THE PREMIER MONTHLY MAGAZINE ON THE ENTERPRISE OF HEALTHCARE IN ASIA & THE MIDDLE EAST VOLUME 14 / ISSUE 07 / AUGUST 2019 / ` 200 / US $20 / ISSN 0973-8959
Raghubar Das Chief Minister of Jharkhand Ramchandra Chandravanshi
Minister of Health, Medical Education & Family Welfare, Government of Jharkhand
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iz/kku ea=h Prime Minister
MESSAGE It is pleasure to learn that Health, Medical Education & Family Welfare Department, Government of Jharkhand and Elets Technomedia Pvt Ltd are jointly organizing a ‘Healthcare Summit Jharkhand’. Proper healthcare is the prerogative of every individual in any society. Every person wants to a lead a healthy and stress-free life. It is our Government’s commitment and firm resolve to deliver affordable healthcare to the poor, needy and underprivileged sections of the society at their door steps. We want affordable and holistic healthcare to reach the remotest villages and corners of our country. We have implemented initiatives like Pradhan Mantri Jan Aarogya Yojana, Pradhan Mantri Surakshit Matritva Abhiyan and Mission Indradhanush to reach out to the people. The unimaginable power of Yoga can bestow health benefits and prevent the onset of diseases to the people at almost zero budget. Widespread community participation is a must to make these initiatives successful. The gathering of health professionals, experts and doctors at the ‘Healthcare Summit Jharkhand’ is an ideal platform to share the latest technological advancements and experiences for mutual benefit. The discussions will surely suggest a roadmap to make holistic and affordable healthcare for all. My best wishes for the noble initiative of holding ‘Healthcare Summit Jhakhand’. I am sure that the souvenir being published on the occasion will inform and educate the people on various initiatives in the health sector.
New Delhi Jko.k 8, “kd laor~ 1941 30th July, 2019
(Narendra Modi)
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AUGUST 2019 | VOLUME 14 | ISSUE 07
11
COVER STORY
Jharkhand Making Giant Leap to Ensure Inclusive, Affordable Healthcare POLICYMAKER’S PERSPECTIVE
PPP PERSPECTIVE 24 Medall — Fostering Accessible, Affordable
Model of Patient Care 28 Emergence of PPP in Diagnostics in India
20
Dr Nitin Madan Kulkarni
Secretary Department of Health, Medical Education & Family Welfare Government of Jharkhand
32
Sanjaya Kumar Singh
Niraj Arora
CEO, HealthMap
30 Ziqitza HealthCare Optimising Healthcare
Delivery in Efficient-Way
Managing Director, Bihar Medical Services and Infrastructure Corporation Limited
TECHNOLOGY PERSPECTIVE
SPECIAL FEATURE
EMS: The Lifeline for Critical Patients
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26 Digital Dispensary in Jharkhand — A Boon 38 Tata Winger Ambulance Facilitating
Emergency Care
BEST PRACTICES IN HEALTHCARE 36 Delhi’s Healthcare Delivery System: Best
and Next Practices Dr Ashok Kumar
Director General, Directorate General of Health Services, Government of NCT of Delhi
Editorial Jharkhand ensuring last-mile public healthcare delivery With healthcare becoming a focus point, as reflected through Narendra Modi Government’s game-changer Ayushman Bharat scheme, the Government of Jharkhand has gone out of its way to evolve the State’s healthcare delivery system, enabling people of all strata of the society better patient care in terms of accessibility and affordability. One must have vivid memory of last year’s incident when Prime Minister Narendra Modi had launched the scheme from the soil of Jharkhand, providing much needed succor to poor and vulnerable section of the society. Taking a leaf from the Centre, the Jharkhand Government is taking all measures to improve care delivery system to ensure wellbeing of each and every citizen of the State. Our latest cover story titled ‘Jharkhand Making Giant Leap to Ensure Inclusive, Affordable Healthcare’ thus touches upon various aspects of this all-important healthcare sector. It highlights how the State has come a long way since its inception in 2000 and has made tremendous progress in every sectors including healthcare. Despite having lots of challenges in terms of hilly terrain and a large swathe of tribal population, the State has improved its rank in healthcare index and recent Niti Aayog report vouches for the same. The story encapsulates how the State Government has leveraged Public Private Partnership (PPP) model to fill infrastructural gaps on many fronts. The latest issue also features insightful interview of Dr Nitin Madan Kulkarni, Secretary, Department of Health, Medical Education & Family Welfare, Government of Jharkhand, who sheds lights on various initiatives of the Government undertaken to improve healthcare delivery to the last mile. We also have a special feature on Emergency Medical Services which takes into account various aspect of emergency care and its significance in providing immediate care in critical situations. The magazine has also insightful articles on Public Private Partnership model which plays a pivotal role to resuscitate healthcare infrastructure. The articles on behalf of Medall, Ziqitza HealthCare, Apollo Tele Health Services, Healthmap, and Tata Motors present comparative accounts of their contribution to bolster patient care across length and breadth of India. With such a bouquet of articles, interviews and stories, we hope this edition will evoke an invaluable response from our esteemed readers.
Dr Ravi Gupta Editor-in-Chief eHEALTH Magazine and Founder Publisher & CEO Elets Technomedia Pvt. Ltd. ravi.gupta@elets.in
COVER STORY
Jharkhand Making Giant Leap to Ensure Inclusive, Affordable Healthcare Despite huge demographic challenges in terms of large swathe of difficult terrain and tribal population, Jharkhand has come a long way serving the people of the State with quality and accessible care. The Government has leveraged Centre’s game-changer scheme Ayushman Bharat and various other initiatives through PPP mode to resuscitate healthcare infrastructure across the State, writes Mukul Kumar Mishra and Gopi Krishna Arora of Elets News Network (ENN).
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W
ith India facing a double whammy of communicable, and non-communicable diseases due to a number of reasons including sedentary lifestyle and changing food habits of people at large in cities, accessible and affordable care hold huge importance. In the light of huge demographic variations across India, technology and innovations play a pivotal role to boost healthcare delivery system especially in rural areas. Understanding the needs and requirements pertaining to quality care, the Centre, Jharkhand Government and various other State Governments are leaving no stone unturned to improve patient care. JHARKHAND RECORDED POSITIVE IMPROVEMENT IN VARIOUS HEALTH INDEX As per 2018 Niti Aayog Health Index report, Jharkhand showed a positive improvement on various healthcare parameters. The State maintained a strong growth trend with an increase of 33 percent in the health index from 2014-15 to 2017-18. It recorded a progressive trend in 9 out of the 10 primary health outcomes along with a strong system of qualified healthcare
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professionals. PM ROLLED OUT AYUSHMAN BHARAT IN RANCHI The Central Government is resolutely working towards realising the dream to provide affordable care to people of last mile and various initiatives including the game-changer scheme Ayushman Bharat are proof of its intent for making honest endeavour in this direction. The Jharkhand Government is also trying to align itself with the Centre’s healthcare delivery bandwagon. Last year Prime Minister Narendra Modi had launched the gamechanger scheme from the soil of the Jharkhand, which shows the strategic importance of the state which has registered a tremendous progress in all sectors including healthcare in last decade. HYBRID MODEL OF AYUSHMAN BHARAT Jharkhand has adopted hybrid model of Ayushman Bharat where a part of the claim comes under the insurance model while the balance gets processed under trust. As per the State official, 630 hospitals have been enlisted in the scheme and out of them, 216 hospitals are run by
the Government. Under the scheme which promises Rs 5 lakh/family to vulnerable section for tertiary care a total of around 1,73,501 patients have been treated. Out of these patients, at least 1,51,668, around 90 percent of the total number, have been treated in private hospitals. PPP MODEL RESUSCITATING HEALTHCARE INFRASTRUCTURE Despite Jharkhand being predominantly a rural and tribal society with half of the areas falling into hilly terrain, the State has evolved in terms of different deliverables of healthcare. The State has 26 percent tribal population and its 15 districts are LWE (Left Wing Extremism) affected. In this light, taking rural healthcare to people’s doorsteps is a challenge. Nonetheless, the State is taking all measures to improve existing machineries of delivery process to ensure hassle free quality and affordable healthcare services. With an aim to take healthcare to the last mile, a comprehensive effort is being made in by the State Government to fill the infrastructural gaps on many fronts. Public Private Partnership (PPP) model is being explored to improve healthcare
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State Government’s Initiatives: In nutshell Free diagnostic and free radiological on PPP mode in all district hospitals Free dialysis on PPP mode at district hospitals 108 ambulance service to provide emergency services 104 toll free service for health advice Separate cadre for specialist doctor and recruitment through bidding system under NHM Telemedicine service for 100 PHC is ready to be rolled out Running of CHC and HSC on PPP mode MMU service for rural area
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COVER STORY
infrastructure at various levels which in turn bolsters patient care in rural areas. Medall, Ziqitza HealthCare, and Tata Motor are working on various projects to improve patient care in every nook and corner of the State. Niraj Arora, CEO, HealthMap, said, “PPPs model are becoming a preferred mode of delivery across various geographies of the country. There are enough good examples of this model generating the desired level of services at affordable price which have led the government and the private players to work more closely and deliver better results. The government of Jharkhand has rolled out PPP for both Radiology and Pathology for all districts of the State and Healthmap, SRL and Medall are the service providers.” “All the 12 labs in Jharkhand are high end advanced labs with NABL accreditation. Patients now have access to advanced tests in biochemistry, haematology, immunoassay, cytology, microbiology & histopathology with consistent TAT,” a statement on behalf of Medall, a diagnostic company which works on various PPP projects in Jharkhand said.
