INTERVIEW
Healthcare Times
Health Policy, Research & Industry Magazine Vol. 01 | Issue 1
Amit Munjal CEO of Doctor Insta Sushil Eapen Founder and CEO of Silver Oak Health
Affordable Healthcare Decoding the National Healthcare Policy Making healthcare affordable in rural areas Bridging gap in Indian healthcare system
Surgery Pain Management after Surgery
Products Eppendorf BioFlo 320 Universal Bioprocess Control
Secret to India’s affordable healthcare
HEALTH PRIORITIES ARE CHANGING
The policy directions of the “Health for All” declaration became the stated policy of Government of India with the adoption of the National Health Policy Statement of1983. India’s health. sector has always posed major challenges to policy makers, with increased budgetary spending not always yielding commensurate returns in terms of a more healthy nation. And, it is an accepted fact by experts that there is a strong relationship between economic growth and better health – it being a two way relationship. A population with major health problems cannot become part of the Nation's growth process. On the other hand, a nation beset by health problems can have a retarding effect on the country’s development goals. Both the Millennium Development Goals and later the new set of Sustainable Development Goals had appreciated this fact and integrated Health Goals into their agenda. India, as a signatory to the SDGs needs now to gear up its policies and work out its health priorities to achieve those targets. Equally importantly, it needs to work towards greater cohesiveness in integrating its policies and actions in the health sector to its developmental programmes in other sectors. Our policy makers had appreciated this fact and launched several health programmes which have been immensely successful over the years. There has been a successful reduction in infant and maternal mortality rates, our immunization programmes, specially for pulse polio have been lauded the world over and we have almost won the war against small pox, once a deadly killer disease. Our medical system can compete globally with the best in the world. We sincerely hope you enjoy reading the April issue of our magazine. Best Regards, Sagar Rawat Senior Editor Health Care Times
The Team Managing Editor: Abhishek Pr asad abhishek@healthcaretimes.org Senior Editor: Chandan Singh chandan@healthcaretimes.org Senior Editor: Sagar Rawat editroial@healthcaretimes.org Head Office: Health Care Times E/218 B, Sector 63 Noida, U.P. PIN Code – 201301
For Editorials, Advertising and Media Partnereship: editorial@healthcaretimes.org Our Contributors:: Amit Munjal, Sushil Eapen. Kinkini Chakr avar ty, Santanu Mishra, Social: Facebook: https://www.facebook.com/hctimesor g/ Twitter: https://twitter .com/hctimes Google+: https://plus.google.com/102503225563756320347 Pinterest: https://in.pinter est.com/healthcar etimes/
CONTENTS
Decoding National Health Policy 2017
COVER STORY
Prime Minister Shri Narendra Modi called it a “historic moment…to create a healthy India where everyone has access to quality healthcare”. The National Health Policy 2017 seeks to reach everyone in a comprehensive integrated way to move towards wellness. It aims at achieving universal health coverage and delivering
quality health care services to all at affordable cost. It also aims to attain the highest professional standards, integrity and ethics to be maintained in the entire healthcare delivery system.
INTERVIEW
RELATED STORIES
Amit Munjal CEO of Doctor Insta talks about the future of telemedicine in India 22
Basic health care should be the immediate focus 9
Sushil Eapen CEO and Founder Silver Oak Health talks about the role of telemedicine in online delivery of Cognitive Behavioral Therapy (CBT) program. 24
Secret to India’s affordable healthcare 13
SPECIAL
Pain Management after Surgery 20
Bridging gap in Indian healthcare system 17
Healthcare Times E/218 B, Sector 63 Noida Uttar Pradesh India | Email: editorial@healthcaretimes.org | Web: www.healthcaretimes.org DISCLAIMER: Reader s ar e r equested to make appropr iate enquir ies to satisfy themselves about the veracity of an adver tisements befor e resp onding to any in this magazine. Healthcare Times, Publisher and Owner of this magazine do not vouch for the authenticity of any advertisement or advertiser or for any of the advertiser’s product or services. In no event can the Owner, Publisher, Printer, Editor/s, Director/s, Employees of this magazine/company be held responsible/liable in any manner whatsoever for any claims and/or damages for advertisements in this magazine.
