behind the global average, when we talk about numbers. The financial requirements are actually much larger than what is targeted in the new policy. The allocation still falls short of the targeted 2.5 per cent of the GDP. However, the new NHPS is a big step in the direction of universal healthcare. The intent of the announcement is definitely positive. The government-funded healthcare scheme will cover a large chunk of the population which was not previously covered, which is laudable, since we all know that a sudden medical event is one of the major reasons why people get pushed into poverty in our country. On the other hand, though the announcement is huge, the detailed contours of the programme are awaited. We are seeking better processes from the government, right from ease of implementation, to simplification of the regime.

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DR VISHAL BERI CEO, HINDUJA HEALTHCARE SURGICAL

Further, a scheme of this size is going to take at least a couple of years to materialise, and only then would it be fair to comment on its true potential and the im-

pact that it will have on the healthcare scenario. The exact role of the state’s required funding, as also the fate of the state’s existing schemes, is yet to be defined. The government would also need to boost healthcare infrastructure, in the rural areas. Lastly, the sole focus on tertiary healthcare is not appropriate, as prevention and primary healthcare would provide superior and sustainable long-term outcomes for the entire population. A collaborative approach is needed, to be able to achieve the true potential of the Indian healthcare sector. The government could help by freezing the contours of the plan as soon as possible, defining the role of states v/s Centre, discussing with insurance companies to work out the lowest premiums, involving private hospital stakeholders to arrive at viable price points for proposed packages, and by working out modalities to minimise leakages and fraudulent practices, during the implementation of the NHPS.

The role of the private sector would be to provide its full cooperation to the government, and ensure that the entire healthcare delivery and claim process is managed seamlessly. The government’s idea to set up 24 new medical colleges and hospitals, by upgrading the district level ones, will help address the shortage of skilled medical professionals. The shortage of nurses and paramedical staff would also need to be addressed simultaneously. The Union Budget 2017 talked about re-naming primary healthcare centres as 'Health and Wellness Centres,' with the focus on catering to non-communicable diseases, mental health challenges, geriatric and palliative care, and rehabilitative care services. The allocations towards these initiatives must be on a priority basis, which will be a great step towards decreasing the burden of disease in the country. Also, finding the talent to man these proposed centres in the rural areas, would be a significant challenge.


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BUDGET REACTION

The health and wellness centres should be well leveraged

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he focus on health and wellness of its citizen indicates that the government is driving a robust health and well-being ecosystem. Deduction under Section 80D – that includes amount paid towards health insurance premium for covering senior citizens has been increased from existing limit of ` 30,000 to ` 50,000. It is a positive step and would help increase penetration of health insurance in India. It would have positive impact on the health insurance companies. However existing limit of ` 20,000 for citizens below 60 years has not been revised. The health and wellness centres should be well leveraged. It is a great opportunity for the government to educate people about health, sanitation, hy-

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giene and so on. The step to provide universal healthcare of an unprecedented amount of ` 5 lakh medical insurance cover per year for 10 crore families across the country means that more people will now have access to health insurance who have affordability issues. Increase in medical colleges is a positive step forward to meet the growing healthcare demand in India. The government taking concrete steps to help people with TB with free drugs and ` 500 per month.

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EXPRESS HEALTHCARE

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March 2018


cover ) Abold and visionarymove

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he government for the first time has come up with a healthcare scheme which is moving beyond subsidies and promises. The proposed healthcare coverage plan for 10 crore families will give a fillip to the entire ecosystem including hospitals , pharmacies as well as diagnostic chains. It will also ensure that there is standardisation across healthcare channels as well because everyone will be eyeing the same business. The country will benefit a lot from this bold step to bring every Indian under a universal healthcare coverage. It is a bold and visionary move. A lot of things will need to be made right for this to work and the implementation will be key but the step is in the right direction. The devil always lies in the details. Waiting to hear the scheme document and wait for the next steps to comment on how it will impact the sector in the coming years. Digital healthcare ecosystem is something that comes before this implementation. In simple words - getting the patient, practitioner and pharmacy

DR DHAVAL SHAH CO-FOUNDER, PHARMEASY on the same platform in a digital format is key for success. The government needs to ensure that this is done before roll out can happen. linking the scheme with Aadhar will be the first step and ensuring that the entire implementation happens through Aadhar will be key to moving ahead and success.

The private sector can play an active role. However, there needs to be clear cut demarcation. If the scheme is structured well where the first reliance is on the public sector and if needed private players can come into play at a predefined cost, it will give a boost to the public sector healthcare facilities as well as ensure that the private players are incentivised to provide state of the art facilities and ensure quality healthcare is given out. For the private sector working with the government is always difficult from reasons of cash flows. Payments are delayed and that leads to issues across the chain. If this can be dealt with well - I am sure the private players will be happy to setup facilities in remote areas as well where its otherwise difficult for them to sustain them for a longer period of time. I would say this is the single most important step taken in the budget. More doctors is the need of the hour in the country. The current lot of doctors coming out don't have enough avenues for higher education in the country and are forced to move abroad. With this

step, we can expect a lot more quality doctors coming out which are aware of the local problems and issues at large and help fulfil our dream of a healthy India. Public health centres in the country have always faced an issue of supply in terms of raw materials to medicines and even the required technology and machinery to ensure that the best quality healthcare is given to the people at large. The problem in the current scenario is that everyone wants to have the doctor accountable without giving him all the tools and mechanisms. Healthcare cannot operate in silos or in the hands of individuals - it needs to be the entire ecosystem that works well. The intent of the government has always been in the right direction. I would have expected more doctors and better healthcare facilities in the earlier budgets but this is a welcome move nonetheless. We have been seeing public healthcare facilities being overburdened since decades now. Waiting for signs of revival , which I am sure this budget should be able to do.

This budget will definitelyhelp to boost the growth of the sector

T

his Union Budget 2018 has definitely been a game changer. The government has launched one of the most ambitious project by any scale and if succeeded, the state of the primary and secondary healthcare in this country will change for good. As per the data presented, the National Health Protection Scheme would cover 10 crore poor families and provide up to `5 lakh per family per year for hospitalisation in secondary and tertiary care institutions. With 50 crore beneficiaries, this would be one of the largest benefit programme of its kind in the world. Getting the poor the access of secondary and tertiary care also indicates penetration of hospitals into smaller cities and villages, thus improving accessibility. Another impactful measure to tackle rural healthcare is the opening of 1.5 lakh healthcare centres that will provide comprehensive healthcare including

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JOY CHAKRABORTY COO, PD HINDUJA HOSPITAL & MRC

non-communicable diseases and maternal and child health services. The cen-

tres will also provide free essential drugs and diagnostics. Both the above schemes have been the highlight of this year’s budget but there are still some questions unanswered like the fate / role of existing health policies initiated in states, the number and type of diseases that will be covered under NHPS, role of insurance companies in taking this policy ahead to the rural India and its final implementation. However, if executed structurally, quality and affordable healthcare will finally reach the villages of India. This budget will definitely help to boost the growth and development of the sector. The most notable initiative of this year’s budget, is the world’s largest government funded healthcare protection scheme that aims to cover close to 10 crore Indian families. With this, the burden of out-of-pocket expenditure faced by most of the Indian population, irrespective of socio-economic strata, will

drastically reduce, making quality medical facilities reach the underprivileged. The surprise element in this year’s budget was the government’s commitment to reach out to the elderly. The increase in the deduction limit for senior citizens will encourage the ageing population to buy a higher health insurance policy and hence boost the entire ecosystem (patients, insurers, care providers) of healthcare specifically targeted for senior citizens. Besides, policies for the health sector, there were other plans announced this year, which would indirectly impact the health sector. Chief among them was the focus on pollution control and sanitation (plan to open two crore additional toilets). This would definitely impact public health by reducing infection and pollution-related diseases, thus reducing the burden on health systems by some degrees. On the whole, this budget marks the


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BUDGET REACTION

importance of social sectors and the government’s focus on healthcare for the common man is a step in the right direction for India’s health. Had there been any incentives for private care takers set up hospitals in rural areas or announcement of schemes for Public Private Partnership (PPP), the implementation of NHPS would have been easier. Since there has been no announcement on a PPP model in setting up healthcare centres in the rural, the government can look into join hands with the private sector to set up medical colleges that will provide quality learning to aspirants. The government can then look into incentivising doctors, healthcare practitioners who are willing to step into rural villages and work. This model has worked in the past considering currently nobody wants to go to the villages apart from a few passionate ones. Furthermore, government should connect the digital drive with certain sectors like healthcare and education. The government in the last Budget and this one too has emphasised on increasing the medical seats. As per data available, the undergraduate seats in the government medical colleges in the country is likely to increase to 85,525 while postgraduate seats will go up to 46,558 by 2020-21. The announcement of setting up 24 new medical colleges, one in each state, is a welcome step. This will create additional seats in MBBS and PG in the country, promote affordable medical education, utilise and eventually better the existing infrastructure of district hospitals and increase the availability of health professionals in the rural areas. However, shortage of manpower is not limited to doctors. There is an equal dearth in allied health services professionals and nurses in the country. Although, these are positive steps in closing the gap, a lot still needs to be done to take affordable and quality healthcare to the villages of India. The success and legitimacy of good public health revolves

around process, transparency, participation, fairness and accountability. Good governance

is necessary to ensure that health system rules and institutions are beneficial to the popu-

lation. The government should also more and more interact with the public in general to un-

derstand the basic needs of the community or population as a whole.

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THIS DAY THIS MONTH

Express Healthcare and Bayer collaborate to raise awareness on women’s health Members of the medical fraternity, media professionals, social activists and representatives of the pharma industry come together to discuss and deliberate on measures to enhance women’s health and empower them to lead a better life Lakshmipriya Nair Mumbai

W

omen have come a long way. They have battled for their rights and proved their mettle, be it science, politics, sports, business, literature or art. Alas, their health, an important aspect, continues to be overlooked and neglected. Gender-based health disparities continue to exist and hamper women’s strides to progress. Therefore, recognising the urgent need for renewed commitment towards women’s health, Express Healthcare and Bayer Zydus Pharma, came together to bring key stakeholders on a common platform to educate and inform about the advances in this sphere. At an event held at St Regis, Mumbai on February 20, 2018, eminent members of the medical fraternity, media professionals and representatives of pharma major, Bayer Zydus Pharma shared a stage to discuss and debate on the best strategies to inform and empower women to make the right health decisions. Welcoming the esteemed guests and dignitaries, Viveka Roychowdhury, Editor, Express Healthcare set the context for further discussions and highlighted how vital it is to address inequities in women’s health. She urged the stakeholders to join hands to enable more funding, research and creation of effective policies and programmes to deal with women’s unique health needs. Stressing on the essentiality of making women’s health a major priority to ensure progress of the nation and the society, she also drew attention to the role of the media, as a watchdog, to help ensure higher visibility and under-

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Mass media can play a crucial part in generating awareness and sensitising the society about women’s health and hygiene needs

Our country is mired in outdated traditions and practices, be it about menstruation, pregnancy or contraception DR RISHMA PAI Consultant gynaecologist, Lilavati Hospital, Jaslok Hospital, and Every Woman Clinic

SPRUHA JOSHI Marathi film and theatre actress

Women living in slums face several health hazards. It is important to devise effective strategies and solutions for their better health

Timely and appropriate counselling for women of all ages is important to empower them to lead a healthy life DR NANDITA PALSHETKAR Infertility specialist, Lilavati Hospital and Fortis Group of Hospitals

SHUBHALAXMI PATWARDHAN Director, Niramaya Health Foundation

standing of this issue. Next, Manoj Saxena, MD, Bayer Zydus Pharma took the

stage to speak on Bayer’s work and offerings in women’s health. He elaborated on the company’s

contributions towards innovative contraception and gynaecological therapies. He assured

that Bayer has pledged its allegiance towards the cause of improving women’s health,


(L-R) Viveka Roychowdhury, Editor, Express Healthcare; Manoj Saxena, MD, Bayer Zydus Pharma; Shubhalaxmi Patwardhan, Director, Niramaya Health Foundation; Dr Rishma Pai, Consultant Gynaecologist, Lilavati Hospital, Jaslok Hospital, and Every Woman Clinic; Dr Nandita Palshetkar, Infertility specialist, Lilavati Hospital and Fortis Group of Hospitals and Spruha Joshi, Marathi film and theatre actress