JHARKHAND MAKING GIANT LEAP ON VARIOUS DETERMINANTS OF HEALTHCARE The State Government is undertaking a number of initiatives to cater quality and cost efficient healthcare facility to every citizen, though lots need to be done on fronts of doctors’ shortage, primary healthcare infrastructure in rural areas, infant mortality rate (IMR) and maternal mortality rate (MMR). A slew of measures have been taken on every level i.e policy, schemes, and implementation. The State Government has not only announced many flagship programmes to improve patient care but also ensured that it should reach people in the remotest corner of the State. From maternal and neonatal care to urban and tribal health, the Government has undertaken many initiatives including Mukya Mantri Janani Sishu Swasthya Abhiyan and Mobile Medical Unit to improve accessibility of care. Some of the healthcare interventions by the State Government to augment overall healthcare delivery enabling people to get better medical facilities in
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terms of quality, accessibility and affordability are: URBAN HEALTH Rapid urbanisation has given rise to a range of issues like contaminated water, poor sanitation, and air pollution in the cities. These factors are responsible for deteriorating health status of the urban poor in the long run. Existing systems and available resources are often found to be inadequate to deal with the situation. In this light, the State Government has launched various programmes to improve the living condition of the urban poor. Strategies adopted by the State include strengthening all the UHCs, formation and training of Mahila Arogya Samittee (MAS) and Urban Social Health activist (USHA) in districts, PPP with local bodies/non-government institutions/ hospitals to ensure health services for the urban poor population, and formation of a state and district level task force. TRIBAL HEALTH Jharkhand holds 6th and 10th position respectively in terms of Schedule Tribe population and
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the percentage share of the ST population to the total population of the State. Tribal communities are vulnerable and often face social exclusion because of their habitation, social networking pattern, low level of awareness, poor penetration to media, and lack of availability and accessibility of basic health services. Most of these groups are small (numbering just over two lakhs), have not attained any significant level of social and economic progress, and generally inhabit remote localities with poor infrastructure. The awareness regarding treatment and care is considerably low among tribal people. They visit health facilities only when the problem becomes serious enough. Tribal health strategies include setting up tribal friendly integrated quality healthcare services, outreach activities, including health camps, signing up of MoUs with the private and public-sector undertaking health facilities for providing healthcare services, making drugs available at all remote facilities for snake, dog, other animal bite, and periodical monitoring of facilities in the tribal area by a special monitoring team. MOBILE MEDICAL UNIT (MMU) Being a plateau, Jharkhand has many
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hard to reach areas and inaccessible localities. Poor infrastructure in terms of basic amenities of living has made life difficult for the inhabitants. Though, most of the health issues are preventable and easily treatable, lack of awareness and basic accessibility make thing difficult. In addition, lack of proper maintenance and management of the existing Government healthcare facilities worsen the situation, affecting whole delivery mechanism of care. In light of above issues, the Mobile Medical Units proves to be helpful to ensure quick delivery of accessible, affordable and quality healthcare services to people. The project has been designed to cater to rural communities with special focus on people residing in hard to reach areas. MMU will provide all basic facilities including OPD services, X-ray, ECG test, general physician consultation, obstetric and gynaecological consultation, ANC check-ups, treatment of minor ailments and minor injuries, immunization to children, and providing appropriate referral services to malnourish children. MATERNAL HEALTH Maternal health includes curative and preventative care for women
of reproductive age. The social determinants which are responsible for poor maternal health include poor educational levels, early age of marriage, early pregnancy, and large family size. Though the State Government is making all out efforts to improve various indicators but a lot needs to be done. The steps taken to improve maternal care includes strengthening the MCH tracking system, skill training of health workers to address ANC (Antenatal care), perinatal and PNC situations, scaling up of the labour room in tribal area, regular house-visits by Sahiyyas, Anganwadi Workers (AWWs) and Auxiliary Nurse Midwives(ANMs) within 48 hours of delivery, strengthening of Mukya Mantri Janani Sishu Swasthya Abhiyan (MMJSSA) and setting up of grievance redressal cells to monitor the progress and implementation of JSY. CHILD HEALTH Infant Mortality Rate (IMR), under five Mortality Rate, Child growth status (age-weight) are some of the indicators which determine child health of any country. Diseases like diarrhoea, acute respiratory illness, malaria and measles, are responsible for more than 50 percent of child deaths in India. In addition, social determinants like poverty, nutrition, access to healthcare, and education also affect child mortality. In this light an integrated effort in terms of syncronisation of various components of NRHM is needed to save the life of children. Several initiatives have been undertaken in this direction including establishment of Special New Born Care Units, New born Stabilisation Corners, Scaling up of Integrated Management of Neo-natal and Child Illness, control and prevention of Acute Respiratory Infections and Diarrhoea. In addition, various facility-based interventions including strengthening
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of referral facilities, operationalisation of new born care corners (NBCC), improved routine immunisation and Vitamin A coverage, Convergence with ICDS for nutritional aspects, and integrated management of Neonatal and Childhood Illnesses (IMNCI), have also been adopted to make child healthy. TB PROGRAMME The Government provides free treatment to drug-sensitive as well as drug-resistant tuberculosis patients under RNTCP (Revised National TB Control Programme). There is a network of around 340 DMCs, 36 CBNAAT Labs, one Intermediate Reference Lab at Ranchi and about 20,000 treatment providers. TB
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patients are also being provided Rs 500 per month during entire period of treatment for nutritional support under Nikshay Poshan Yojna. For better engagement of community, TB forums are being formed in each district along with regular community meetings and patient – providers meetings. An MoU has also been signed with Medanta to make Jharkhand a TB free State with active cooperation from the PSU located in the State. INTEGRATED DISEASE SURVEILLANCE PROJECT In an endevour to strengthen surveillance system in connection with communicable diseases and risk factor of non-communicable diseases,
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Integrated Disease Surveillance Project was launched in November 2004. One of the important components of the project, funded by the World Bank, is to use Information Technology and Communication Technology in data management, analysis and rapid response in case of impending outbreaks. AYUSH The State Government has robust plan to implement Ayush (Ayurveda, Unani and Homeopath) systems of medicine, which holds huge significance to keep people hale and hearty. Plan and strategies which are afoot to streamline this alternative treatment process include mapping and establising AYUSH facilities, organising AYUSH MELA in all ten tribal districts, establishment of State Level Warehouse of AYUSH (Ayurveda, Unani and Homeopath), and training of ANMs and Anganwadi workers on AYUSH system of medicine. In essence, the State Government is going all the way to improve things on every fronts of care delivery system. Though the existing challenges try to jeopardize the way, nonetheless the intent of making tangible difference will help it to create an enhance care model.
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SPECIAL FEATURE 16
EMS: The Lifeline for Critical Patients In today’s time, the patient’s life depends on how fast they can be brought under medical supervision and treatment. The emergency medical services(EMS) hold huge significance in cases of strokes, cardiac arrest, and life-threatening accidents, providing immediate care to patients, says Reetika Bose of Elets News Network (ENN).
AUGUST 2019
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Emergency Medical Services (EMS) is an essential part of the overall healthcare system as it save lives by providing care immediately. With the country advancing in nearly all the sectors, the healthcare sector is not behind with regards to providing patient care and proper healthcare facilities in the quickest time possible. EMERGENCY MEDICAL SERVICES – THE NEED OF THE NATION Emergency Medical Service or EMS is of immense importance to the world at large. Losing a loved one to illness or an accident is painful. However, what often stings even more, is the realisation that they might have been alive today if medical action was taken swifter and more urgently. Highlighting the importance of EMS, Dr Shailesh Shetty, Consultant, Emergency Medicine - Aster CMI Hospital said, “Emergency Medical services cater to the immediate needs of a person requiring medical attention. They are formed by a group of trained personnel and include a paramedic, driver and a doctor depending on the case.” When asked about the current scenario of emergency health services in India, Manish Sacheti, CFO, Ziqitza HealthCare said, “While EMS services are extremely well developed in countries like United States, they were severely lacking in India till early 2000. Despite other developments in the healthcare sector, India had yet to establish a single, comprehensive EMS system that could be accessed by all. The existing system was fragmented and did not meet the acute demand. The main providers of ambulance services were private ambulance owners, hospitals, NGOs, and government agencies. Some services were free, while others were not.” ARE WE MISSING OUT ON THE GOLDEN HOUR? Sometimes even minutes matter when it comes to the battle of life
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MORE RECENTLY, NGOS AND HOSPITALS HAVE COME FORWARD TO PROVIDE THEIR OWN EMSS. THERE HAVE BEEN CONSIDERABLE EFFORTS BY STATES ACROSS INDIA TO DEVELOP EMERGENCY SERVICES.
SPECIAL FEATURE
I
n any emergency, time is considered very crucial. Sometimes even a minute matters the most when it comes to the battle of life and death. The value of time should be given much more importance, to be able to take quick and right decisions. Any delay in time, or a simple mistake can cost a patient his life. It is a well-accepted fact that a patient who receives basic care from trained professionals and is transported to the nearest healthcare facility within 15-20 minutes of an emergency has the greatest chance of survival. Talking of timely patient care,
and death. We all deserve the right to timely medical care but are we really getting that swift and smooth medical care? Well, in today’s time, a patient’s life depends on how fast they can be brought under medical supervision and treatment. Yes, especially in cases of strokes, breathing problems and life-threatening accidents, emergency medical services become extremely important. The first crucial minutes really matter for a patient. Someone struck with cardiac arrest needs the revival to be done within four minutes, angioplasty in a heart attack needs to conducted within 90 minutes and a road traffic accident victim needs to be provided on the spot first aid within 10 minutes and the victim’s vital parameters should stabilise in an hour. Advanced ambulance care needs to reach the victim within four minutes. Talking about the challenges, Dr Rajeev Boudhankar, CEO-Bhatia Hospital, Mumbai said, “There is the need for an effective healthcare system with good facilities and pre-arrival notifications. Needless to say that in order to augment the productivity of EMS in an emerging economy such as India, it is essential to create general awareness about the EMS ecosystem.
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SPECIAL FEATURE
Paramedics need to be trained on new life-saving techniques. Further, EMS documents should be standardized so that there can be seamless interfacility patient transfer. Addressing these gaps will help mitigate the challenges of all the key stakeholders and their capabilities on the EMS supply side.” “An early response can sometimes be crucial in emergency cases that require immediate attention such as a patient suffering from a stroke or a heart attack”, Dr Shetty added. With such primary concerns, it is essential to see how the hospitals and the government in particular are getting proactive in bringing out measures to solve these problems of immediate patient care. HOSPITALS & NGOS- SAVING LIVES It is disheartening to see the increase in number of people who are dying due to inadequate medical emergency services. Recently, NGOs and hospitals have come forward to provide their own EMSs. There have been considerable efforts by states across India to develop emergency services. Stating about emergency medical services take us back to the first ever service in India that has been the pioneer in this segment, more
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than 2 million patients since its inception. Since August 2005, the 108 medical emergency response, started by Emergency Management & Research Institute (EMRI), a nonprofit organisation, has touched a population of 800 million till date. On similar grounds, the Kashmiri American Society of Healthcare, Medical Education and Research (KASHMER) is all set to launch EMS services in Srinagar. In collaboration with SAVE HEART Kashmir and HELP Foundation, this non-profit organsiation is paving the path for urgent patient care where these kinds of services were almost nonexistent till now. This will have a huge impact in Kashmir’s healthcare delivery system. All patients should have access to world-class care no matter where they live. To achieve this goal, Multi Super Speciality Hospital, Medanta, with its dedicated team of specially trained doctors, nurses, pilots and support staff, has created ‘Flying Doctors India’ to help evacuate patients from even the most remote areas. It is one of those few hospitals in India to provide tertiary medical care on board an aircraft even at an altitude of 30,000 feet. Medanta’s Flying Doctors is available round the clock, eliminating all geographical barriers in the city.
On similar grounds, Chennaibased Apollo Hospitals has launched an air ambulance service to connect small cities in the South. Later it expanded its services to Delhi and Bengaluru. The idea was to launch air ambulance network that connects smaller towns, thus creating an ecosystem that facilitates better access to the tertiary care at the right time. Dr Rajeev Boudhankar, CEOBhatia Hospital, Mumbai said, “EMS and private hospital systems must interact in such a way that there is a synchronized effort in saving patients’ lives.” GOVERNMENT INITIATIVES To start with, the Government should implement policies that provide effective, quality service - i.e. to ensure that patients iget immediate care at health facilites from experts. Moreover, the service that is cost efficient in implementation, maintenance and development is the primary concern. Since no person should be refused the care, the government has come up with several initiatives pertaining to immediate medical care. With the worsening traffic conditions in the capital, it is high time that the government should experiment with different modes of transport in metro cities. Talking of which, Delhi has witnessed some of the advancements in terms of medical emergency. The Aam Aadmi party led Delhi Government has started bike ambulance services in the capital city. Recently, a fleet of 16 bikes was launched by Delhi Chief Minister, Arvind Kejriwal at the Secretariat in order to provide services to patients residing in narrow bylanes of the city where it is convenient for the bikes to provide immediate medical care. Known as ‘First Responder Vehicles’, these bike ambulances are equipped with a portable oxygen cylinder, first aid kit, air splints as well as GPS and a communication device.
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TECHNOLOGY – BRINGING A PARADIGM SHIFT Technology, with its rapid evolution has been taking several industries in India by storm. Likewise, healthcare has been very welcoming to technological advancements like Artificial Intelligence due to its effectiveness of saving lives with speed being their biggest advantage. AI has been making inroads in this sector to ensure not just a quick turnaround, but also accessibility to those in dire need of medical aid and care. Keeping the quality consistent, sophisticated machine learning algorithms are being developed to enhance the Emergency Medical Services. The country is indeed
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hopeful of prompt medical services for urban and rural areas in the country. Experts believe that this will indeed be a big step towards sustainable healthcare, which will ensure quality and accessibility, along with affordability for all. AI’s promise to enhance emergency care and healthcare via robot-assisted services, early detection, virtual medical professionals and more is a big ray of hope for India. AI, specially Machine Learning is expected to become an integral part of emergency medical care and healthcare in the near future. Technological advancements primarily help improve the quality and accessibility of services by maintaining health records and a GPS tracking system in ambulances. With the right blend of its boons like AI and IoT, a bright future in the business of saving lives across India is not far away. FUTURE FOCUSED EMERGENCY SERVICES Commenting on the future of the EMS, Dr. Boudhankar said, “There is a need for evidence-based and futurefocused work in EMS. It requires for state government data to be made available to academics, policymakers, and the public.” Over the years several
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Furthermore, the government is doing wonders in providing air ambulance services not just for the common people but also for the ones who serve at the the borders. A one of its kind air ambulance service has been sanctioned for troops deployed in anti-naxal operations and those posted at high-altitude border posts. The ambulance will be on a Mi-17 helicopter platform of the Border Security Force (BSF) and it will be stationed at Jharkhand’s capital Ranchi. Medical equipments like oxygen cylinders and stabilisers will also be provided on the chopper.
THE FIRST CRUCIAL MINUTES OF THE PATIENT REALLY MATTERS. SOMEONE STRUCK WITH CARDIAC ARREST NEEDS THE REVIVAL TO BE DONE WITHIN FOUR MINUTES, ANGIOPLASTY IN A HEART ATTACK NEEDS TO CONDUCTED WITHIN 90 MINUTES AND A ROAD TRAFFIC ACCIDENT VICTIM NEEDS TO BE PROVIDED ON THE SPOT FIRST AID WITHIN 10 MINUTES AND THE VICTIM’S VITAL PARAMETERS SHOULD STABILISE IN AN HOUR. ADVANCED AMBULANCE CARE NEEDS TO REACH THE VICTIM WITHIN FOUR MINUTES.
advancements have been made and research is underway to create services that provide medical assistance to patients at the earliest. However, the state of EMS varies drastically from developed to developing countries like India. In spite of the development in the healthcare sector over the past decade, India is yet to create a single, comprehensive EMS that can be accessed throughout the country.
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POLICYMAKER’S PERSPECTIVE
‘Jharkhand Striving to Bolster Patient Care’
Jharkhand has made significant improvements in terms of providing accessible, affordable and inclusive healthcare to the last mile. This transformation is underscored by improved health indictors, emergence of health and wellness centres to provide quality and comprehensive primary healthcare services and more number of medical colleges planned to boost availability of doctors and healthcare professionals across the state. The State government aims to provide National Quality Assurance (NQA) Certification to all the hospitals in order to provide quality medical facilities to masses, says Dr Nitin Madan Kulkarni, Secretary, Department of Health, Medical Education & Family Welfare, Government of Jharkhand in an exclusive interview with Gopi Krishna Arora and Mukul Kumar Mishra of Elets News Network (ENN).
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How do you assess evolving healthcare delivery system of Jharkhand which aims to provide quality care to people at large? Jharkhand has made a significant improvement in healthcare delivery through its careful planning and execution of healthcare programmes. We have been constantly evolving to enable people of all strata to avail accessible and affordable care.
National Health Mission (NHM) has helped the State of Jharkhand to build better capabilities for healthcare, be it in terms of infrastructure, better healthcare resources or better trained personnel. After the launch of NHM in Jharkhand public health services have become more flexible and government of Jharkhand is able to address more maternal and child health-related issues. Dr Nitin Madan Kulkarni
Secretary, Department of Health, Medical Education & Family Welfare Government of Jharkhand
Regarding health indicators, we have improved in several aspects. IMR reduced from 72 (in 2000) to 29 (SRS 2016), MMR reduced from 400 (in 2000) to 165 (SRS 2016) and TFR reduced from 3.2 (NFHS 3 -2007-08) to 2.5 (SRS 2016). The State eradicated Polio in 2014-15. HSCs, PHCs and UPHCs have evolved into health and wellness centres to provide quality and
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Shed some light on the schemes and initiatives which have been undertaken by the NHM in order to improve accessibility and affordability factor. To provide accessible, quality and affordable medical facilities with minimum out-of-pocket expenditure to the last person of the last village following schemes have been initiated
under NHM: 1. Free referral services through 108 ambulance service and Mamta Wahan. 2. Free diet, free drugs, free diagnostics under JSSK, both for mother and infant. 3. Free dialysis facility in some of the district hospitals 4. Telemedicine services in 100 PHCs. 5. Tele-helpline through 104. 6. Cash incentive to beneficiaries under JSY, Family Planning Schemes and Nikshay Poshan (for Tuberculosis patients) Due to above initiatives, in 2015-16, Jharkhand ranked second in reducing out-of-pocket expenditure.