Bayer’s presence in women’s health is 90 years old, since its research on a contraceptive pill MANOJ SAXENA MD, Bayer Zydus Pharma

worldwide and in India. He also informed that it is investing significantly in research and product development to meet heretofore unmet needs in this sphere. Renowned Marathi film and theatre actress, Spruha Joshi was the Chief Guest at the event. As a modern woman who has donned several hats successfully, she gave a great perspective on the health needs of today’s women. She pointed out that despite being the custodians of their family’s health, women often tend to overlook their own well being which have severe and significant adverse effects later. Joshi also urged parents to empower their girl children with the right knowledge to help them make the right choices for their health and wellbeing throughout their life. She cited the example of her parents’ role in making her a woman capable of making her own choices when it comes to her health and thanked them for their support. She was also very emphatic

that mass media can play a very crucial part in generating awareness and sensitising the society towards women’s health and hygiene needs. Yet, in her opinion, mass media hasn’t been optimally utilised to achieve this objective. To prove her point, she highlighted that it has taken the Indian film fraternity over 100 years of existence to make a movie like Padman, the recently released Askhay Kumar starrer which addresses menstruation and issues related to it. An interesting panel discussion followed Joshi’s insightful address. An eminent panel comprising Dr Rishma Pai, consultant gynaecologist at Lilavati Hospital, Jaslok Hospital, and Every Woman Clinic; Dr Nandita Palshetkar, infertility specialist associated with Lilavati Hospital and Fortis Group of Hospitals, Delhi; Spruha Joshi, Actress; Shubhalaxmi Patwardhan, Director, Niramaya Health Foundation and Manoj Saxena, MD, Bayer Zydus Pharma. The moderator,

Viveka Roychowdhury, Editor, Express Healthcare, steered and veered the discussion through various pertinent aspects of women’s health. The panelists touched upon women’s health problems ranging across all age groups across different strata of the society. Dr Pai spoke on how she encounters various young girls with health problems, often caused and aggravated due to ignorance about their bodily processes and sexual health. She lamented that despite advancements in various areas, our country continues to be mired in outdated traditions, beliefs and practices, be it about menstruation, pregnancy or contraception. Citing examples, she pointed out that women are shunned during days of menstruation, many believe in mahurats for C-section deliveries and often become victims of STDs and unplanned pregnancies as religion prevents them from using contraception. She opines that these obsolete notions and ideas are very detrimental to women’s well-being. Dr Palshetkar threw light on the various complexities in women health issues arising in these rapidly changing times. She gave valuable insights on the different causes of infertility among women such as stressful lifestyles, diseases like endometriosis, delayed pregnancies due to late marriages etc. She also informed that with advancements in healthcare, now women have various ways and means to make their pregnancies safer. She also recommended options such as freezing of their eggs and preserving them for a later stage in life, if women need

to delay child-bearing. Dr Palshetkar also advocated timely and appropriate counselling for women of all ages to empower them to lead a healthy life. Joshi recounted some harrowing real life experiences of dealing with abysmal sanitary conditions and unhygienic toilets in the course of her career as an actress. She emphasised that hygiene and sanitation are major aspects of women’s health and urgent attention is needed towards these areas. Patwardhan, as a social activist, drew a very realistic picture of the deplorable conditions of women living in the slums and the various health hazards faced by them. She pointed out that the health issues faced by these women have different causes from those faced by women living in better socio-economic conditions. Therefore, the strategies and solutions to deal with them also need to be different. She said that when basic amenities are lacking, it is hard to educate and enforce other learnings. First and foremost, in the lower strata of the society, it is important to meet the basic needs of women such as daily nutrition, safe drinking water and clean toilets. She also spoke on the importance of imparting sex education to young girls in these areas as teen pregnancies, poor sexual health, unsafe abortions, high risk of sexual infections etc. are also challenges that need to be tackled. Patwardhan also informed about the various initiatives undertaken by the Niramaya Foundation to deal with these issues. Saxena, as the only male member on the panel, spoke

on how essential it is to sensitise men in the society to the health needs of women. He opined that men too will have to uphold and champion the cause of women’s health as it is directly proportional to a family’s health. All the panelists were in complete accordance with these views. The moderator, adding her insights to these statements, said that behind every empowered woman there is an enlightened man. As a representative of Bayer Zydus Pharma, Saxena reiterated once again that his company is fully empathetic to women’s health requirements and is in the pursuit of discovering and tailoring solutions to suit individual needs of women across all ages, geographies and socio-economic conditions. The panelists were also unanimous in their opinion that sex education, timely counselling at educational institutes and workplaces on women’s health, encouraging women to go for regular health check-ups, instilling and adopting a scientific approach towards these issues are some very crucial measures to bring about significant improvements in this area. They collectively promised to do their bit to ensure better health conditions for women and advised everyone to do the same by passing on the right message and spreading knowledge to ensure better outcomes. The discussion ended on a hopeful note that in times to come, women will truly have the freedom and knowledge to take the right decisions for their good health and well being. lakshmipriya.nair@expressindia.com

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STRATEGY

Investment planning: The holy grail for healthcare organisations Figuring out which area of your healthcare business needs more investment is easier said then done. Here are some basic fundamentals which can get you started on the right path. By Raelene Kambli

T

he year 2018 has brought a lot of promise and business prospects for the healthcare sector in India. Especially, with the recent announcements made by the Union Finance Minister, Arun Jaitley during the Budget 2018 clearly indicated that the government now wishes to shift its focus on the healthcare sector with a view to increase accessibility and affordability of services to all. This indeed, is an opportunity that every healthcare organisation would vie. Industry optimists believe that this move would create an effective demand to trigger private investments in supply deficits areas. They also feel that this endeavour would increase insurance penetration in the country and create huge opportunities for insurance players, hospitals, diagnostic chains, local equipment players and telemedicine providers. Moreover, some also feel that this changing dynamics of the sector will open avenues for more private equity investments into the market, giving impetus to fund activity as well. Going by this effervescence, some of the large hospital groups and diagnostic chains are now planning to expand their services in tier II and III cities and towns. Large hospital chains such as Aster Medicity, Wockhardt Hospital are already planning new strategies to capture untapped markets. Dr Azad Moopen, CMD, Aster DM Healthcare, during his recent IPO announcement informed that the group will be chalking out a new investment strategy after the recent budget announcement by the government. They informed that they would see the tier II and III

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valuable investment that needs to be judiciously executed. Here is where an effective and well-planned investment strategy comes to play.

Investment planning: For long-term goals

cities as a good investment area. Likewise, Zahabiya Khorakiwala, MD and Executive Director, Wockhardt Hospitals, in a recent meeting informed that the group will be looking to venture into new cities and town in the western region of India.

2018 investments on the card This indicates that the year 2018 can prove to be an exciting year for Indian healthcare with more government focus, expansions and consolidations in the private sector as well as increased funding and investment activity to follow suit. Sharing his investment plans, Varun Gera, CEO and Founder, HealthAssure, informs, “HealthAssure is looking to build new products and continue our aggressive expansion through the various channels of sales. We are also

looking to continue our IT investment and our digital thrust which would help make the primary care ecosystem more accessible. We will also enrich our medical network which currently covers 3,100 primary care medical centres in 1000 cities. HealthAssure has also initiated international expansion and would continue to explore opportunities in Far East Asia and the Middle East. With a fresh round of investment, we are aiming to take our current figure of 1 million active subscribers to up to 2.5 million customers by 2020.” Huzaifa Shehabi, COO, Saifee Hospital adds, “The company’s business plan for 2018 is striving very hard for quality across all spectrum. Quality is fundamental to every business and attaining a highlevel of quality will have a direct, sizeable, impact in ensuring our patients are able to get cured of the various ailments

that are afflicting them. Hospitals are judged not on how many patients visit their premises but how well they are able to serve the patients and provide solutions to healthcare issues and we believe that in order to achieve our targets, our efforts have to be bulwarked on quality.” Dr Mradul Kaushik, Director, Operations & Planning, BLK Hospital, updates, “We at BLK are looking at investing $5-6 million in upgrading our clinical programmes and expertise in robotics, radio therapy etc. This is a new area we would like to explore as we believe that investing in it will add value the existing services we provide to our patients.” Interesting to note that the above mentioned players are looking to invest in areas as digital technology deployment, human resource training, operating systems and more. Howbeit, all these plans will require

World over, business experts say that strategic planning is the holy grail for any organisational investment. Especially, for healthcare organisations such as hospitals, diagnostic centres, medical equipment players and technology providers, these decisions are crucial not only for resource allocations but for meeting longterm organisational goals. According to financial experts, strategic investment in right areas at the right time leads to growth of business in terms of operational and business efficiency that promises higher profitability. “A carefully planned investment strategy is a practical way that can make sure that one maintains the direction and discipline needed to reach the desired goals,” opines Manish Sacheti, CFO, Ziqitza Healthcare. Referring to Saifee Hospital's plans in this direction, Shehabi states, “Investment planning is definitely necessary in order to provide the best services to our patients. At Saifee Hospital, our investment planning revolves around striving to achieve quality across the board, be it for patients seeking a cure for a certain ailment, consultation or even a health check up. We also agree that an investment strategy is an important cog in driving business growth as without proper planning, how can any organisation be truly innovative or


ensure operations flow seamlessly across all divisions?”. Similarly, Gera mentions, “It is important to create an investment plan by studying strategic impact, market and industry conditions, which is more relevant in changing business environment now days. Right decisions, investments and implementations would help organisations concentrate their energies on the higher-yield actions, and not dissipate their resources on quixotic ventures and forlorn causes, thus leading to higher ROI.” Well, Gera rightly points out that a clear and intelligent plan will yield higher ROI. In order to do so the following principals will play a key role in determining an effective investment strategy.

AREAS TO LOOK FOR FUTURE INVESTMENTTO CREATE VALUE FOR ALL

Five pre-requisites that is sacrosanct

◗ Product development To stay ahead of competitors, organisations should always look at incorporating innovation very frequently. Companies that focus on innovation deliver a consistent stream of market successes via successful businesses and products/services enhancing competitive advantage and achieving sustained growth.

Chalking out an investment plan sometimes seems complicated and arduous as it involves risk taking. Healthcare organisations sometimes end up exhausting their investment budgets on areas such as high-end equipment which at that point of time is not necessary to their business requirement, leading to wastage of resources and capital, which later become challenging to recover. Therefore, experts recommend breaking down investment planning into some basic fundamentals which can get you started on a path to better investing and achieving your long-term organisational goals. ◗ Set your long-term goals: Goal setting is the most important principal that every business organisation needs to follow. It becomes the corner stone of every business activity within the said organisation. “A clear vision for your business is a must before you make that investment plan. One needs to be absolutely sure of what they want out of this investment be it, infrastructure developments, human resource, equipment installation or some business acquisition. It all boils down to your end goal. This will be the

◗ Digital technologies In the age of the digital revolution, every healthcare organisation need to invest in digital technologies that will help create value for patients and employees. Experts say keeping aside at least 20 per cent of your investment budget for deploying digital technologies will be fruitful in the coming times. ◗ Employees Investment in employee upbringing, training and welfare will bring increase the motivation and increase the efficiency of the staff which will help an organisation to grow. ◗ Operational system An organisation should always invest in latest systems to improve the operational efficiency and remove the processes which are redundant. Japanese companies, for example, always look for the best operational system which reduces the procedural delay and increases the turnaround time of the product resulting in faster growth of business. ◗ Brand building Investment in brand building ensures brand equity. It not also attracts the attention of the customers but also investors, which helps in bringing more investment resulting in the business expansion, new products introductions, new technologies.

Goal setting is the most important principal that every business organisation needs to follow. It becomes the corner stone of every business activity within the said organisation

Additionally, Sacheti says, components such as return on investment, investment timing and profits the investment can bring in to the organisation and the time frame for the same, need to be studied while preparing the budget. This will help in designing an accurate budget and avoid unnecessary wastage of resources. Be flexible while on the road: A successful investment strategy is one that is malleable to market trends and circumstances. Experts say that investment decisions are usually characterised by two important factors- uncertainty caused by market volatility and irreversibility of decisions due to various factors concerning the then market conditions. Both these factors are significant for investment decision and execution, thereby making it imperative for organisations to be flexible while preparing the blueprint of your investment. “Since the healthcare market is very dynamic and not much goes as per plan, it’s also very important to have the ability to be flexible while on the road and make corrective actions or change investment allocations, accordingly,” Gera sums up.