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Though the State has registered a remarkable progress in delivery of care,
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comprehensive primary health care services that have become more accessible to the people. More number of medical colleges will be started in Jharkhand to improve the doctors’ availability across the state. In addition, the State Government is planning to provide National Quality Assurance (NQA) Certification to all the hospitals in order to provide quality medical facilities to masses.
REGARDING HEALTH INDICATORS, WE HAVE IMPROVED IN SEVERAL ASPECTS. IMR REDUCED FROM 72 (IN 2000) TO 29 (SRS 2016), MMR REDUCED FROM 400 (IN 2000) TO 165 (SRS 2016) AND TFR REDUCED FROM 3.2 (NFHS 3 -2007-08) TO 2.5 (SRS 2016). THE STATE ERADICATED POLIO IN 2014-15.
maternal and neonatal care are big challenges which require urgent attention…What steps are being planned on this front? To improve maternal health, strengthening of FRUs, JSY, JSSK, PMSMA has been initiated. To improve Neonatal health, SNCU, NBSU, NBCC, MTC, HBNC is on board. For facility strengthening to provide quality care, Kayakalp, Laqshya, NQAS and various other certification processes has been started.
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Access to nutrition and medicine is a major issue among people residing in remote tribal districts. What steps have been taken to improve infrastructure in rural districts? Undernutrition and malnutrition remain the most crucial challenge for the State. In spite of the best of efforts from the government, the figures are still daunting. Malnutrition treatment centres are functional throughout the
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State. We regularly conduct school health checkup programme, vit-A , Deworming, ORS rounds in the State. Infrastructure and manpower are being upgraded to IPHS standards. However, availability of trained manpower and reluctance of doctors to work in rural areas remain key issues.
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As community health workers Auxillary Nurse Midwives (ANMs) and General Nurse Midwives (GNMs) play a key role to boost healthcare in rural areas…Can you further elaborate their role in context of Jharkhand? ANMs and GNMs are playing a major role in boosting healthcare in rural areas. They are engaged in community sensitisation programmes to provide accessible and affordable services
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the people on village level as per the need. In order to meet the shortage of GNMs, we have employed more ANMs in the field.
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Jharkhand has used hybrid model to implement Ayushman Bharat scheme. Shed some light on advantages of this insurance model. The pricing of any risk from an
insurance point of view would always be based on the amount of coverage being asked for. Since under the Ayushman Bharat, the insured sum of Rs 5 lakh for each family per annum has been fixed and hence going for absolute insurance model with Rs 5 lakh coverage would have been costly for the government. Our analysis and historical data taken from various other States have shown that number of claims for over Rs 1 lakh would not be more and hence we fixed the threshold limit for insurance to Rs 1 lakh and decided to settle directly all the claims beyond this limit. Hence, the State government saved a lot in terms of premium. Out of the total about 60 thousand claims, till date there have been only 0.01% number of claims which exceeded one lakh. This itself proves that the model, which our State has opted, is better suited. With hybrid model we are able to utilise the experience and strength of the insurance company and simultaneously keep all the controls and monitoring with SHA (State Health Agency) to avoid any leakages. However, we didn’t go with the complete trust model because of constraints in terms of manpower and experience in running such a mass scheme directly. Today, in comparison to nearby States with Trust Model we are performing better on all parameters; be it BIS pendency, hospital claim payment, claims generated, and portability numbers.
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What is your viewpoint on National Medical Commission Bill and its role to bring radical change in medical education in India? As there is a shortage of doctors in Jharkhand, NMC Bill is a positive step to enhance the quality of medical education in the state. The Bill aims to provide an education system with improved access to quality and affordable medical education, ensure availability of adequate and highquality medical professionals.
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INDIA’S LARGEST INTEGRATED DIAGNOSTIC SERVICES PROVIDER
Presence in 9 States & 71 Districts
24 NABL Accredited & 108 ISO Certified Labs
6,000+ Customer touch points
PPP AP, TN, Telangana, Karnataka, Jharkhand
Touching 1 Cr. People & Performing 4.3 Cr. tests
Over 135 Competent Radiologists & Pathologists
SERVICES OFFERED LAB (BIOCHEMISTRY HAEMATOLOGY CLINICAL PATHOLOGY SEROLOGY IMMUNOLOGY MICROBIOLOGY HISTOPATHOLOGY)
PREVENTIVE HEALTH CHECKUPS HOME COLLECTION
SASH
MEDALL DIAGNOSTICS MEDALL SCANS AND LABS RANCHI PVT LTD Above SBI Bank (TB & Chest OPD) Emergency Block, Rajendra Institute of Medical Sciences, Bariatu Road, Ranchi, Jharkhand, India. Ranchi
Jamshedpur Palamu Khunti Garhwa Gumla Latehar Saraikela Chaibasa Chatra Simdega Lohardaga
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Medall — Fostering Accessible, Affordable Model of Patient Care With many clinical and technological innovations – such as health on wheels, Medall, the leader in integrated diagnostics services, is trying to create niche in diagnostic area. With over 600 outlets providing services in 9 states across 71 districts, the company is trying to create tangible difference in delivery of patient care to people at large.
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iagnostics market in India is growing in rapid manner at around 17 percent annual rate and estimated to be at $10 billion. Awareness among doctors and public is increasing in unprecedented manner and diagnosis in general is now becoming an integral part of any consultation provided by doctors today. MEDALL’S JOURNEY Medall was started in 2009 with the objective to become one stop solution for all diagnostic services. Since then it has been catering people with passion, competence and commitment.
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Providing the best health services at an affordable cost is its mantra. We put together a group of passionate and committed radiologist and pathologists who want to a make a substantial difference in delivery of care and today Medall serves over 10 million customers every year both in PPP and the private segment of the business. With over 600 outlets we are providing services in 9 states across 71 districts, dominating southern part of India. Accessibility and affordability are some of our biggest differentiators. We complement with home collection
services so that people don’t have to spend too much time travelling to get the services. Medall is a leader in integrated diagnostics services. Our aim is to become top provider which contributes to create a healthy India. Stay aware and stay healthy is the mantra that we follow. We focus on to increase awareness about health and wellness concept among common people. Medall serves patients who belong to economically weaker sections of the society with same passion, competence and commitment that are usually made available to private patients. They are being catered with same dignity, respect and quality as patients of higher echelon who are financially strong. Through PPP contracts in Andhra Pradesh, Telangana, Jharkhand and Tamil Nadu, we serve the poorest of the poor people. We are also reaching out to the
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JHARKHAND LACKS DIAGNOSTIC SERVICES Jharkhand, a low income State in eastern India, faces a significant shortfall in public health delivery services aggravated by a severe lack of diagnostic services. The lack of quality and standard diagnostic services forces people to either forgo them or purchase services from private facilities of mostly poor and varying quality, while incurring heavy out-of-pocket expenses and additional costs related to travel and over-testing. In a bid to address these long
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standing issues, and driven by a desire to provide equitable access to quality and affordable diagnostic services to its residents, the Department of Health, Medical Education & Family Welfare of the Government of Jharkhand has proposed to set up advanced pathology diagnostic centers in all the 24 district headquarters hospitals (DH) and three medical colleges (MC) in the state. It seeks support from International Finance Corporation (IFC) to structure and establish the pathology centers through a public private partnership (PPP). In Jharkhand, Government’s aim was to develop and manage a network of advanced radiology and pathology diagnostics services under publicprivate partnership in all 24 district hospitals and in the three state-owned medical colleges. The challenge was to ensure that the technical configuration and project structure aligned with the Government of Jharkhand’s overall strategic vision for augmenting health services, while ensuring it also was tailored to local conditions and requirements. After competitive bidding, the project for 12 districts was awarded to Medall Healthcare Private Limited, which is one of the most reputed and largest players in the diagnostics sector in India. The concession agreements were signed with Medall, and the company was expected to start operations within nine months. Medall Healthcare Private Limited was supposed to be responsible for financing, equipping, operating and maintaining stateof-the-art pathology laboratories across Jharkhand, and providing quality services to its citizens. We are passionate to serve the denizens of Jharkhand. Our mission is to serve poorest of the poor. All the 12 labs in Jharkhand are high end advanced labs with NABL accreditation. Patients now have access to advanced tests in biochemistry, haematology, immunoassay, cytology,
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WITH AN OBJECTIVE TO MAKE EVERY INDIVIDUAL TO STAY AWARE AND STAY HEALTHY, MEDALL IS PLANNING TO MOVE SIGNIFICANTLY INTO THE PREVENTIVE SPACE THROUGH PACKAGES LIKE SASH FOR AN INDIVIDUAL TO KNOW HIS / HER HEALTH SCORE, HMP - A COMPLETE FAMILY HEALTH MONITOR AND PRIVILEGE CARD.