Bottom line guiding force for the implementation of your plan,” suggests Dr Vishal Beri, CEO, Hinduja Surgical, Mumbai. ◗ Analyse the current and future demand for your products/services: No plan would work effectively, if it is not based on research and analysis of the market trends and dynamics. “To take positive steps towards a strategic investment plan, it is important that a thorough SWOT analysis is undertaken. This will help in breaking down each segment and then assess where your organisation stands vis-a-vis the healthcare ecosystem. But in order to drive real value, more time is spent on planning on how to capitalise on opportunities whilst simultaneously reinforcing against threats prevalent

within and outside the system. These seemingly simple steps will in the long run allow an organisation to maximise benefits from their investment plan,” says, Shehabi. ◗ Research on your need for investment: A thorough analysis of your organisation's current opportunities and challenges will lead you to understand the need for investment. “Before you chalk out an investment plan, it is important to understand the need of your investment in a particular area. I have mentioned earlier that we plan to invest in robotics and radio therapy technology. Therefore, our first step was to evaluate the need of our investment, to see whether there is a true need and demand for this investment. How

much will this investment help in creating value for our patients, employees and others associated with our hospital? All of these areas need to be looked at before delving into this decision and making a plan for execution,” instructs Dr Kaushik. ◗ Capital budgeting: Once you have envisaged the organisation's long term goal and analysed on the market demand and the need for the investment, the next step to prepare a comprehensive budget. Capital budgeting is a step by step process that businesses use to determine the merits of an investment project. According to Dr Beri, an healthcare organisation need to keep at least 20-30 per cent of their revenue for investments that will yield them better returns.

Having said that, it is evident that the healthcare sector in India is currently at crossroads, where it needs to address several challenges that tamper its growth, while enabling itself to take advantage of the many opportunities open to it. Going by the words of Benjamin Graham, the author of the book The intelligent investor, “An investment operation is one which, upon thorough analysis, promises safety of principal and an adequate return. Operations not meeting these requirements are speculative.” It is time healthcare organisations look at investing in areas that facilitate organisations to create value for its patients, partners, employees and shareholders in order to build a sustainable healthcare ecosystem for the future. raelene.kambli@expressindia.com

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STRATEGY I N T E R V I E W

‘Gaps in public health facilities must be addressed to ensure effective implementation’ Ashok Alexander, Founder & Director, Antara Foundation, shares his insights on the major pillar of a successful healthcare system for India, in a conversation with Raelene Kambli What are the changes you think are needed to strengthen India’s public health scenario? Two key changes are needed – government should reach for its wallet and then know how to spend money well. India’s public health spending is abjectly low at around 1.2 per cent of GDP. Public health expenditure of each of the BRICS nations exceeds 3 per cent of GDP. Even smaller south Asian nations like Nepal and Bhutan have public health spends over 2 per cent of GDP. Consequently, the poor are forced to pay. India’s out of pocket spending as a percentage of total health expenditure is among the highest in the world at over 62 per cent. This money must be spent to address severe infrastructure gaps. Only 36 per cent of primary health centres (each serving 2030,000 people) have operation theatres. 20 per cent of sub centres (each serving 35,000 people) don’t have regular water supply. Investments must also be made in strengthening the hands of frontline workers (ASHAs, Auxiliary Nurse Midwives, Anganwadi Workers), especially with respect to data use. Technology can enable this process. What according to you are the major pillars of a successful healthcare system for India? Adequate spending, sound policy framework, visionary programmes, adequate facilities from sub-centre level upwards, well trained and fully capacitated frontline workers, win-win publicprivate partnerships and an

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informed, aware community strong enough to demand health as a fundamental right are all important.

System has received some criticism for its inefficient spending. However, there is much to learn from its emphasis on access, affordability, and preventive healthcare. The ubiquity of ‘family doctors’ also ensures that care is well-coordinated. The Commonwealth Fund’s ranking of 11 wealthy countries’ health system puts the UK near the top on several parameters.

How should India go about achieving these goals? To begin with, India needs to spend more on health. Spending must match up to citizens’ needs and global benchmarks. Then, the nation must know how to spend that money well. Inadequate spending on primary health and under-utilisation of funds by states should be well documented. What is your opinion on the National Health Protection Scheme (NHPS) which has been recently announced by the FM? It is a well-intentioned scheme but has many unanswered questions. First, funding needs to be sorted out. Estimates vary from ` 10,000 crore by a NITI Aayog adviser to 10 times that figure by a professor at NIPFP (National Institute of Public Finance and Policy). The initial corpus announced in this year’s budget is ` 2000 crore. Will states pick up their share of 40 per cent? Bengal has opted out already. Recurring needs are yet to be addressed. Moreover, gaps in public health facilities must be addressed to ensure effective implementation. What lessons India should learn from the US and UK’s healthcare systems? The US healthcare system is no exemplar. While it has premier institutions, strong doctor-patient relationships and superior care for serious issues, it has major flaws. It is prohibitively expensive and there are wide disparities

If the NHPS scheme doesn’t get rolled out in the current government’s term, questions of accountability and fixation of responsibility may arise among income groups. This is reflected in outcomes. Infant mortality rate (deaths per 1000 live births under one year of age) is close to six, among the highest for developed countries. It is close to double for the AfricanAmerican community. Repealing Obamacare is a step backwards. The lesson for India is to invest in primary healthcare for disadvantaged groups in rural areas. UK’s National Health

What are the pre-requisites for an effective implementation of the National Health Protection Scheme? To achieve desired results, emphasis must be on implementation and learning from the scheme’s predecessor, the Rashtriya Swasthya Bima Yojana (RSBY). Few important actions – One, effective monitoring of private facilities and accommodation of providers’ reasonable needs to keep them interested. Two, build awareness in the community. Only 35 per cent of eligible households knew about the RSBY, according to a study by TISS. Importantly, strengthen quality and accessibility of rural health facilities. Swift rollout is preferable. If the scheme doesn’t get rolled out in the current government’s term, questions of accountability and fixation of responsibility may arise. What is Antara Foundation’s focus area in healthcare? What is your vision for public health in India? Antara Foundation’s focus is on bringing the know-how of scaling up public health delivery, working in

partnership with government. The foundation currently works on Maternal and Child Health and Nutrition in Rajasthan. My vision is for all elements of a good healthcare system to be well on track in five years. To recap, these elements are adequate spending, sound policies, visionary programmes, adequate facilities down to the lowest rung, well trained and effective frontline workers, dynamic public-private partnerships and an active, empowered community demanding public health services. Would also want to see spending increase, in real terms, from the next budget. You have worked with the Gates Foundation, what are key strategies and models of healthcare delivery that you would like to replicate in India? It was a privilege to lead the inception and growth of the Gates Foundation in India. Establishing a model of delivery at scale through the HIV prevention programme, Avahan, and knowing to spend money effectively was a great learning experience. Elements necessary to build a model of scaled delivery are threefold: ◗ Supply – Enhancing effectiveness of frontline health workers through use of data and technology ◗ Demand – Nurturing active, empowered communities who demand public health services ◗ Enabling ecosystem – Working with government and ensuring effective data-voice i.e. backing influential voices and channels with fool-proof data. raelene.kambli@expressindia.com


STRATEGY

Consumer health: The role of marketing Nachiketas Nandakumar, Assistant Professor – Marketing, Great Lakes Institute of Management, Chennai, gives an insight on the need to understand the role of marketing in addressing social problems MARKETING AND advertising have long been known to be the catalysts for consumption in our economy. Close to 30 years since the policy reforms and liberalisation, our economy has seen huge changes in consumption patterns from a massive influx of brands all over the world. Marketing firms have been working overtime, some of them non-stop, in their effort to deliver goods and services. The focus of these firms have been in finding solutions for core business problems; of that of driving sales and generating profits for organisations by serving consumer wants and needs. While there are many success stories of the efforts of the marketers in creating the economic value there has been very little attention paid to understanding the role of marketing in addressing social problems. Is it not in the best interest of any nation to have their citizens have the best of healthcare, better social conditions, access to quality education and eradicating poverty? Can marketing help here? Persuasive communications are interesting and challenging, depending on the nature of the problem and the context in which they are set in. Let’s take consumer healthcare, focus of this article. In India, there are many public health issues to choose from, starting from addictions, like alcoholism, smoking, and drugs, lifestyle cropups like obesity, diabetes, stress, and depression, age-related break-ins like alzheimer’s, cataracts, arthritis, quality of life and so on. The list can be quite lengthy and all of it quite real. Of particular interest amongst those listed and that which is urgently relevant to India, is cataracts, a medical discomfort of the eyes born out of ageing, mainly, and affects people in their mid-45s and above. Amazingly, the cure for

tions in eye-care and made it very much affordable.

What then is the problem?

While there are many success stories of the efforts of the marketers in creating the economic value, there has been very little attention paid to understanding the role of marketing in addressing social problems treating cataracts is through surgery and only that. There are no known and approved medicines for easing the problem; glasses could help with blurry vision, a usual symptom in cataracts, but it is only a means to cope and not the cure to restoring vision. FACT: India is home to the most number of blind people in the world. Primary cause: Cataracts. The eye condition, seemingly benign in the beginning, could

turn itself into a potentially vision-threatening issue if left untreated and the resulting blindness, in many cases is irreversible. The prevalence of such unnecessary blindness is most rampant in the rural areas than in urban cities. Clearly, the many who have been rendered blind because of untreated cataracts is not because that surgery is dear or that it is not accessible. Prominent eye-care organisations in India (like Arvind Eye Hospitals and Sankara Nethralaya) have made tremendous innova-

The problem, like in many health-related issues, is 'the last mile'. The mental attitude problem. Individual’s attitudes towards one’s health have been observed and linked to exhibited behaviours, and damaging attitudes often lead to damaging health consequences. Easy as it may sound then, that the solution is to help shape consumer attitudes to access positive health outcomes, but it is tricky. Can marketing play a role here? Over the years, psychologists have tried to arrive at explanations that drive attitude which include things such as beliefs, past experiences, culture, social norms, etc. These existing beliefs are a result of individual and social conditioning over many years, thus making oneself think in a particular way and behave in a particular manner. To break up troublesome attitudes is therefore not an easy task and often takes repetitive attempts at good campaigning to secure a breakthrough. Repeated exposure to alternative yet compelling reasons to change is the way. FACT: Apathy or laziness is the confounding mental block standing between the problem and cure. Can principles of marketing help in addressing apathy? Our problem is, therefore, tackling consumer indifference to an available cure for a nagging social problem that has implications at all levels of the society. Providing incentives to change is a nice place to start the health promotion campaign, but polite incentives don’t usually work. Research has found out that, in many cases, providing dramatic examples have helped shake people out of their indifference. Such dramatic examples can be

found on cigarette labels carrying statutory textual warnings and graphic pictures, road signs carrying gory accident images, an amputated leg in the case of chronic diabetes and so on. These are attempts made to threaten people with dire consequences should individuals persist in harmful behaviour or show neglect. The idea is to make the threat seem personally relevant and to bring a proxy to an untimely death or something similar, like loss of vision in our example, as close as possible. Having said that, shaking people out of their laziness is one thing but making them move towards cure or solution is another challenge. Can marketing help nudge consumers towards a cure? There are many not for profit organisations and NGOs in India who have made it their agenda to serve the society, but many of them, while they have the heart, seem to be still searching for ways to sell their agenda. There is no doubt that healthcare marketing is multifaceted, moving from print and billboards campaign, now the focus has come down to social media campaigns. And, this is where the healthcare entities should try to build, engage and support their consumers based on their preference and style. It would be wise to learn from successful marketers, the good principles of marketing, the critical skills of understanding consumers, by listening to them, gaining insight about their personality types, segmenting their needs, tailoring and communicating their solutions in an effective manner. The role of marketing is critical for consumer healthcare. If marketers can successfully shape consumer attitudes towards thirst and take a can of cola to the remotest areas in India, I am sure they can also help in delivering ‘cure’ to every citizen.

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OPINION

Chasing SDG goals Dr Monika Choudhary, Associate Professor, IIHMR University, Jaipur, gives an insight on how interconnectedness of health, poverty and livelihoods, will help India achieve SDG goals

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eing the second most populous country, India and the efforts it makes would be important for the achievement of overall sustainable development goals (SDG) targets which the world adopted a couple of years ago to end poverty, protect the planet and ensure prosperity for all. The strategies that India adopts to frame and achieve SDG goals and targets would be of relevance for the rest of the world, as best practices, models, and paradigms. However, India’s journey towards sustainable, equitable development would be one of the most complicated and unique, given the level of socioeconomic diversities in the country. While there are states like Kerala, which are already far ahead and at par with the world on some of the SDG goals and targets, there are states like Bihar, UP, Rajasthan, Chhattisgarh, and Jharkhand, which are far behind. India has fared badly on SDG goals and particularly on goals related to health and poverty.

Structuring an optimal ‘big push’is the most critical link to chasing SDG goals.The efforts made at the macro level by government should be supported by efforts made at the micro level by households. Creating infrastructure and systems should be balanced by creating skills, education and awareness fordability of healthcare because they are forced to make huge out of pocket expenditures. They work for unorganised sector and cannot resort to health insurance largely. They fall into a vicious cycle of poverty - which results from inadequate source of livelihood, low productivity due to bad health.

Interconnection of goals

Micro level data and planning must

SDG goals are interconnected to each other. Universal Health Coverage, becomes a very difficult goal to achieve when about 276 million people (or about 23 per cent of the population) live below poverty line. According to Census 2011, the workers (consisting of main workers and marginal workers) formed 39.79 per cent (481.7 million people) of the total population as against 39.10 per cent in 2001 census. Only a small percentage of the total workforce of the country is employed in the organised sector. Organised sector employment as on March 31, 2011 was 29.00 million of which 60.52 per cent or 17.55 million was in public sector. The population that lives below poverty line falls short on the aspects of accessibility and af-

Structuring an optimal ‘big push’ is the most critical link to chasing SDG goals. The efforts made at the macro level by government should be supported by efforts made at the micro level by households. Creating infrastructure and systems should be balanced by creating skills, education and awareness. When there are resource constraints, optimal solutions are reached at by permutations, combinations and an interplay of variables, which would be too many in case of health, poverty, and livelihoods. There are zero sum situations, and a negotiation between various outcomes is hard to make. One of the factors which accounts for an interplay of variables with-in resource constraining situation is an

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imperative out of pocket expenditures to be made by those belonging to the lowest quintile in terms of disposable income. According to National Health Accounts statistics (2014), all households' out of pocket expenditures is 69.1 per cent of the total health expenditure. Households must resort to their own financing resources to seek healthcare. Many studies have indicated that households belonging to lower quintiles of disposable income are pushed back to below poverty line status because of imperative health expenditures. One of the main source of financing is assets and debt, for households. Healthcare expenditures thus account for dissavings for households having lower disposable incomes. Savings as a percentage of disposable incomes rise when incomes increases. Households that must make healthcare expenditures are not able to save enough to do capital formation, which leads to subsistence existence. Health-Wealth nexus, cannot be broken unless a push in terms of public health and livelihoods is provided. At the district level, a primary effort should be made to

identify these households. District level data related to poverty, unemployment, seasonal and disguised unemployment, nutrition, disease surveillance, health indicators, water and sanitation should be disaggregated at the panchayat and block level. Research related to epidemiology of the district should be collected by district health officer.

Health expenditure details are of paramount importance Health expenditure on preventive care is a very small percentage of curative care expenditure in India. As per National Health Accounts estimates general inpatient curative care accounts for 20.5 per cent of the total expenditure while outpatient care accounts for 29.5 per cent of total expenditure, while preventive care is a mere 9.6 per cent of expenditures. The underserved population with regards to health in India is huge and it is difficult to achieve the goal of universal health coverage or healthy India through curative way. It will require huge funds, and will cut into other essential developmental expenditure on educa-

tion, infrastructure, and energy. That is where the interconnectedness of health-poverty-livelihoods variables and the dynamic of interplay of these variables becomes extremely important tounderstand. Increasing public expenditure on preventive care is one such ‘big push’ that could be provided. Government budgets for all the preventive health programmes mentioned above should be increased at the centre and the state level. District level public health management cadre of officials, and larger investment in primary health has been mentioned as essential steps to be taken by the government in Health Policy 2017. Department of Statistics and Planning are working in close co-ordination with public health officials, to generate data, and design localised solutions for health problems in the district would bring results. The district public health office will prepare regular reports on epidemiological surveillance studies conducted in the district and combine it with poverty and unemployment data collected by department of statistics and planning to identify vulnerable population groups.

Employment generation schemes Linking MNREGA, and other employment generation schemes with health insurance, nutritional programmes, awareness programmes, disease surveillance and developmental works like infrastructure development, and water conservation would bring about bigger outcomes with cost effective investment. District level planning of comprehensive development schemes for a household which requires assistance in all the three areas of health, employment and poverty is the key to achieving SDG goals in India.


START-UP I N T E R V I E W

‘Building a solid business case is a better area to focus with approaching investors’ Manish Singhal, Founding Partner, pi Ventures, shares insights on the parameters required for startups to attract investors, in an interaction with Raelene Kambli Tell us a little about yourself and how you got involved in working with startups and early stage entrepreneurs? After doing my engineering from IIT Kanpur in 1992, I began building several products across startups and established organisations like Sling Media, Ittiam Systems and Motorola. Subsequently, we spent a few years mentoring and investing in several startups from technology and strategy perspective. In the process, also co-founded LetsVenture.com, a platform for investors and startups to discover each other. In short, I have been deeply engaged in the ecosystem for the last few years. What attracted you to invest in healthcare companies? India as a market is deeply underserved as far as healthcare is concerned. We have an abysmal patient to doctor ratio and if you talk about access to quality healthcare, the ratio further takes a beating. We simply cannot train enough doctors to bridge this gap. However, AIbacked technology can create a middle layer between the doctors and patient to make the system more effective. Hence, I am quite excited about how technology can make a difference to the entire healthcare space. What are the parameters you set for startups who approach you for fund raising? Beyond the usual parameters like team, product and market size, etc., we gauge how good the IP is, what are their real differentiators in IP, what is the

real AI algorithm that they have built. We also look at the data strategy they have put together; how do they plan to acquire data, who will the data belong to, how will it grow, what is its cost, etc. Third prerequisite is the specific business case of the start-up as we look to fund companies in the applied AI space. All the companies we have funded so far have a business case, which states the problem that they are solving, using AI to their advantage. In your experience, when is the best time for an early stage healthcare startup to raise capital that has been bootstrapping its operations? A key milestone in any startups’ journey is product market fit. That stage tells you that the market is somewhat receptive to the disruption the startup is causing. That is critical for a startup to further build on it and scale. I think reaching this stage is a very good stage for a fund raise. If, however, the startup needs capital to get product market fit stage, that can also be achieved if the innovation is unique and solves a real problem. Some validation on those fronts would be helpful.

A key milestone in any startups’ journey is product market fit. That stage tells you that the market is somewhat receptive to the disruption the startup is causing. That is critical for a startup to further build on it and scale

In the West, there are intermediaries who guide companies in their fund raising activities. How many of these firms exist in India and how much are they relevant to healthcare companies? What do these intermediaries really do? Intermediaries (also called Investment Bankers) are a part of the Indian eco-system as well. Our bias generally has

been that at early stage, the founders need to have enough skills and hustle to work their own fund raise out. Investment bankers can play a critical role in the advanced stages of funding. A lot of startups focus on valuation in order to attract investors and of course grow their business. Is this the right approach? What is your opinion on the same? Valuation is a result of a demand and supply problem. Over focussing on this can lead one on the wrong path. Focussing on building a solid business case is a better area to focus. Funding, valuation etc., will all fall in place if the core construct is in place. Which are the companies that you have invested in so far and how are they performing? We have invested in three health-tech companies; Sigtuple - a startup revolutionising digital pathology through data-driven intelligence, NIRAMAI Health Analytix - a startup that is building a revolutionary noninvasive, non-touch, nonradiation approach to detect breast cancer and ten3T – a medical grade wearable device for continuous monitoring of patients. What is your expectation from each of these companies and what is your vision for them? I expect each of these to become global players in the days to come. They should become the number one player in their respective fields. raelene.kambli@expressindia.com

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IT@HEALTHCARE INSIGHT

Current state of AI in radiology Dr Vidur Mahajan, Associate Director, Mahajan Imaging, mentions that the day is not far when software algorithms would assist radiologists and physicians in making diagnoses and imparting treatment to patients

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N 14TH November, 2017, a team of Stanford University scientists led by Andrew Ng, considered the foremost machine learning expert in the world, published an open paper describing an algorithm that can diagnose pneumonia in chest X-Ray at a rate much better than independent radiologists at Stanford. While many questions have been raised on the methodology associated with the development and validation of the results of the algorithm, one thing is clear – healthcare is now definitely on the radar of artificial intelligence experts and the day is not far when software algorithms would be assisting radiologists and physicians in making diagnoses and imparting treatment to patients. The day of 'replacement' radiologists and physicians though, in my opinion is much further away. The definition of artificial intelligence (AI) has changed through time based on variation of its applications, advancement in computing power and general dissipation of use-cases through society. In fact, John McCarthy, who coined the term AI in 1954 complained that as soon an algorithm or product 'works', it isn’t called AI any more. The reason for this is that AI is projected to be a future-state and hence, anything that works flawlessly now, is not given the glamour of being called an ‘AI product.’ Take Google Search for example, it might just be one of the most advanced AI applications around us, but no one really calls it that because it has become ingrained in our day-to-day existence. In truth, AI is the application of large scale statistical data analysis for predicting a result, having an in-built ability to learn from responses to such results.

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The definition of artificial intelligence (AI) has changed through time based on variation of its applications, advancement in computing power and general dissipation of use-cases through society (For more insight into this, I would recommend reading www.waitbutwhy.com’s blog post on Artificial Intelligence.) More specifically, in radiology, AI will bring about changes in two fairly obvious dimensions in the short to medium term – quality and efficiency.

Quality improvement in radiology using AI The first, and maybe the most direct way that AI will improve the quality of radiology will be by acting as an 'assistant' to radiologists, improving the consistency and accuracy of radiologists’ reports – essentially making a junior or general radiologist as accurate as a senior or subspecialised radiologist. An example of this is the chest X-Ray algorithm being worked on by Qure.AI, an Indian radiology AI company. A chest X-Ray is one of the most basic, but also one of the most difficult radiology investigations for a radiologist to report – such an algorithm, that can 'steer' a radiologist in the right direction, as far as a diagnosis is concerned, can go a long way in getting to a correct diagnosis. The other way quality will be improved is by the merging of the fields of AI and quantitative radiology (also called radiomics). This relatively old

field of radiomics has gotten a push recently given the reduced cost of computing power today and also the great abundance of AI tools that can be integrated. An example of this is a brain volumetry algorithm developed by QUIBIM (Valencia, Spain), which enables radiologists and neurologists to calculate the volume of a patient’s brain and its various components, enabling objective evaluation of several neurological illnesses. This quantitative approach means that new findings can be extracted from existing data simply because computers are able to 'see' in many more dimensions than the human brain. In fact, more recently, studies have been conducted which blend radiological and genomic data (a new field called Radiogenomics) enabling prediction of outcomes of diseases by taking into account both, radiological and genomic data.

Improving efficiency of radiology departments and radiologists While quality improvement in radiology might sound like a more distant concept, AI has already started bringing about huge improvements in efficiency in radiology departments. The most obvious application of AI in this sense is the

reduction of time associated with certain complex analysis. A fairly well-developed example of this is a liver tumour segmentation algorithm made by Predible Health (Bengaluru, India) which cuts down on postprocessing time associated segmenting out the liver vessels, parenchyma and tumour from 45-60 minutes to 5-10 minutes. Such algorithms are especially relevant in the developing world where companies have to operate in resource constraints. The other way in which AI is bringing about efficiencies in the radiological world is by helping with triaging. Picture this – there is a teleradiology centre that receives emergency CT scan images from 50 hospitals simultaneously. Currently, there is no way that a radiologist can ascertain which CT scan is most relevant and hence, starts reporting them in chronological order – a scan done earlier is reported earlier. In comes an AI algorithm that can 'read' the CT scan even before the radiologist sees it in her/his worklist. Eventually, a short while after the scan is acquired, when the CT scan does on the radiologist’s worklist, it is prioritised on the basis of the content of the actual scan. The algorithm may be able to detect, with a high degree of

specificity, which scans are normal, and might de-prioritise them, making optimal use of the radiologist’s time and delivering a quicker result to the patient that needs it more.