PPP PERSPECTIVE
lower middle class through products and services that are accessible, affordable and cost-efficient as well. With an objective to make every individual to stay aware and stay healthy, Medall is planning to move significantly into the preventive space. We have packages like SASH for an individual to know his / her health score, HMP - a complete family health monitor and privilege card. State Governments are also actively promoting healthcare to the citizens by becoming a payer and not a provider allowing private service providers to participate in private public partnership to provide better diagnostic services. To accomplish all of the above objectives, Medall has incorporated many clinical and technological innovations – such as health on wheels, service at door step, mobile lab collection vans, teleradiology, error proofing in lab processes, digital dashboards for process monitoring, and IT-enabled internal and external quality routines. PPPs are all about balance: maintaining equilibrium between public and private, risk and reward, cost and impact. Understanding this balance is especially important in regions with extreme poverty, where access to infrastructure can mean life or death.
microbiology & histopathology with consistent TAT. We have the highest number of pathologists, microbiologists and biochemists located in each district and dedicated to the state for timely and diligent approval of the patient reports. Skills of our phlebotomists and lab technicians are constantly upgraded. Our quality systems go through rigorous Internal and External Quality Assurance (EQAS). Medall’s operational excellence strives to enhance customer experience and customer intimacy. As we move forward we will continue to leverage our proven processes, methodology and practices that we have built over the years to become India’s largest diagnostics company by increasing our footprint in more states in India and Internationally.
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TECHNOLOGY PERSPECTIVE
Digital Dispensary in Jharkhand — A Boon
Jharkhand is leading the way in accepting digital technology for governance services in all sphere of the State Government. Jharkhand government recognizes the challenges in provisioning health care services the conventional way and has yet again adopted technology for enabling quality health care in the nook and corner of the State for providing medical treatment. Digital Dispensary is one such move that has not just eased out the way of work, but have also come up with satisfactory treatment results for the locals.
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ith technology invading almost every sector of the economy, the area of health is no different. Leveraging IT at its best, the state government has come up with digital dispensaries that have not just eased out the way of work, but have also come up with satisfactory treatment results. The digital dispensary centres function as an OPD with virtual consultation with doctors through video. The dispensaries are equipped with basic but advanced essential set of investigations such as routine testing of urine, blood, haemoglobin, blood sugar, malaria, dengue, BP, ECG, sPO2 and pregnancy detection. PRESENCE IN JHARKHAND Jharkhand is leading the way in accepting digital technology for governance services and providing medical treatment, with implementation and provision of services at Common Service Centres across the state, launched under Digital India initiative. Since then, the state has grown many folds. Introduction of Digital Dispensary is another feather in the cap added by the state government. CASE STUDY Jharkhand medical services have improved massively with the emergence
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of digital dispensaries. Out of many successful cases, here’s one example that proves how technology is playing a vital role in the state’s healthcare services. Jeevan (Name Changed), a 32-year old, the only bread earner of family working in a private company in Dhanbad visited his home in Asanbani, Dumka district. He had complaints of severe skin infection. He consulted at two clinics locally but could not get solace from his condition even after over six months of regular follow-ups. The situation hampered his professional as well as personal lives. After locals from his district feared that Jeevan could spread an epidemic being affected by a severe skin disease, they advised him a Digital Dispensary. Jeevan visited the Digital Dispensary at Asanbani village of Dumka District on one fine morning. After recording the vitals as normal, using the vital signs monitoring device interfaced with the electronic platform, the tele-coordinator at the Digital Dispensary connected him to the General Physician. The physician at the Apollo TeleHealth hub in Hyderabad assessed his condition and took the medical history. Giving provisional diagnosis as a Chronic skin disease, Jeevan was then referred to the Dermatologist and given symptomatic medication.
Using the integrated medical platform, Jeevan got an appointment with the Dermatologist at the Apollo Tele-Health hub, Hyderabad. The dermatologist consulted him over a video conference integrated to the electronic platform. After examining him, the doctor made a diagnosis of “Tinea Corporis” and prescribed him the required medicine and other lifestyle precautions. After following the line of treatment advised by the Dermatologist, Jeevan came for a review and was examined again. It was found by the dermatologist that; the infection was subsiding. Continuing the treatment for another week, Jeevan was able to get solace from his condition and got back to normal life. This power of ICT in healthcare has proven to be a boon for the general public. Today, the patients can access specialist doctors over the telemedicine centers almost at their doorsteps. These facilities are inculcating the health seeking behavior in the general public. The digital dispensary has gained
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ABOUT APOLLO TELEHEALTH SERVICES Apollo Hospitals remote health care has over 19 years of experience in the field of Telemedicine; the organization is a pioneer in designing and developing high end Telemedicine services such as Tele emergency, e-ICU, super specialist tele consultation on demand, etc. Apollo Hospitals remote health care has created the largest and oldest multi-specialty Telemedicine network
in South Asia. As one of the pioneers of Telemedicine across the world, Apollo has always striven to enhance the access to quality healthcare for communities both in urban and rural geographies. With the vision of bringing healthcare of International standards within the reach of every individual, Dr Prathap C Reddy in 1999 established Apollo Telemedicine Networking Foundation (ATNF) and Apollo Telehealth Services (ATHS). On March 24th, 2000, Bill Clinton, the then US president, commissioned the world’s first VSAT enabled village hospital at Aragonda in Chitoor District of Andhra Pradesh. This marked the formal introduction of telehealth services in India. By synergizing healthcare services, Information & Communication Technologies (ICT), medical equipment and patient information system, Apollo provides specialized solutions like Teleconsults, Tele-radiology, Telecardiology,
TECHNOLOGY PERSPECTIVE
recognition both at the state and central Governments of India. In a short span of 6 months 65,000 patients have been benefitted so far and close to 100,000 consultations have been delivered. This could not have been possible, if not for the visionary state administration which has made effective utilization of technological advancements in health care for bringing healthcare closer to the doorsteps of people and by ensuring continuum of care.
APOLLO PROVIDES SPECIALIZED SOLUTIONS LIKE TELE-CONSULTS, TELE-RADIOLOGY, TELE-CARDIOLOGY, TELE-CONDITION MANAGEMENT AND OTHERS; THEREBY EMPOWERING A REMOTELY LOCATED CONSUMER ACROSS THE GLOBE TO ACCESS APOLLO’S WORLDRENOWNED DOCTORS.
Tele-condition Management and others; thereby empowering a remotely located patients and beneficiaries across the globe to access Apollo’s worldrenowned doctors. Apollo Telehealth Services has delivered successful remote healthcare services at Primary and Secondary care levels in association with many state governments and industrial set-ups. Since 2014 Apollo’s Remote health care initiatives have benefitted over 10 million population in the country. REWARDS AND RECOGNITION Apollo Telehealth Services has been recognized with the “Innovation in the quality of Service Delivery” by World Health and Wellness Congress and Awards 2018, “Best use of Technology in Healthcare”, by World Mental Health Congress and Awards 2019 at company level. Whereas projects have been recognized by varied forums like World Innovation Summit for Health 2018 and SKOCH Awards 2019 for our projects like eUPHC, Telemedicine in Himachal Pradesh and TeleOphthalmology.
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PPP PERSPECTIVE 28
Emergence of PPP in Diagnostics in India
The paradigm of healthcare delivery mechanism is evolving as never before. With the focus of the government on making healthcare more accessible to masses; the implications for the industry are coming thick and fast.
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he biggest challenge for India’s healthcare delivery system is to provide care that’s affordable and accessible to its population of 1.3 billion people, almost 70 percentile of whom live in rural areas. Public healthcare institutions — ranging from Primary Health Centers (PHCs) that form the backbone of the system in rural areas to larger districtlevel hospitals — are hampered by a lack of manpower and inadequate resources such as diagnostics, pathology services and stock-outs. As a result, most people rely on the private sector for healthcare, which provides almost 80 percentile of outpatient and 60 percentile of inpatient care. India’s 2017 National Health Policy emphasises the role of the private sector, helping the country to achieve its aim of Universal Health Coverage. The government advocates for the “strategic purchasing
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Niraj Arora CEO, HealthMap
or partnership” of care from private facilities and clinics to improve access, affordability and quality of care. However, in case of diagnostics, beyond the scope of the treatment under Government of India driven initiatives like Pradhan Mantri Jan
Arogya Yojana(PMJAY), the masses are dependent on the various state level schemes and policies. The National Health Mission or the NHM, as it is popularly known as, comes to the rescue of such requirements as it oversees such programmes, spread across various states and UTs. It implements subsidised or free diagnostics, especially for the masses unable to afford the high end scans, especially MRI and CT. Public Private Partnerships or PPPs as they are commonly referred to are becoming a preferred mode of delivery across various geographies of the country. There are enough good examples of this model generating the desired level of services at affordable price which have led the government and the private players to work more closely and deliver better results. In fact, the government of Jharkhand has rolled out PPP for both Radiology and Pathology for all districts of the State and Healthmap, SRL and Medall are the service providers. Currently, approximately 24 states, including the north eastern states of India are delivering radio diagnosis through PPP module. As a result some large players like Manipal Group (through its group entity Manipal Healthmap) Medall, SRL etc have focused their energies on this collaborative mode of delivery system. These services have not only been successful in providing quality and
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PPP PERSPECTIVE
About Manipal Healthmap HealthMap Diagnostics Private Limited, a Manipal Group entity, is running successful PPP projects in diagnostic imaging. It inked its first PPP in mid of 2015 and 2016 with the government of Haryana for providing radiology services (CT and MRI). The company then signed up with the Government of Jharkahnd for providing radiology services in the state of Jharkahnd. Today, it is providing these services at multiple locations. The scans are conducted using cutting-edge technology. Manipal Healthmap provides a gamut of services including MRI, CT, ECG, X-ray, Ultrasound etc. It proudly serves approximately 30,000 patients per month across all its locations. The entity has till date performed more than nine lakh plus scans for the masses. In addition, seven of its centres are accredited with the NABH certification from the Quality Council of India (QCI), a first for any PPP service provider for radiology in India. The company recently received investment from a global marquee Private Equity fund and is working with various government bodies to take its journey to the next growth phase.
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affordable scans to the masses, but a larger chunk of the population is now showing confidence in these services. PPP in radiology is perfect solution to deliver quality and affordable diagnosis to the masses. An interesting phenomenon is that at their locations, they serve a decent number of patients who can afford private healthcare facilities as well but come to their PPP set ups inside government hospitals and medical colleges. This category of patients is assured of the clinical quality of the scans and of course the scan prices are much lower than the private healthcare facilities. Quality certifications like NABH, NABL etc add a definitive comfort to the patients from all strata to get their scans done at these locations. PPP is poised to take giant leap not only in radiology but even beyond as well and the Central and State Governments along with the private players are trying out innovative models to carve out a truly inclusive vehicle for a more comprehensive coverage of the complete healthcare cycle. The runway has been laid, it’s just a matter of time that the flight takes off !
PPP IS POISED TO TAKE GIANT LEAP NOT ONLY IN RADIOLOGY BUT EVEN BEYOND AS WELL AND THE CENTRAL AND STATE GOVERNMENTS ALONG WITH THE PRIVATE PLAYERS ARE TRYING OUT INNOVATIVE MODELS TO CARVE OUT A TRULY INCLUSIVE VEHICLE FOR A MORE COMPREHENSIVE COVERAGE OF THE COMPLETE HEALTHCARE CYCLE.
(The writer is Niraj Arora, CEO, HealthMap)
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PPP PERSPECTIVE
Ziqitza HealthCare Optimising Healthcare Delivery in Efficient-Way
From a start-up with 10 ambulances to a well-established corporate entity with a fleet of 3,300 ambulances, Ziqitza HealthCare has come a long way, serving masses with quick and best emergency medical services. With different models including Cross subsidy 1298, it is contributing to bolster emergency care.
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he system of Emergency Medical Services, commonly referred to as EMS, has witnessed constant evolution, ever since its inception. Particularly, in India, EMS has been described as ‘fragmented’. However, with the technological and infrastructural advancements, a lot has changed with time. The country takes pride at EMS delivery services that has grown exponentially and continues to expand. As one of the pioneer companies in Emergency Medical Response Services and Patient Transport Services in India since 2005, Ziqitza Healthcare Limited (ZHL) has had its biggest USP in its robust ambulances, 24X7 helplines, and the holistic medical training that it provides to Emergency Medical Technician (EMTs) and drivers. NEED FOR EMS SERVICES IN INDIA While EMS service system is welldeveloped in countries like the United States, they were severely lacking in India till early 2000. Despite other developments in the healthcare sector, India had yet to establish a single, comprehensive EMS system that could be accessed by all. The existing system was fragmented and did not meet the acute demand. The main providers
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of ambulance services were private ambulance owners, hospitals, NGOs, and government agencies. Some services were free, while others were not. There was no ambulance service to cover the entire city, that could be reached 24 hours a day at an easy-toremember phone number similar to the 911 system in the U.S. The founders of ZHL were also very clear that the service should be accessible and affordable to all sections of the society without putting burden on those who did not have the capability to pay for the same. OUR SERVICES The solution of the above issues was
to set up and operate the different business models / innovative service solutions to address different customer segments: • Cross subsidy 1298 model: The cross subsidy model based on the ability of the patient to pay in accordance with the choice of the hospital. For example, if a patient goes to a government hospital, this is an indicator for the person’s inability to afford high quality medical care. ZHL understands this and offers its service at a highly subsided rate for such patients. Moreover, accident victims are transported free of cost to the nearest hospital • Ambulance Outsourcing 1298
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scale public private partnership with the government of India through the Nation Rural Health Mission initiative in India. PPP Emergency Ambulance services have been provisioned in fivestates namely- Madhya Pradesh, Jharkhand, Orissa, Bihar and Punjab as the 108 Ambulance service. ZIQITZA’S USP Over the period of 14 years, the company has grown exponentially from being a start-up with 10 ambulances to become a wellestablished corporate entity with a fleet of 3,300 ambulances and almost 10,000 employees across the country. The company has operations in 18 states across India and has served over 20 million people till date. ZHL has served 17, 54,019 pregnant women and helped in the delivery of over 10,000 babies across 18
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ZHL HAS BEEN PROVIDING EFFICIENT EMS FOR SEVERAL YEARS NOW WITH TRAINED AND WELLEQUIPPED EMTS TO HANDLE EMERGENCY SITUATIONS ACROSS URBAN AND RURAL AREAS OF THE COUNTRY.
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Model: Hospitals and nursing homes want to focus on their core competency of quality and clinical treatment to their patients and outsourcing model helps to improve ZHLs ambulance utilisation and help a mortised fixed cost better. Today’s hospital and nursing homes want to focus on their core competency and quality clinical treatments to their patients. They are outsourcing pharmacy, canteen, security and housekeeping. Management of ambulance, which is a heavy fixed asset as well as operationally intensive process is providing to be a huge non-core activity in many hospitals. ZHL offers this end to end emergency management systems to hospitals so that they can focus on their core competencies • Public Private Partnership 108 Model: ZHL operates on a large
states. ZHL also won the prestigious Godfrey Phillips National Bravery Awards 2007 and TOI Social Impact Awards 2013. ZHL has been providing efficient EMS for several years now with trained and well-equipped EMTs to handle emergency situations across urban and rural areas of the country. They are skilled not only to promptly deal with the potential crisis and complications during critical periods, en route medical centres, but provide care and relief to victims. In a short span of time, ZHL has proved that it is a one-stop solution provider for EMS across the country by making its ambulance services accessible and affordable to both urban and remote regions. Moreover, it caters to every industry and sector and provides services in accordance, be it for events, construction sites, corporate parks, or schools among others. From operations, helpline services and ambulance services to EMT trainings, ZHL has consistently reinforced its unquestionable expertise in the healthcare sector of India.
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POLICYMAKER’S PERSPECTIVE 32
BMSICL — Bolstering Healthcare Infra to Boost Patient Care
In an endeavour to improve overall delivery of patient care, Bihar Medical Services and Infrastructure Corporation Limited (BMSICL) is making resolute step. From transparent procurement policy of equipment and drugs to development of required infrastructure in various health facilities across Bihar, BMSICL is going out of way to ensure quality delivery of care to masses, says Sanjaya Kumar Singh, Managing Director, Bihar Medical Services and Infrastructure Corporation Limited, in conversation with Elets News Network(ENN).
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Around a decade ago, BMSICL was established under the aegis of Health Ministry, Bihar with the objective to streamline things. What are its key role & responsibilities? In an endeavour to expedite whole process of development of healthcare infrastructures across the State, the Government of Bihar established Bihar Medical Services & Infrastructure Corporation (BMSICL) in 2010. It plays a pivotal role in quality improvement in delivery of overall care process. The Corporation is the sole procurement and distribution agency of drugs and equipment i.e. autonomous centralised procurement agency for all healthcare facilities of Government of Bihar. Key role & responsibilities of BMSICL include: • To promote value for money services in a transparent and equitable manner. • Procurement, storage & distribution of quality drugs & surgical items. • Procurement, distribution, installation and maintenance of medical equipment/instruments required in different hospital/ institution of Bihar and maintenance of comprehensive maintenance contract (CMC) with the supplier. • Development of infrastructure
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• To establish warehouses, storage rooms and cold storage facilities in different districts for providing safe, secure and convenient places for storage of medicines, surgical products and other medical products of all kinds. • To enter into contracts necessary or desirable, for the conduct of the Company’s affairs.
Sanjaya Kumar Singh Managing Director, Bihar Medical Services and Infrastructure Corporation Limited
for establishment of certain medical equipment. • Construction & maintenance of entire healthcare facilities and health-related infrastructure/ buildings across State. • Ensuring an efficient supply chain network for timely distribution of drug/medical devices, medical/ non-medical equipment/instruments to all healthcare facilities of the Government of Bihar. • Streamlining the procurement process in order to ensure that all healthcare facilities of the State get free of cost service at one point.
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Shed some light on procurement processes on fronts of drug and equipment. In order to support drug procurement processes and medical equipment procurement processes, a procurement manual- ‘a comprehensive policy for procurement of drugs/surgical items and medical equipment’ has been formulated and documented. It was finally approved in September, 2018 by Health Department, Government of Bihar after legal and financial vetting from the Law & Finance Departments. The procurement manual as the procurement policy document provides a detailed guideline and a legal coverage to the entire procurement processes of BMSICL. Empanelment of five NABL accredited QC (quality check) labs for drug testing has been done to
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the vendors/bidders and within the market due to issues like delayed and pending payments, improper response etc. In addition, the manufacturers were not directly participating in the bidding process and there were local representatives who acted as business mediators in the entire bidding and contracting process. In order to remove these barriers and to create a positive image of BMSICL, all pending payments of the previous suppliers were released except those pertaining to legal matters. To do away with the business mediators, BMSICL in association with CAREIndia organised first large scale state level ‘PartnersConclave’ in April 2018 in which more than 200 manufacturers and their authorized suppliers participated. The conclave laid strong foundation of mutual trust among various stakeholders as a result BMSICL is now getting a greater number of bids for its tenders. In addition, BMSICL has invited expert officials from Government (Central/State) and Semi Government organisations so that they could provide an insight about the technical aspects to various partners.