When will AI take over the radiologists’ job? This has to be the number one question on radiologists’ mind these days. Thoughts on this range all the way from 'never' to 'tomorrow'. After having spent a considerable time studying the current state of AI both generally and as it relates to radiology, my views are a little guarded. Before imagining a future state where ‘AI takes a radiologist’s job’ it is important to know that most technological innovation comes in phases. There will not be a single day where AI algorithms take over radiologists’ jobs, there will be an incremental shift where radiologists will eventually become many times more effective. A radiologist who reports 20 MRI scans today will report 50 or 100 cases per day. A junior radiologist will be as good as a senior, more experienced one. And then, most importantly, there is the issue of liability, one which is curtailing the implementation of AI without human supervision. Who takes the blame if the algorithm goes wrong? Even the world’s most specific algorithm will one day label an abnormal case as normal, leading to some loss to a patient – who will take the blame for this? Will it be the software company that sold the algorithm? Will it be the organisation that bought it? Or the doctor who should have been there to monitor it? (The author is unable to discuss specifics of most algorithms due to confidentiality and disclosure concerns)


POLICY WATCH I N T E R V I E W

Don’t imagine that a new model of healthcare will solve most problems of the population Sir Malcolm Grant, Chairman of National Health Service (NHS), UK was in India in early February, leading a Healthcare Innovation Trade Mission, Createch 2018, to the country. He tells Viveka Roychowdhury that India’s aspiration to move towards a model of universal health coverage (UHC), is the right one but cautions that it is the provider who wins the trust, expanding on the drawbacks of insurance-based UHC systems. Edited excerpts from the interaction

You started your address at the Healthcare Innovation Trade Mission to India by refuting US President Donald Trump’s tweet that the ‘NHS was broken and not working.’ India is taking baby steps towards its own brand of universal health coverage (UHC), through the National Health Protection Scheme announced in the Union Budget 2018. What are your comments on the amount of allocation, these measures? For me, UHC is the ultimate desire and should be of any civilised nation. But we have to appreciate that the healthcare system of any nation is a product of its culture and history. In America, it is not a model of UHC but the federal government intervenes throughout the process to ensure that the provision of healthcare is regulated and gets extended. So, Obamacare is built on a model of insurance. Insurance models, sometimes called the Bismarck model, after Otto von Bismarck, is probably the more common model around the world, certainly in France, Germany and much of the rest of Europe. The UK model, which is a very specific one, is almost entirely borne out of taxes. If you take the economic theory, we pool the risk across the whole population. We take from those who can afford, not from those who can't because that’s the nature of a graduated tax system. But it’s important to remember that not every nation can get to that. It was possible in the UK as a result of the social resettlement after the second World War which saw an enormous amount of government intervention in the economy. Which would have had to be the case through the war, so people saw this as a continuation, the redistribution of wealth and investment in the social fabric of the country. I would say that a huge advantage of a model of UHC under the British model is that nobody has to pay. People pay relatively small amounts on prescriptions, and for optical treatment and dentistry. But nobody is bankrupted by

medical bills. I feel that that is effectively a very strong moral statement. There is a small market of health insurance, it is probably less than 10 per cent of the population but many of those who have health insurance for many conditions would rather go to an NHS hospital rather than into a private one. Because the private one does not have the array of technology that a modern government NHS hospital would have. That’s why I was very strongly resistant to President Trump’s characterisation of UHC system being broken. It is just nonsense. He’s got a system in which there isn’t healthcare for some 22 million people in the US. I feel that his comments were ill informed and just wrong. So, when we come to India, again, I think the aspiration to move towards a model of UHC is the right one. There are many variants within it so you could have a model of UHC which has a insurance basis to it which could probably be France or Germany. Or you could have a model which is a mixed economy in which some people fall onto to the states for healthcare and others opt for private provision. Or you could have a model in which the state stands back and is not the sole payor but is the regulator of the system to ensure that through regulation of private, charitable and government operators you get uniformity of cover. That is more the German model where hospitals are one third private, one third state and one third charitable. So, it is a more mixed economy. The UK is probably towards one extreme in which we the NHS are both the single payer and the single provider. It is a much more complex ecosystem than that suggests. The advantage is that it reduces overheads. If you insert an insurance model then there are quite a lot of costs in setting policies, taking premiums, paying or resisting claims. And also of course, in an insurance model, having to tell the patient that their cover is not sufficient for this particular condition. Or,

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POLICY WATCH there is a pre-existing condition which they are not willing to offer cover for. That I think again provides a quite discriminatory model of healthcare as opposed to a universal one where rich or poor get the same treatment. So, from the Honourable Finance Minister’s statement. First, I would put great emphasis on the intent to move towards universal model of healthcare. Secondly, it will take a long time. Thirdly, it mustn't be simply investment in shiny new hospitals. It has to continue to increase the investment into primary care and to the prevention of ill health, particularly into rural areas, bringing down infant mortality rates, etc to bring primary care into the most remote areas using new technologies, all of which are at the forefront of the government’s mind. We now know that with smart phones, we can do a great deal for healthcare that previously required a physical visit from a trained professional to the patient. How can we apply the learnings from other countries in terms of health systems that the Indian government is trying to set up? Any particular country or model that you would suggest? Sri Lanka and Thailand are commonly cited examples. What are your views? I think these are very good examples. But you can look universally. If you go to the Commonwealth, then that gives you 11 models of healthcare. You have to ask, what are you judging it by? And if you judge it by outcomes and the health of the population then you have to realise that the uniformity on healthcare has a relatively small part to play in that. It has to do with the genes, environment, where people were born, live, work, etc. So to promote the health of a nation requires quite different actions such as enhanced sanitation, clean water, clean air, clean dwellings, and those are the major determinants of

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The UK model, which is a very specific one, is almost entirely borne out of taxes. If you take the economic theory, we pool the risk across the whole population. We take from those who can afford, not from those who can't because that’s the nature of a graduated tax system. If you are a good physician, the NHS can give you some really good specialist training which is in high demand back in India health for a big section of the population. So, we shouldn’t start by imagining that a new model of healthcare will solve most of the problems of the population. What it can do is give hope to those who suffer from a disease, and who are otherwise denied the right to means to have their proper treatment, I think we could look at any of the models around the world. The critical thing is how is risk shared. Is it shared with the whole or a part of the population? So in the American model of insurance scheme for example, would cover just those people who work for a company or maybe their families as well. The effect of that is that when you move to another employer, you lose your benefits. You might move to another employer whose health scheme doesn’t cover preexisting conditions. That is what I would warn those designing the Indian system of, if it is to be an insurance model. And I think as things are starting to go in India, I think that’s the likelihood. Then I think you need to move to an insurance to cover most of what is currently taken as out-of-pocket, which is around 68 per cent. Which is, going back to my original point, a huge burden on families. So there are 180 different health systems in the world, with a wealth of models. What is the impact of Brexit

on the NHS in terms of funding, etc? At the moment, it is difficult to say because we currently have no idea of where Brexit is going to land. There are two extremes. Britain ends up in a very close relationship with the rest of the EU, which is possible at the moment through a single market. You might call that the Norwegian, or actually Switzerland option. Or it comes out completely and starts out on its own. The consequences of that are quite different. The way in which it affects the NHS is first of all in terms of adequate funding. There was a great promise made at the time of Brexit that the UK government was sending off 350 million pounds a week to the EU, why wasn't that being invested back into the NHS? That was the rhetoric. That actually creates quite a great expectation. People went in for it (Brexit) because of that. And so we would anticipate that, and a number of senior politicians are agreed, that the Brexit bonus must be to the NHS. So, that I think is important. These are political promises, we wait to see its realisation. I think the second issue is around employment. We have a number of staff who are from other EU countries and there is quite a lot of concern being expressed at the moment as to whether we will lose these staff. There have been people who have left the NHS, a falling away in the

number of nurses seeking to be registered with the NHS. So, there is speculation on whether this just a short term blip, or will confidence return, as I suspect it will. This has been reinforced by statements made by the Prime Minister last week that the country is open still for people to come, work and live in the UK. The third element is the cost of drugs and equipment. For us, as far as cost is concerned, one of the by products of Brexit was the deterioration in the value of the pound. So, we are already bearing surplus costs, as much of our medical equipment and drugs are brought in from abroad. How that will be absorbed, remains a matter of uncertainty. Regulation likewise, the European Medicines Regulation Agency (Medicines and Healthcare products Regulatory Agency, MHRA), will move from London to Amsterdam. The question is, can the UK remain effectively a full member? Which is obviously desirable because then we have a single certification across Europe and we do not have to push pharma companies into different forms of accreditations. We and the government are all very sympathetic to the UK remaining in the EMEA (European Medicines Evaluation Agency) because for up to now, it has been the UK scientists who has been effectively running the EMEA.

What is the rationale behind the partnerships that the healthcare delegation seeks to cement during Createch 2018? And what are the next five years going to be like for the NHS, given the fact that you’ve completed 70 years? 70 years! Seems just like yesterday! But it is a serious point. It may be 70 years but its not been a static 70 years. It has been 70 years of innovation, change, development, churning through different institutions, different structures, different technologies. It is a very complex ecosystem. The partnerships that we hope to promote (during Createch 2018) are along the following lines. We’ve brought 14 institutions, three of them really good NHS Trusts. And, they were all chosen on the basis of their innovations. What are they doing that could help transform healthcare? Secondly, what could they do that could benefit them from coming to India, in terms of learning from India but also bringing products and ideas to India. Sometimes it is easier to get a product under development in the UK and manufacture here. What strikes me is that a number of them are so well suited to what is required in India. They are here talking to a number of investors, CEOs of healthcare companies to try to marry up an interest on the British side with an interest on the Indian side. You also talked about doctors and nurses from the NHS leaving possibly due to Brexit. The NHS has always had a very high percentage of healthcare professionals from India as well as other countries. Are they contributing to the development of healthcare manpower in India, as we have a dearth of doctors and nurses, both in terms of the capability as well as the numbers? How is the NHS collaborating either with the government or private institutions, on this aspect, given its strengths in


POLICY WATCH education, training and research? Historically, the NHS has employed quite a lot of Indian physicians. We think we've got around 50000 physicians of Indian origin working in the NHS. Not all of them were born in India, many were born in the UK but they are very proud of their Indian origins. Secondly, I've been surprised, since I've been here, of the number of people who have done their training in the NHS and are now physicians working in India. So, there has always been almost a pilgrimage to come and work in the NHS. If you are a good physician, the NHS can give you some really good specialist training which is in high demand back in India. As for nurses, again, there are quite a few nurses from India in the NHS. We also recruit quite heavily from the Philippines and else where. I think that will continue but I think there is a very strong moral case for recruiting professionals from a lower income country and then keeping them there. The visa system will continue to ensure that nurses can continue to come work in the UK but will then return to India. So, I think we need to do that in order to maintain supply here. The NHS has played a very pivotal role in keeping down the prices of medicines. Pharmaceutical companies don’t like the NHS for doing

that. And the Indian government is also taking steps towards this goal, with their decisions to cap the prices of medicines, including more medicines in the national list of essential medicines and also capping the prices of medical devices like heart stents. Is there any advising the NHS does for India’s Ministry of Health & Family Welfare, on a government to government basis. Are you looking at any collaborations within the government? Yes I think so. I had a meeting yesterday with the Additional Secretary, Ministry of Health & Family Welfare. We talked about an array of things but the critical thing is that NICE (National Institute for Health and Care Excellence) in the UK is a phenomenon. To have been able to set up an organisation which will give price regulation on the basis of cost effectiveness is quite extraordinary. A number of the pharma companies don't like that but actually most of them understand the rationale for it and are quite keen to have their drug accepted onto the NHS. So, what often happens is that if they are not regarded as cost effective, then they reduce the cost, There have been a number of instances where we have been able to complete an agreement with a drug company under completely confidential arrangements. We don't

It is the provider who wins the trust. Nobody cares about the Obamacare model. What they really care about is will they get safe and effective healthcare from a good provider

disclose the cost but we are able to bring benefit to NHS compared to what patients pay in unregulated markets. Particularly when its cancer medicines, which are very expensive and there are always claims that patients need a particular drug. We’ve turned the former cancer drugs fund into an experimental medicines fund, allowed medicines to come into it and have a trial for a couple of years whilst we measure its effectiveness in the clinic before we take a decision whether to include it or not into our formulary. I think the NICE model is one that many countries have wanted to emulate. India

would be in an ideal position to emulate it but I don’t know whether there is such a mechanism in place. Trust is very important, especially in the healthcare sector because the patient is in a very vulnerable state. Whether it is trust in the pill that you take or in the hospital that you go to, or in the system itself. The NHS is a very trusted healthcare brand. Other systems in the world, be it Obamacare, Trumpcare have not been trusted as much. And now as we start to put Modicare into place, it is going to take a long time to trust the system. What have been the key facets to build up trust? A couple of years back, the argument against the NHS was there was a long queue to get an appointment. Many countries built their medical tourism around the fact that people could not get an appointment at an NHS facility. First on the long queues. Certainly, 10 years ago that was a huge problem. People were waiting 18 months for elective surgery. Today, it is 18 weeks. We are mandated to start elective surgery within 18 weeks of the patient’s first appointment. How did you move from 18 months to 18 weeks? Several billion pounds! This was during Tony Blair’s premiership and he was challenged on TV on the UK’s

healthcare versus the rest of the EU and he said, I’ll fix that. So, we in the NHS were told, (this was before my time), here is the additional money, this is what you’ve got to do with it. So 85 per cent of our patients will have their elective care within 18 weeks and that globally is a really impressive figure. It’s much faster for cancer, and depending on the type of cancer it could be as little as two weeks. In the emergency room, we are the only country in the world which says you have to have a 95 per cent standard, not just of seeing patients, but treating and discharging them or admitting them in four hours. That is really amazing. Canada has six hours, other countries have eight hours. A lot of the government funding came on condition that we met those targets. The NHS does what it does and gets trust for being able to perform on this basis of being a very safe system. I would draw a distinction between Modicare and Obamacare on the one hand and the NHS on the other. The former are sort of funding streams, they are not provider streams. NHS is the provider. It is the provider who wins the trust. Nobody cares about the Obamacare model. What they really care about is will they get safe and effective healthcare from a good provider. viveka.r@expressindia.com

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POLICY WATCH I N T E R V I E W

‘Indian healthcare can transform if the one nation one public insurance system, delivered as promised’ Dr Mark Britnell, Chairman and Partner of the Global Health Practice at KPMG, informs that the world’s largest health protection scheme, the National Health Protection Scheme (NHPS) ‘is a clever move’ in an interview with Prathiba Raju How feasible is the new National Health Protection Scheme (NHPS), under the Ayushman Bharat plan, that will cover 100 million poor and families and 500 million people, providing each family an insurance of up to ` 5 lakh every year in case of secondary and tertiary hospitalisation? How will NHPS change the Indian healthcare system? Lot of promises were made earlier on the Universal healthcare system, but the promises have been kept hollow. I genuinely believe and hope that the announcements made in the recent Budget will be a seminal point for Indian healthcare. I have palpably sensed that people in the country believe that this change in the healthcare system is real for three reasons. First being it such a big statement to cover 100 million families and 500 million people and it is very important that its implementation is planned properly. Second, the budget has made a financial provision for launching the first phase of the Universal Healthcare. The third reason is India’s economic growth, which is about six per cent per annum and the introduction of the Goods and Services Tax. All these reasons make me feel that this development is real. The people I have spoken to in the Indian healthcare industry are filled with enthusiasm, particularly the private hospitals who will have a

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I genuinely believe and hope that the announcements made in the recent Budget will be seminal point for Indian healthcare. A healthcare cover for 100 million families and 500 million people is a big announcement and I hope that the promise is implemented in a proper manner. Being a full and final budget before the election and such a large promise, I believe its implementation will be of utmost importance significant expansion opportunity. I have been coming here to (India) for the past 20 years and I have never seen such prospects for growth, innovation, improvement and enthusiasm in the healthcare industry. With unfavourable conditions like public health expenditure by the government being 1.5 per cent which is very less compared to other BRIT nations, life expectancy is under 70 years of age. Frankly, there can be no national wealth in India unless there is

national health. KPMG today is 150-yearsold and in our experience of working with over 156 countries, and particularly a lot of work done on the Universal healthcare front, I can say that there was one key fault line in the budget announcement by India. It doesn't join the development of primary healthcare. In any high performing and relatively low cost healthcare system, there exists a need for a strong primary healthcare platform. A major downside of the

budget was that it did not have any announcement regarding spending enough money on primary care. It only talked about having wellness centres, the amount of money that is being directed towards these wellness centres and how they seem to be insufficient to meet the needs of the patients. We all know that public hospitals are overcrowded and they don't have enough capacity. I hope the government spends some of the budget allocation towards improving public health. The ideological

barricade between the private and public sector was wide, but this government is more plural in approach. The budget had a clear dictat for the private sector, i.e. to innovate itself and produce higher quality and low cost healthcare models. It has also indicated to the private sector not to follow the traditional business models and not to look on to the affluent section of the society. It clearly wanted the private sector to explore business models, which are indigenous. To sum up, it was a


POLICY WATCH very clever budget. The real action will be in engaging the private sector. Do you think private players in public health will work in India? We have had lot of PPP healthcare models which have failed? The reason for the Public Private Partnership (PPP) not working in healthcare could be due to lack of proper coordination and other operational issues. KPMG will be happy to partner with government and other relevant agencies so as to provide a truly global experience and develop an attractive business model. The government has to increase the way they pay and as mentioned earlier, private hospitals should change their business models. They till date follow the 20th century-based traditional, hospital and inpatients based service. So, this can be looked after in primary care, ambulatory care, diagnostic center, 18 to 23 hour facilities, emergency medicines, surgery and diagnostic facilities are taken care of. As stated previously, the Indian private sector has to be innovative, and change the business model. If they don't there would be new entrants from outside India as the political urgency for the universal healthcare is so strong. In India, for most healthcare facilities which were PPP based, land was free and treatment was available at a low cost, which was one of the reasons most of them failed. The challenge with the model is they should understand that P&L (Profit and Loss) statements are made every year and not once in a period of time. What would be KPMG’s role in the NHPS? An Indian firm with a global reach is needed, when you are launching a scheme such as this, both at the central and state government levels. There needs to be a perfect orchestration effort. There are many concerns post the budget announcements, so KPMG wants to help the central and state governments

An Indian firm with a global reach is needed, when you are launching a scheme such as this, both at the central and state government levels.There needs to be a perfect orchestration effort in this endeavor. We want to press upon the centrally coordinated capabilities and an execution plan that enables to implement UHC. In the past, we have seen many programmes that have not reached the intended beneficiaries. For such an ambitious plan there needs a radical, disciplined and focussed mindset, which works with and between the various states and the union government. For example, we are helping the Chinese to implement the UHC. China made the announcement of UHC in 2009 and they have now covered 100 millions of people over a decade. They had executed this with careful and proper planning specifically asking different states to lay down various issues. They also have a reform program which encourages FDI and they are now spending a lot of money on Primary Healthcare plus are improving pharmaceutical payments so as to reduce corruption. With increased payments to doctors and nurses the Chinese now have more central control and direction to the programme. Apart from China, we are working with Vietnam, Indonesia, Philippines, Brazil, Bangladesh, Pakistan and many other countries. What are the main components needed for a robust public insurance system? We are talking here about 'one nation one public insurance system', it takes time to have such a system as it needs a well-designed public enroll and claim settlement system in place. Five lakh rupees is a very big large amount and the uptake is going to be quite significant. Therefore, the government should be ready and design an insurance

system, which improves the health outcomes exponentially and keep the premium relatively low. What gets covered and how do you design it will have a significant impact on the premium if not in the first year but in the upcoming years. The NHPS has hinted about 1000 health packages. Can you explain how it should be designed? Bundle payments for care packages is a very progressive and advanced form of healthcare payment. KPMG is

concerned that India needs a very sophisticated payroll and purchasing mechanism to start, establish, monitor, direct and control these packages. Packages are in principle a great idea, in practice it needs to be carefully implemented. The NHPS is seen as Modicare and it is been compared to Obamacare. Your comments? The only similarity is that President Obama was trying to provide affordable healthcare to millions of people, who didn't have insurance and Prime

Minister Modi is trying to provide insurance to hundreds of millions. Under the Affordable Act or the Obamacare, Obama was trying to reduce the cost of healthcare by creating more accountable care organisations viz. primary care, hospital care and social care provided by the government. Individuals had to be covered by insurance. This is not the same with India, there is no legal penalty. Differences are obvious, US spends 18 per cent of its GDP on healthcare and India spends only 1.5 per cent of its GDP on healthcare. US has some form of primary care, though it is not excellent but India doesn't. There are superficial comparisons and they are not substantial ones. I don't think India has to mimic America and there are many other better healthcare systems to follow. prathiba.raju@expressindia.com

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POLICY WATCH INSIGHT

Amatter of concern for states NHPS may squeeze out funds from the public health system, writes Mita Choudhury, Associate Professor, National Institute of Public Finance and Policy (NIPFP), and informs that it will leave little room for other health spending in states THE NATIONAL Health Protection Scheme (NHPS) was the centrepiece of the Union Budget 2018. The NHPS is aimed to provide increased access to secondary and tertiary healthcare services through health insurance cover. This is, however, not a new announcement. The scheme was announced earlier by the Finance Minister (FM) in his budget speech of 2016, then with an insurance coverage for hospitalisation expenditures up to ` 1 lakh per annum for each underprivileged family. The scheme was, however, not rolled out, and the 2017 budget speech had no mention of the scheme. This year, the announcement has been made again, with an enhanced coverage of ` 5 lakh per annum. As per the estimates from NITI Aayog that have been made available after the budget speech, the NHPS is expected to cost around `10,000 crore to 12,000 crores. At this cost, the financial protection that can be extended to 10 crore households will be limited. The low expectation of the cost of NHPS possibly arises from the fact that, even after a decade of the launch of Rashtriya Swasthya Bima Yojana (RSBY) which provides an insurance coverage of ` 30,000 per family, less than four crore families have been enrolled under the scheme and several states have opted out of the scheme. In some of the poorer states, there have been major implementation hurdles. In Bihar, only around 50 per cent of the targeted households could be enrolled and, in UP, the scheme is yet to be operational. At the expected cost, while the Union Government’s fiscal

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burden on account of the scheme could well be covered through the additional 1 per cent cess imposed for health and education, there will be additional fiscal burden on the state governments. Given the focus on fiscal discipline in states, the need for additional payment toward NHPS may squeeze out funds from the public health system, and leave little room for other health spending. This will also infringe upon the autonomy of the state governments to independently design policies and programmes in the health sector, which is constitutionally a

more than three-fourths of the claims in existing health insurance schemes are for treatments in private facilities. This suggests that much of the additional public spending on health insurance will be absorbed by the private sector, and only a small part will go to the public health system. In the absence of a strong public sector (or any other viable alternative), it will be difficult to keep the cost of the insurance scheme down in the medium term. Moral hazard problems including overuse of medical services further escalate cost.