Q
Govt facilities at times lack required equipment and other necessary logistics pertaining to care. What steps have been undertaken to improve infrastructure?
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WITH THE AIM TO ENSURE AMPLE AVAILABILITY OF NECESSARY EQUIPMENT IN DIFFERENT MEDICAL COLLEGES/HOSPITALS OF BIHAR, BMSICL HAS ENTERED INTO RATE CONTRACT FOR 60 MOST IMPORTANT EQUIPMENT.
POLICYMAKER’S PERSPECTIVE
ensure that testing of medicine samples for every procured batch is undertaken on time. This would help in timely distribution of quality medicines to the various stores across districts and to entire health facilities in the State. EDL (essential drug list) review and updation for more comprehensiveness in medicine procurement- EDL review process was started in 2015. The technical core committee earlier formed for the purpose of review of the EDL was also restructured for more inclusiveness from the peripheral health facilities and development partners. The main idea of the EDL review was to have facility-wise EDL with more number of drugs for more comprehensiveness and a wider disease coverage including the noncommunicable diseases as well. The latest version of EDL launched in March 2018 comprises 310 products as compared to 180 products of the earlier EDL of 2011. Periodical and structured procurement review meetings are being conducted from 2016 onwards with an objective to monitor the progress in the procurement process. Vendor Partnership platform has been established and active interaction with existing and prospective vendors has also been started by BMSICL. For many years, BMSICL faced a major challenge of distrust among
With the aim to ensure ample availability of necessary equipment in different medical colleges/ hospitals of Bihar, BMSICL has entered into rate contract for 60 most important equipment. Construction of new medical colleges and hospitals has been taken up on a large scale to improve healthcare infrastructure across State. Under the State Government’s ambitious 7 Nischay Scheme many institutes including one ANM training institute in every sub-division of the State, one GNM and paramedical institute in every district of the State, and one BSc nursing institute in every medical college of the State are being developed. A Center of Excellence (COE) building has been set up at Nalanda Medical College and Hospital (NMCH) for providing high-end diagnostic tests. For maternal and neonatal care, 100-bed MCH hospital is being set up in six medical colleges & hospitals, and two district hospitals at Muzaffarpur and Sitamarhi. In addition, following infrastructure related development work is also being carried out by BMSICL: • Development of PMCH with a total
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POLICYMAKER’S PERSPECTIVE 34
expense of Rs 5540 cr. • Upgradation of nine district hospitals with a total cost of around Rs 160 crores. • Development of 272-bed capacity Mental Healthcare Hospital at Koilwarand and Ara. • Development of medical college and hospital at Madhepura, Bettiah, Purnia & Chapra. • Development of dental medical college & hospital at Rahui (Nalanda). • Construction of 106 bedded superspeciality eye hospital at Rajendra Nagar, Patna. • Development of superspeciality 106-bed eye hospital & 400-bed orthopaedic hospital at Rajwanshi Nagar, Patna.
Q
PPP is being perceived as the best model to improve infrastructure. How is it being leveraged across to streamline things? Public-Private-Partnership (PPP) provides an opportunity for private sector participation in financing, designing, construction, and operation & maintenance of public sector programmes and projects. It’s high time to forge a greater interface between the public and the private sector in a wide range of activities especially in the area of healthcare delivery services where shortage of trained / skilled manpower
AUGUST 2019
is a big challenge. Leveraging PPP model, BMSICL has established CT scan and MRI machines in PPP mode in all working Medical College & Hospitals of the State. Besides this, x-ray services on PPP mode through State Health Society, Bihar, is also in line at the district level and below. These services require huge investment as well as trained manpower and we have better experience running these services on PPP mode across health facilities in Bihar. We are also gearing up to operate the Centre of Excellence at NMCH Patna under PPP-mode. It will enable masses to avail high-end diagnostic tests.
Q
What steps have been taken by the agency to ensure quality and regular drug supply to masses & to avoid any malpractices on this front? BMSICL ensures timely procurement and regular supply of quality drugs, surgical and suture items every year by getting the requirements from various Government health facilities across the State by means of online indenting by the concerned authorities. The indenting of drugs/medical devices is done as per the EDL. Some of the measures which have been undertaken on this front
include e-tendering process, technical evaluation of bids, and inspection of the respective manufacturing units. Supply of quality drugs is done in accordance with the indent received from different medical institutions and the health facilities. The monitoring of the entire process is done through C-DAC owned DVDMS (Drug and Vaccine Distribution Management System) at the district level and below.
Q
India needs indigenous medical equipment to contain costly medical facilities. How do you read the statement in context of Bihar? I do agree that India needs indigenous medical equipment to combat costly medical facilities. At the same time, BMSICL is ensuring quality and safety standard of the medical equipment by adopting prevalent safety and quality standard like USFDA/ European CE/ BIS at the time of designing their technical specifications. Being nodal procurement agency for the Health Department of Government of Bihar, we ensure procurement of quality equipment so that people of all strata get quality care. BMSICL undertakes following procedures for quality assurance:• Technical evaluation of bid document submitted by the bidder is done by verifying the quality certificate as well as technical data sheet of the quoted medical equipment. • Demonstration of quoted medical equipment by the bidder in presence of specialist (doctor) who ultimately will be using it. • The consent of OEM (Original Equipment Manufacturer) to ensure uninterrupted service of the supplied equipment for three years during the warranty period, and during the consecutive seven years under the AMC/ CMC (Annual/Comprehensive Maintenance Contract) period is essentially obtained.
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BEST PRACTICES IN HEALTHCARE 36
Delhi’s Healthcare Delivery System: Best and Next Practices
With four-tier system including Mohalla clinics and many other health schemes, the Government of NCT of Delhi is taking all possible measures to create accessible, affordable and quality model of health care delivery system in National Capital.
D
elhi is a city that reflects a perfect blend of modern and traditional architecture and one of the fastest growing cities in India. It is also the center of the government’s legislative and judicial systems. Spread over an area of 1,483 sq kilometers, 216 meters above sea level, the city shares its boundary with two states i.e Haryana and Uttar Pradesh. In 1992, Delhi was declared as a state under the National Capital Territory Act, 1991 and has a complex administrative structure with dual jurisdiction i.e. Union and State Government known as Govt of NCT of Delhi. There are 11 districts, including New Delhi and 33 subdivisions, with 110 census towns and 112 villages. The Delhi metropolitan area has five local municipal corporations- North Delhi Municipal Corporation, South Delhi Municipal Corporation, East Delhi Municipal Corporation, New Delhi Municipal Council and Delhi Cantonment Board (DCB). As per the 2011 Census, the density of population in Delhi is 11,320 persons per square kilometer (as compared to the national level of 382 persons per square kilometer), highest in all states and union territories during this period. Health being a State subject has become top priority to people living in the national capital. Despite multitude of facilities being offered by different government bodies including the
AUGUST 2019
Central Government, Railways ESI, Municipal corporations , New Delhi Municipal Council, Cantonment board having their own dispensaries, and hospitals, besides AIIMS and more than 1000 private hospitals/nursing homes , Govt of NCT of Delhi realised that facilities were still not adequate & accessible to each and every citizen. In order to provide free healthcare facilities to population in Delhi, it has been decided to have a four tier system i.e Mohalla clinics, polyclinics, secondary care hospitals and tertiary care hospitals considering the facts that some areas of Delhi are still unserved and underserved, whereas, some areas are over served. At a glance, it could be seen that while considering the concept of Mohalla Clinics Government of NCT of Delhi, Department of Health and Family Welfare had 36 allopathic hospitals (including exclusive institutions for dental care, cancer care, cardiac & neurology care and liver ) , with more than 10,000 beds, over 260 dispensaries, 45 mobile health clinics and 150 ambulances and a medical college. In addition there were facilities in Ayurvedic, Yoga, Unani & Siddha, and Homeopathy (AYUSH) stream. With increasing population, government faced a big challenge to expand the existing repository of facilities every year to meet the demands of inhabitants living
Dr Ashok Kumar Director General, Directorate General of Health Services, Government of NCT of Delhi in Delhi or coming to Delhi for better care facilities. The best idea to meet the challenge was to provide primary healthcare through Mohalla clinics for a population of approximately 10,000 people so that they need not to travel more than two kilometres to seek medical facilities. Earlier, the availability of a dispensary was planned for a population of 30,000- 50,000. A geo-spatial analysis of primary health facilities belonging to all agencies combined, revealed that there was an inequitable distribution of facilities with 85 dispensaries serving less than 25,000 population, 121 dispensaries serving about 25,000 – 50,000 population, 122 dispensaries for around 50,000 – 75,000 population and
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29 dispensaries serving about 75,000 – 100000, while 19 dispensaries served more than 100000 population. More than 9 lakh population was still unserved. The Government decided to have an innovative plan to open 1,000 Mohalla clinics involving various government agencies including participation of private people. It was also decided to add 10,000 more beds by reviewing the ongoing construction of three new hospitals and increasing their beds strength at construction stage and further by way of remodelling / expansion of existing 17 Delhi Government Hospitals. PRIMARY HEALTH CARE Presently, primary healthcare services are available through 202 Mohalla Clinics which have been functioning and another 350 are going to be started including double shift within next two months. Similarly, 25 polyclinics have been set up for providing specialised facilities through specialists from Medicine, Paediatric, Eye & ENT, etc in out-patient departments near to the community. Remodelling of existing 94 dispensaries to set up polyclinics has been sanctioned so that people
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requiring OPD consultations in various specialties need not to go to hospitals. All Mohalla Clinics and polyclinics have the backup facilities of laboratory services of providing more than 200 tests through outsource mechanism. DELHI’S RECORD SPEAK VOLUME ABOUT THE GOVERNMENT’S INTENT TO IMPROVE HEALTHCARE DELIVERY SYSTEM On front of important vital indicators like Infant Mortality Rate 16/1000 live births, Neo-natal Mortality Rate 14, and under Five Mortality Rate 22, Delhi has fare record in comparison to All India levels. Delhi’s total fertility rate (TFR) of 1.5 is among the lowest in India (All India level 2.3) which indicates achievement of the replacement rate. Through another scheme Delhi Arogya Kosh Delhi Govt provides financial assistance to the extent of Rs 5 lakh to the needy eligible patients for treatment of any illness /disease in Government Hospital. From 2017 the financial assistance has been extended for Ultrasound, Doppler Studies, Mammography, EEG, EMG, TMT & ECHO from private empanelled standalone diagnostic centres.