Given the focus on fiscal discipline in states, the need for additional payment toward NHPS may squeeze out funds from the public health system, and leave little room for other health spending in the states.This will also infringe upon the autonomy of the state governments to independently design policies and programmes in the health sector, which is constitutionally a state subject state subject. States that already have their own health insurance schemes will face other problems. In many such states, the population covered under the state schemes is larger than the BPL population identified by the Union Government though the sum assured is lower than the amount announced by the FM. Given this, there would be pressure on these states to upgrade their state-level schemes to match the benefits provided under the Central government

scheme. This would further add to the fiscal burden in such states. Since implementation of such a scheme would invariably involve additional fiscal resources of the Union and the state governments, it is important to reflect on the effectiveness of public spending on such schemes. The proposed scheme will cover secondary and tertiary care, which may be provided by the public or private facilities. However, experience shows that, in most states,

Given the weak regulatory environment in India and experience from existing schemes in states, such schemes are likely to be fraught with moral hazard problems. Even if one uses a trust to implement the scheme, as is the case in many states, the costs of monitoring and containing the moral hazard are likely to be substantial and grow with scaling up of the operations. In the absence of effective gatekeeping through a wellfunctioning primary healthcare system, there will also be

a shift in public spending towards more expensive hospitalisations. The need for secondary and tertiary care will be high, and this will escalate the cost for the government. In this context, although the announcement to strengthen primary care through ‘health and wellness centres’ is welcome, the allocations are far lower than required. The scheme is also unlikely to significantly reduce the burden of out-of-pocket expenditure, as only around a third of the out-of-pocket expenditure on healthcare in India is on inpatient care. Besides, evidence suggests that such schemes are not effective in extending financial protection to the poorest of the poor. These have implications for effectiveness of public spending through the scheme. On the whole, given the low expected cost of implementing the NHPS, the financial protection that can be potentially extended through the scheme is likely to be limited. Additionally, the need for states contribution towards the scheme may have adverse financial implications for public health systems at the statelevel. This will also curtail states’ autonomy to design their own policies in a sector that is constitutionally mandated to be in their domain. There are also concerns about the effectiveness of public spending and cost inflation in the scheme in the absence of a competitive alternative, and effective gatekeeping at the primary healthcare level. Evidence around the world has shown that such insurancebased healthcare is an expensive model of financing healthcare for the government.


KNOWLEDGE I N T E R V I E W

‘Ruby Hall has been at the forefront in delivering high quality care in organ transplant’ Dr Sheetal Dhadphale Mahajani, Hepatologist, Liver Transplant Physician & In-Charge, Department of Liver Transplant, Ruby Hall Cinic, in an interaction with Mansha Gagneja, throws light on the evolution of liver transplantation techniques and how technology is playing an integral role to bring in better quality and affordability

Ruby Hall has been at the forefront in delivering high quality care in organ transplant. We are ahead of all the hospitals in Pune in promoting and initiating organ donations

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Can you elaborate on how much has the liver transplantation technique evolved since 1960’s? Liver transplant is the treatment offered to patients suffering from end stage liver disease across the globe. The first liver transplant was done by Late Dr Thomas Starzl in 1963. It took good six to seven years before it was regularly offered to the patients in the US/UK. It was in 1993 when the first transplant was conducted in India. Subsequently, in the 20th century, it was available to Indian patients. However, this treatment modality was available only to patients residing in the metros, mainly Chennai, Delhi, Hyderabad, Bengaluru and Mumbai. There was a huge demand for this procedure in Pune and rest of Maharashtra. Ruby Hall Clinic, Pune was able to bring this treatment to Pune in 2013 and set up a liver transplant programme of international repute for patients residing in Pune and rest of Maharashtra apart from Mumbai. ◗ First successful liver transplant was conducted in January 2013 ◗ First combined liver and kidney transplant was conducted in March 2013 ◗ First adult to adult living donor transplant was conducted in May 2016 ◗ Liver transplant surgery without using any blood products What is the role of technology in the field of

liver transplantation? How has it changed in recent times? The understanding of the process of transplant surgery, post-operative management and long-term management has remarkably changed. Some of the surgical techniques have changed for example no venovenous bypass is needed now. The surgical technique has refined so much that the time incurred is really less compared to before, the blood loss is minimised, anaesthesia has changed. The blood component requirement has gone down significantly. Surgical innovation has allowed split transplants, adult donor left lobe transplants. The risk to the living donor has minimised significantly. The recovery post transplant is very fast, patients can go home on an average in seven to ten days. The immunosuppression medicines are more safe and effective. In the coming five years, What changes do you predict in this field? In the next five years, our centre will evolve as country’s advance care giving centre for all liver disease patients and liver transplants. We wish to take the deceased donor programme to another level. More complicated surgeries of split transplants and domino transplants will be routinely done. More research will be done on hepatocyte transplants and liver support devices.

How can the affordability be improved? The increasing number will definitely bring down the cost. Drugs and disposables can have subsidy so that cost can go down. The transplant facility can be made available in the government set up so that it will be available for the economically challenged group. Can drone technology, green corridors aid in bringing about more timely and effective transplants? Intercity and inside a city transport of organs gets facilitated by creating green corridors. Traffic police play a crucial role in minimising the delays in transfer of organs. Newer technology like drones have a lot of scope in improving organ transport. How has Ruby Hall been at the forefront in delivering high quality care in liver transplants? Ruby Hall has been at the forefront in delivering high quality care in organ transplant. We are ahead of all the hospitals in Pune in promoting and initiating organ donations. We have received government of India – NOTTO best transplant award. When it comes to the innovations and nuances in medical technology ,Ruby Hall has been always leading. We have been helping the needy patients who require transplants though the social work department and help them raise the funds. mansha.gagneja@expressindia.com


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The combination of results can be used as an aid to identify the disease.

Individual febrile antigens are available for Brucella abortus and Brucella melitensis.

Antigen suspensions for S.typhi (OD and Hd) and S. paratyphi (OA, OB, OC, Ha, Hb and Hc)

Individual febrile antigens are available for Proteus OX-2, Proteus OX-K and Proteus OX-19. ●

Stained Febrile antigens in convenient dropper vials.

Suitable for both slide and tube test protocols.

Individual antigens and kits are available with different combinations of febrile antigens with Positive and Negative controls*

508, 5th Floor, Western Edge-I, Kanakia Spaces, Opp. Magathane Bus Depot, Western Express Highway, Borivali (E), Mumbai-400066 T: +91-22-28702251 F: +91-22-28702241 E: info@omegadiagnostics.co.in W: www.omegadiagnostics.com www.omegadiagnostics.co.in A subsidiary of Omega Diagnostics Group PLC ODX/SEP015/FEBIL/EXPHEALTH/V3.0

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CIN :U51909MH2011FTC219692

*please inquire for the various combinations available in kit form.

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TRADE AND TRENDS I N T E R V I E W

‘Our focus is to promote indigenous medical devices’ Himanshu Baid, MD, Poly Medicure, in an interaction with Prathiba Raju, talks about how Poly Medicure is catering to the changes in the Indian medical devices market How do you see the last full budget of the present government? As far as the healthcare is concerned, I’m very happy that the government has taken a huge step in making healthcare affordable and accessible by launching Ayushman Bharat, the world’s largest healthcare scheme. We need to wait and watch how the government is going to fulfill the promise of bringing over 10 crore Below the Poverty Line (BPL) families under a health insurance scheme and enhance health insurance cover up to `5 lakh, which is a big amount. For example, if a family of four is covered under the `5 lakh plan, the cost of premium under the private insurance as of now is nearly `20,000 a year. Moreover, as it is a government programme, the premium can be reduced to `10,000, but still the budget required is ` 1 lakh crore. Nevertheless, the government has informed that `5,0006,000 crore is needed to get the budget going in the first year and `10,000-12,000 crore annually as it scales up. I can't understand the mathematics behind it and how the government is going to roll it out. For the medical devices industry, the budget was a disappointment. In 2016, the government had reduced the custom duty of raw materials to 2.5 per cent , but it was not done for In Vitro Diagnostic (IVD)s, which is a part of the sector. If the government really wants to ‘Make in India’, they should have reduced the custom duty of all the raw materials used in the medical devices, particularly IVDs. The government announces a lot of measures to boost local manufacturing, but it is not implemented. For example,

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necessary or an average pricing formula should be brought in and a trade margin should be set and the list should be made public, similar to stents and knee implants.

We will soon launch a miniature portable artificial kidney dialysis, which will help in continuous blood cleansing. In many hospitals to save costs, the dialysis filter is reused in patients six or seven times, it exposes them to infections such as Hepatitis B and C the number of medical parks, which were announced in various states is still a nonstarter as none of them are operational. The projects are delayed in various states. How do you see India’s drugpricing regulator National Pharmaceutical Pricing Authority's (NPPA) move on price control on few medical devices? NPPA and the Department of Pharmaceuticals are in discussion about categorisation of medical

devices into different segments for the purpose of fixing of trade margins. But the medical devices industry is continuing to be divided on the move of rationalisation of trade margins. For me, the trade margin should be made higher. Currently, the margin of certain products from the factory price to the MRP, are 10 to 15 times higher. The common man is not aware of it and he ends up paying what the hospital charges him -- be it a glove or a stent. So, rationalisation of the price is

What is your comment on the National Medical Device Policy? National Medical Device Policy (NMDP) 2015 was drafted to boost the local medical devices industry and enable them to get cohesive, promote innovations and to safeguard medical devices industry against tariff and non-tariff trade barriers. It is still to be implemented. The government should have a separate medical devices department under the Ministry of Health and Family Welfare (MoH&FW). The medical devices cater more to the healthcare than the pharmaceutical sector. Too many governing bodies with diverse requirements and standards, viz Department of Pharmaceuticals, Bio Technology, Telecommunications, Ministry of Environment and Forest, Ministry of Science and Technology, Ministry of Commerce, are a hindrance to promotion of new technology. These affect ease of doing business as the decision making becomes slow. For the industry to grow and make it a hub, we need a nodal department, which focusses on the segment. The medical devices industry is just like the automobile industry, as a lot of Research and Development (R&D) takes place. By allowing weighted tax deduction of up to 200 per cent on R&D investments for the sector will promote innovation. Currently, it is reduced to 150 per cent and further it is said to be reduced to 100 per cent.

How much was invested in the new green field project at IMT Faridabad in Haryana? Can you give us some details of the facility and which new products are manufactured in the new facility? Poly Medicure has spent ` 60 crore on the new green field project, another ` 50 to 60 crore will be spent on the capacity expansion, automation and new products to be launched. Polymed produces 100 different types of medical devices, the category ranges from infusion therapy, central venous catheter, blood management system, surgery and wound drainage, anaesthesia, urology, gastroenterology and dialysis. With 98 per cent products of the renal care imported, we will soon launch miniature portable artificial kidney dialyser, which will help in continuous blood cleansing. In many hospitals to save costs, the dialyser filter is reused in patients six or seven times, which exposes them to infections such as Hepatitis B and C. Only few patients are able to afford new dialyser as it costs ` 2500 to ` 3000. Most of these filters are imported and they remain a financial burden to the patients. A filter developed indigenous in India will help decrease the cost and more people will be able to afford it. The Poly Medicure dialysis product package will be ranging from ` 500 to 550, which is `800 in the market. Our idea is to make more products in the import substitution. Polymed has over 100 products and every year we try to bring in at least eight new products into the market. prathiba.raju@expressindia.com


Carestream’s successful R&D efforts earn 36 US patents in 2017 The company is developing innovative new technologies for medical and healthcare IT systems CARESTREAM Health was awarded 36 new patents from the US Patent and Trademark Office last year for innovation in radiography; cone beam CT imaging; healthcare IT and other areas. The company also received 43 additional patents in European and Asian countries last year. “These patents demonstrate Carestream’s continued success in developing advanced imaging and healthcare IT technologies that serve providers around the world,” said Susan Parulski, Chief Patent Counsel, Carestream. “We are committed to delivering new products and services that can enhance im-

age quality, deliver greater productivity and offer new ca-

pabilities to help improve the quality of care.”

New patents earned by the company’s scientists and engineers include: ◗ New medical image capture technologies related to the development of cone beam computed tomography (CT) systems designed for orthopaedic extremity imaging ◗ Enhancements to Carestream’s portfolio of healthcare IT systems that manage, store and share patient data and medical imaging exams ◗ Continued technology ad-

vances in Carestream’s growing portfolio of radiology systems that can enhance diagnostic image quality for a wide range of healthcare providers; and ◗ Advancements in Carestream laser imagers that provide affordable output of digital X-ray exams onto medical film and paper. ◗ The company’s product portfolio includes digital imaging systems for general radiology and specialty areas such as orthopaedics and paediatrics; digital laser imagers that output medical images to film and paper; and the latest healthcare IT solutions and cloudbased services for hospitals, clinics and physician practices. Contact: www.carestream.in

Patient safety and powdered gloves Dr Pravin K Nair, Consultant Microbiologist & Head Infection Control, Holy Spirit Hospital, gives an insight on using the right gloves THE TOPIC heading looks very absurd. I would have thought the same if I had read this article 10 years before, but with development of science and more evidence coming in, the heading of my article is more relevant and in context with the current patient safety standards. No one in the healthcare industry would be remembering William Halstead, Chief Surgeon, Johns Hopkins Hospital in 1896 as the person who discovered surgical gloves. He discovered this not to protect patients from infections but to protect his wife’s hands from dermatitis caused by mercuric chloride used for cleaning instruments and with the help of Goodyear tyre company. The discovery and increased incidence of AIDS (HIV) in the early to mid-1980s

resulted in a tremendous increase of latex examination gloves. In 2008 ,more than 12 billion units of medical gloves were sold. Club Moss, talcum powder and finally Cornstarch were used as lubricants for the gloves. Today most international standards do not accept the use of talc as a lubricant. Most developed countries have standards for gloves, unlike in India where atleast I am unaware of the existence of such standards. European standard EN 455part 3, American standards ASTM D3577 besides ISO standards are being followed by Japan, China and others.

Health and safety concerns For patients: Inflammation, granuloma for-

resistant Staphylococcus aureus (MRSA) and Vancomycin resistant enterococci (VRE) may be able to use glove powder as vector in a hospital environment (Newsom & Shaw ,1997). All these contribute to longer hospital patient stay and increased healthcare costs.

mation, granulamatous peritonitis, adhesions, allergic responses,delayed wound healing are enough to alarm us. Cardiac complications such as granulomatous endocarditis, thrombi have been documented (Truscott 1977). Experiments conducted demonstrated that Methicillin-

For healthcare workers: Immediate type I response (Latex allergy) in approximately 17 per cent of healthcare workers. Occupational asthma in 9 per cent of healthcare workers. What are other countries doing? Hospitals around the world are realising the dangers of cornstarch on examination and surgical gloves are being manufactured using powder free

alternatives. ◗ 1997: Banned in Germany ◗ 2000: Banned in UK ◗ 2016: Banned in Japan ◗ 2017: The US, Saudi Arabia, South Korea and Hong Kong In India many hospitals are unaware of the potential hazards compounded with no regulations on glove manufacturing/imports.

Conclusion The significance of these studies and findings justifies the consideration of switching from powdered to powder-free gloves. We at Holy Spirit Hospital, Mumbai has taken a conscious decision for being a patient centric as well as staff centric hospital hence has introduced powder free gloves from November 2017. Come and join us in this endeavour.

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TRADE AND TRENDS

Philips Ob/Gyn ultrasound solutions: Advance your diagnostic confidence Philips’ latest premium ultrasound platform is designed to meet changing healthcare needs and exceed its users expectations WITH A history of proven leadership and innovation fuelling exciting new chapters in ultrasound evolution, Philips' latest premium ultrasound platform is designed to meet changing healthcare needs and exceed its users expectations. As we integrate new applications, improve workflow and produce groundbreaking capabilities, the company will continue to challenge how the industry defines ultrasound technology.

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MaxVue high-definition display - Remarkable visualisation! At the touch of a button, the new MaxVue high-definition display brings extraordinary visualisation of anatomy with 1,179,648 additional image pixels compared to a standard 4:3 display format mode. MaxVue enhances ultrasound viewing and provides 38 per cent more viewing area to optimise the display of dual, side/side, biplane, and scrolling imaging modes.

MicroFlow Imaging Philips MicroFlow Imaging (MFI), is a proprietary imaging mode designed to detect low volume, low velocity blood flow found in fetal, placental, uterine and ovarian vasculature. Mi-

croFlow Imaging overcomes many of the technical barriers associated with conventional methods to detect small vessel blood flow with high resolution and minimal artifacts. MicroFlow Imaging maintains

high frame rate and 2D image quality while applying advanced artifact reduction techniques. New 2D image subtraction, 2D blending and side-by-side display options offer excellent visualization versatility.


TRADE AND TRENDS TrueVue - Making images more realistic TrueVue creates images that are more realistic, appealing and at the same time providing more clinical information. TrueVue, with its virtual light source, is a proprietary advanced 3D ultrasound display method that delivers amazing lifelike 3D ultrasound images and gives the operator the ability to move the light source anywhere in the 3D volume.

GlassVue – Going beyond the surface GlassVue goes beyond the surface to reveal bone, organs, and other internal structures. GlassVue, with internal light source, provides an early, more transparent view of the foetal anatomy than traditional ultrasound.

aReveal – Revealing more details at a click of a button! aReveal is an AIUS (Anatomical Intelligence Ultrasound) feature that automatically sculpts away the soft tissues that lie in front of the foetal face, revealing much better facial features. Thus diagnosing cleft lips or cleft palates becomes easier and faster.

Evolution 4.0 and Continuum 2.0 Philips ultrasound has been constantly bringing to the fore, innovative technologies that are practically useful in the daily clinical practice. These technologies are focussed towards improving the workflow while simultaneously delivering better clinical outcomes. The latest evolution and continuum series further enhance our capabilities in the ObGyn ultrasound imaging.

These include TouchVue (TrueVue 2.0) – With the Evolution 4.0 upgrade, TrueVue adds a new interactive interface called TouchVue. The TouchVue interface utilises the touch panel to allow fingertip control of both volume rotation and position of the internal light source directly on the TrueVue 3D image. This obviates the need to use the control panel - including track ball – for working on

the 3D/4D images. Similarly, the GlassVue is also now available on the touch panel itself. AI Breast – With this feature, anatomical intelligence is now applied for breast ultrasound for enhancing clinical efficiency, while simultaneously improving the ease of use. AI Breast allows visual mapping of screened anatomy, documenting full coverage of the breast during the acquisition phase. During acquisition, key images can be bookmarked for quick review. Images can be auto annotated and quick orthogonal views of anatomy can be retrieved easily for enhanced workflow and documentation. aBiometry Assit– Virtually every obstetrical ultrasound examination includes standardized measurements of fetal structures to assess age and growth trends. aBiometry AssistA.I. uses anatomical intelligence of fetal anatomy to automatically preplace measurement cursors on selected structures, which users can quickly accept or edit. This helps reduce conventional measurement steps and streamlines obstetrical report generation. aBiometry AssistA.I. allows selection of auto measure function for BPD, HC, AC, and FL fetal structures. Tilt – A new Tilt feature provides lateral steering of the 2D image plane to the right or left. 2D Tilt allows scanning access to anatomical structures that are off-axis without having to manually angle the transducer. This helps reduce the pain and discomfort to the patient, while allowing the user to scan a wider region of interest. Contact details For further information contact www.philips.co.in, 18004198844 In the January 2018 issue, on page 59, the introductory line was wrongly mentioned. The correct line is 'Philips’ latest premium ultrasound platform is designed to meet changing healthcare needs and exceed its users’ highest expectations'

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THE GOAL IS TO BRING WORLD-CLASS HEALTHCARE TO INDIA THAT IS AVAILABLE, AFFORDABLE AND ACCOUNTABLE IUIH brings in world-class healthcare for 400 million Indians, the PPP way

T

he Indo UK Institute of Health (IUIH) Medicity Programme brings in world-class affordable, NHSquality healthcare for 400 million Indians. IUIH will contribute to healthcare infrastructure development; management and operations of healthcare facilities for efficiency, economy and quality; capacity building and training; IT backbone and data repositories for access to clinical information; and materials management including supply chains for ready availability of equipment, appliances, medical supplies, etc. The goal is to bring world-class healthcare to India that is available, affordable and accountable. The Indo UK Institute of Health (IUIH) Medicity Programme was announced as a Joint Statement between the Prime Minister of the Republic of India Marendra Modi and past Prime Minister of the United Kingdom David Cameron on November 12, 2015. The programme involves as investment of $1 billion into Indian healthcare. Aimed at opening 11 institutes across India in partnership with the world's best healthcare system – the National Health Service (NHS), UK. IUIH had celebrated its first anniversary in November 2016 at the Indo UK Tech Summit in Delhi inaugurated by Prime Minister Modi and Prime Minister of the UK, Theresa May. IUIH celebrated its second anniversary in 2017 by commencing the construction of its IUIH Medicity Nagpur in December 2017. The masterplan for IUIH Medicity Nagpur has been designed by world-renowned British architect firm – IBI Group. The construction contract for it has been awarded to Larsen & Toubro, one of the leading civil engineering companies. According to Dr Ajay Rajan Gupta, Group MD and CEO, IUIH, “We have been implementing our plans at a rapid pace. In the first two years, MoUs have been signed with eight Indian state governments, land parcels have been identified in six states, the land has been acquired in three

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Dr Ajay Rajan Gupta, MD and Group CEO, IUIH meeting the Prime Minister Narendra Modi at London, UK

If we desire to do something for India, the time is now for we have a progressive Prime Minister at the helm. It is his dynamism and vision that drove me to think of a venture of this scale and magnitude DR AJAY RAJAN GUPTA, Group MD and CEO, IUIH,

states, foundation stones have been laid in two states and construction work has started in the first state.” The IUIH Programme is said to be one the world's largest infrastructure healthcare projects. It is designated for the provision of integrated healthcare facilities to all Indians, and will build a capacity of 11,000 beds, 5,000 doctors, 25,000 nurses and generate direct and indirect employment for over 300,000 Indians. UP to 20 per cent of patients will be given free treatment at IUIH facilities. Each Medicity is planned to include a 1,000 – bed hospital in close partnership with one of the UK's leading NHS hospitals, nursing college, medical college, training academy, manufacturing units, residential units and commercial space. “If we desire to do something for India, the time is now, for we have a progressive Prime Minister at the helm. It is his dynamism and vision that drove me to think of a venture of this scale and magnitude,” added Dr Gupta.


Different zones in IUH Medicities designed by world-renowned architectural firm, the IBI Group

Chief Minister of Maharashtra, Devendra Fadnavis unveiling the foundation stone of IUIH Medicity Nagpur along with Dr Ajay Rajan Gupta, MD & Group CEO, IUIH

Chief Minister of Andhra Pradesh, Nara Chandra Babu Naidu unveiling the foundation stone of IUIH Medicity Amaravati along with Dr Ajay Rajan Gupta, MD and Group CEO, IUIH

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TRADE AND TRENDS

Immunoturbidimetry reagents: Ease of use with innovation in future Dr Rajesh Rengarajan, Product Manager-Clinical Chemistry, DiaSys Diagnostic India, gives an insight on the technique of immunoturbidimetry IMMUNOTURBIDIMETRY (IT) is an important technique in the broad diagnostic field of clinical chemistry. It is used to determine serum proteins which are not detectable with classical clinical chemistry methods and antigen-antibody reaction. Immunoturbidimetry is based on specific and sensitive reactions between an antigen and an antibody. Each antibody binds to a specific antigen (key and lock). Antigens are substances that induce an immune response (production of antibodies). The immunoturbidimetry is further classified into two types such as direct immunoturbidimetry and particle enhanced turbidimetric immuno

assay (PETIA).The principle of precipitation reaction is the interaction of antigen with antibody leading to the production of antigen-antibody complexes. The Prozone security is an optimal antibody-antigen ratio that leads to maximal precipitation. If the antigen concentration exceeds a certain level, antibody saturation occurs, followed by decreased precipitation and, in turn, lowers measuring signals. This effect is described as high dose hook orantigen excess effect. The advantages of immunoturbidimetry versus the conventional slide agglutination method are the high sensitivity, quantitative result, high prozone security, and independency of manual application.

The disadvantages of agglutination slide tests are the differing drop size of sample or latex reagent , the contamination of reagent or use by splattering, visual interpretation (depends on user), time-consuming and labor intense, qualitative (+ or ) or semi-quantitative results (+,++,+++,++++), and false differentiation of borderline cases. DiaSys immunoturbidimetric tests are provided in various kits for multi-purpose or automated use on common clinical chemistry analysers. DiaSys offers a broad range of human matrix based calibrators and controls for general clinical chemistry, lipid parameters, specific proteins, etc. with a variety of interest-

ing analytes. DiaSys immunoturbidimetry has a wide measuring range in combination with high prozone security, no sample dilution and reliable results for all normal and pathological samples due to high prozone limit. It also provides extremely sensitive results (LOD as low as zeptomole level), due to the absence of interfering emissions (i.e. high specificity) leaving No Doubt in immunoturbidimetry test. Contact details DiaSys Diagnostics India Plot# 821, TTC Industrial Area, Mahape MIDC, Navi Mumbai - 400 710 Mob: +91 9766 832 134

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ence 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

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Express Healthcare (Vol.12, No.3) March, 2018  

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Express Healthcare (Vol.12, No.3) March, 2018  

India's Foremost Healthcare Magazine

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