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BEST PRACTICES IN HEALTHCARE
DELHI AROGYA KOSH PROVIDES FINANCIAL ASSISTANCE TO THE EXTENT OF RS 5 LAKH TO THE NEEDY ELIGIBLE PATIENTS FOR TREATMENT OF ANY ILLNESS /DISEASE IN GOVERNMENT HOSPITAL.
The facilities of cashless treatment to victims of road accident, acid attack and thermal burn injury are also being offered in private nursing homes and hospitals through Delhi Arogya Kosh (DAK). This is valid for those accidental cases which occur in the National Capital Territory of Delhi and registered as MLC in Delhi. The idea is that no victim should suffer due to denial of healthcare facilities because of financial involvement. The private nursing homes and hospitals having an agreement with the Department of Health and Family Welfare can claim reimbursement on ceiling rates. Now, the next best practice being considered is to extend this facility to all registered private nursing homes and hospitals in Delhi irrespective of any agreement and they can claim reimbursements on ceiling rates for treatment provided to victims as mentioned above. In the recently introduced Mukhya Mantri Teerath Yojna, the healthcare facilities are being provided to population of Delhi during travel and their stay. In essence, the Health Department of GNCT Delhi is committed to improve delivery of healthcare scheme, enabling every citizen of Delhi to avail best medical facilities in a costeffective manner.
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TECHNOLOGY PERSPECTIVE 38
Tata Winger Ambulance Facilitating Emergency Care Equipped with high-end technologies, Tata’s Winger Ambulance is ensuring better patient care to people at large. Various State Governments are availing the ambulance service to boost existing healthcare infrastructure, enabling people accessible and affordable medical facilities.
W
inger Ambulance from Tata Motors is a single stretcher ambulance that offers extra safety, a smooth drive within a reasonable price. It incorporates an innovative design unmatched by other ambulance vehicles. There is enough room for a patient and attendants, providing comfort for all. The Ambulance is compliant to the latest AIS 125 (Part 1) norms and is available in two wheel-base options. Powered by the 2.2 L DICOR engine, Tata Winger Ambulance is an economical choice for hospitals and ambulance operators. To meet specific needs of patients, Winger Ambulance Multi-purpose utility Vehicle (MPV) can be customised as a mobile medical unit, critical care unit (Advance Life Support Ambulance), blood transportation van and many more. Winger Ambulance sales has shown record breaking growth in last few years. Last year, TATA Motors Limited(TML) sold 2,078 units with 66.7 percent market share, a highest ever volume & market share growth, since the launch of this product. TML has successfully completed
AUGUST 2019
/ in process major bulk orders as below:(a) UP Medical Health, Lucknow1,474 units order completed while we are in process of fulfilling their current order of 1,544 units (853 units already delivered in July’19). (b) NRHM Health, Gujarat - We are in process of fulfilling their current order of 346 unit (254 units already delivered in July’19). (c) Haryana Medical, Gurgaon –
We are in process of fulfilling their current order of 75 units (68 units already delivered in July’19). (d) HP Health, Himachal Pradesh – 46 units order completed for type C vehicles. (e ) NHM, MP - 40 units order completed for type C vehicles. (f) PHSC Punjab - 20 units order completed for type C vehicles. (g) Orissa Health, Orissa - 420 units recently obtained order of type C member ambulance
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NEWS HIGHLIGHTS
Latest from Healthcare World Apollo Hospitals inks pact with Microsoft to combat cardiovascular diseases
Medical education reform: Lok Sabha passes NMC Bill Lok Sabha has passed the National Medical Commission Bill, paving path for replacement of more than 60 years old Medical Council of India with National Medical Commission (NMC). The Bill passed by a voice vote aims to bring reform in medical education and replacement of corruptionplagued MCI is one of such endeavours. The Bill has many provisions to overhaul medical education system including National Exit Test (NEXT) which will be considered as gateway to PG courses and screening test for students who graduate in medicine from foreign countries.
In an endeavour to leverage AI to combat cardiovascular disease, the biggest cause of mortality in India, Apollo Hospitals Group and Microsoft India has joined hands. As per the understanding, a National Clinical Coordination Committee for AI-powered Cardiovascular Disease Risk Score API will be established. The coordination committee will be assisting the core team at Apollo Hospitals and Microsoft by providing guidance on all cardiology and cardiovascular-related artificial intelligence projects. It will also provide insights on developing clinical algorithm and treatment guidelines based on the inferences of national, multi-centre prospective study, a release said here.
Fitness startup GOQii raises Rs 13.81 Cr from parent entity GOQii, a healthcare startup which deals in wearable technology has secured funding of worth Rs 13.81 crore from its parent entity. According to RoC filings, the Mumbai and Palo Altobased startup raised this investment by issuing 6183 equity shares costing Rs 8,535 per share from its parent entity Goqii inc on July 19. Started out as a healthcare focussed wristband seller in 2014, GOQii encourages consumers globally to lead healthier and better lives. It offers a gamut of fitness products under its wearable fitness band.
Commercial surrogacy to be banned soon Commercial surrogacy will be illegal soon and only close relatives to be allowed to act as surrogates, as per the Surrogacy (Regulation) Bill, 2019, which was recently introduced in the Lok Sabha, the Lower House. Provisions of the Bill include the constitution of surrogacy boards at national and state levels, as well as seizing the rights from intended couples to abandon surrogated child under any condition. As per the Statement of Objects and Reasons of the bill, introduced on Monday by Union Minister of Health and Family Welfare Harsh Vardhan, only Indian couples who have been legally married for at least five years would be allowed to opt for surrogacy
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AUGUST 2019
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Govt plans to leverage Artificial Intelligence in public health In a bid to improve clinical outcome in public health, the Union Ministry of Health & Family Welfare is planning to leverage Artificial Intelligence in a safe and effective way. While replying to a question in Lok Sabha, Union Health Minister Harsh Vardhan said the central government has prioritised building AI technology capabilities in order to address gaps in India’s AI ecosystem and realise its economic impact.
Glenmark, Torrent Pharma join hands to co-market diabetes drug in India
Govt’s BP control initiative to be expanded to 100 districts With an aim to control diabetes and other related diseases taking toll on the health of masses, the Government on Wednesday announced expansion of its India Hypertension Control Initiative (IHCI) across the country. A plan is afoot to expand IHIC initiative to 100 districts covering all the states so that a large population could avail quality treatment for hypertension, a disease which makes people vulnerable to heart attack, stroke and kidney failure. As per the official data, uncontrolled high blood pressure or hypertension, which leads to a sudden heart attack at times, is among leading causes for death in the country.
Glenmark, Torrent Pharma join hands to co-market diabetes drug in India Glenmark Pharmaceuticals and Torrent Pharmaceuticals have entered into a licensing agreement to co-market diabetes drug Remogliflozin Etabonate in India. In a regulatory filing Glenmark Pharma said, “Under the terms of the agreement, Glenmark will receive an upfront payment, license fees and royalties for the non-exclusive sub-license rights from Torrent.
Medanta to set up hospitals in Gorakhpur, Varanasi and Allahabad In an endeavour to improve healthcare infrastructure to make people avail better patient care, the Medanta Group s planning to set up hospitals is different parts of Uttar Pradesh. The planning is afoot to establish 1,000-bed hospitals in Gorakhpur, Varanasi, and Allahabad. “The 1,000-bed hospital in Lucknow will be inaugurated on October 15. The group will also open similar hospitals in Gorakhpur, Varanasi and Allahabad,” said Medanta Group Chairman Naresh Trehan while speaking at second ground breaking ceremony in Lucknow.
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