HEALTHCARE TIMES
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APRIL 2017
NEWS Lok Sabha Passes The Mental Healthcare Bill
The Lok Sabha on March 27, passed the Mental Healthcare Bill 2016 that r ecognizes the rights of mentally ill people to affordable treatment and also seeks to decriminalise suicide. The Bill, which was passed by the Rajya Sabha in August last year, will replace the Mental Health Act 1987. The Bill aims to provide health care, treatment and rehabilitation for patients and ensure they are “provided in the least restrictive environment possible, and in a manner that does not intrude on their rights and dignity The most important amendment made in the Bill is that it decriminalises suicide. Electroconvulsive therapy for minors and sterilisation of patients has been barred under the Bill Cabinet Approves Health Policy 2017
National
The Policy recommends prioritizing the role of the Government in shaping health systems in all its dimensions. The roadmap of this new Policy is predicated on public spending and provisioning of a public healthcare system that is comprehensive, integrated and accessible to all. Further, it advocates a positive and proactive engagement with the private sector for critical gap filling towards achieving national goals. It envisages private sector collaboration for strategic purchasing, capacity
HEALTHCARE TIMES
building, skill development programmes, awareness generation, developing sustainable networks for community to strengthen mental health services, and disaster management NHP 2017 seeks to promote quality of care, focus on emerging diseases and invest in promotive and preventive healthcare. It addresses health security and make in India for drugs and devices.
Indian Medical Association Calls For Amendments To Clinical Establishment Law The Indian Medical Association (IMA), a top body of doctors, met Governor Keshari Nath Tripathi and expressed concerns over the Clinical Establishment (Registration, Regulation and Transparency) Act, 2007.
Donald Trump Blames Republican Radicals For Failure Of Healthcare Bill
The recently passed Act envisages a panel to monitor private healthcare institutes and imposes heavy fines in case of medical negligence.
US President Donald Trump blamed Republican lawmakers from the ultraconservative Freedom Caucus for the failure of a Republican healthcare plan to replace former President Barack Obama’s Affordable Care Act, after blaming Democrats for the loss on March 24. Speaking to reporters in the Oval Office President Trump said “We were very close, it was a very tight margin. We had no Democrat support, no votes from the Democrats,” he said. “I think the losers are Nancy Pelosi and Chuck Schumer because now they own Obamacare.” Many, if not all of those people would have lost their healthcare coverage under the now-shelved Republican plan.
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“The bill requires a lot of amendments. Private and government sectors can’t be differentiated. There is no provision for quacks or false complaints. As per the law, doctors would have to face consequences for every complaint, which can be false. There cannot be a penal punishment for doctors” said IMA chief K.K.Agarwal SC Opens Surrogacy Window For Singles
What may turn out to be a positive outcome for single men and women who wish to be parents
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NEWS a Supreme Court Bench led by Justice Ranjan Gogoi allowed a representation to be made before the parliamentary committee to consider including a “specific provision” in the Bill so as to facilitate single persons also to embrace parenthood through surrogacy. The representation will be forwarded to the office of the Solicitor-General of India, who will formally hand it over to the legislative panel for consideration. “There is no specific provision about single parents in the Bill, but the Bill also does not specifically prohibit them,” senior advocate Shekhar Napahade, for a petitioner, submitted.
data required for a standard authorisation but showed an improvement in the survival of patients when compared with historical controls. The EMA also reported withdrawls of several applications: Viridian Pharma Ltd’s medicine Blectifor (caffeine citrate) for treatment of bronchopulmonary dysplasia.
GE Healthcare To Spend $300 mn On Affordable Solutions In India
Dollar Drops To Near 2-month Low On Trump’s Healthcare Defeat The dollar slid to a near twomonth low against a basket of currencies on Monday as concerns mounted about the chances of US fiscal stimulus after President Donald Trump’s failure to push through a healthcare reform Bill.
Dragged down by declining US yields, the dollar index against a basket of major currencies was down 0.4 per cent at 99.258, its lowest since February. 2. FDA Approves Avelumab in MCC
Merck’s
EMA Backs Three Orphan Drugs Three of six new meds to be approved in Europe are orphan drugs and have been backed by the European Medicines Agency (EMA) this month.
The EMA’s Committee for Medicinal Products for Human Use (CHMP) has recommended authorisation under exceptional circumstances for Apeiron Biologics’ (Vienna) anti-ganglioside GD2-tareting chimeric monoclonal antibody Dinutuximab beta (L01XC) for the treatment of high-risk neuroblastoma. Apeiron, which will comarket the treatment with EUSA Pharma could not provide
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GE Healthcare will invest $300 million (Rs 1,996 crore) over five years to deliver affordable healthcare solutions across India, other South Asian countries and Africa. A subsidiary of US-based conglomerate General Electric, GE Healthcare delivers healthcare equipment and technology services that are aimed at reducing cost of care using digital technologies. The firm has also partnered with 11 organisations to provide technical skills to medical industry professionals. “We will invest nearly $300 million across India and South Asian countries to extend our costeffective healthcare solutions.” said Terri Bresenham, president & CEO, Sustainable Healthcare Solutions, GE Healthcare.
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US arm of German Merck: It’s PD-L1 blocker avelumab is the first drug that received FDA approval to treat the rare skin cancer Merkel Cell Carcinoma (MCC). The immune cancer therapy, which will be co-marketed by Pfizer for an annual cost of US$150,000 per patient, is the fourth immune checkpoint inhibitor triggering PD-1/PD-L1directed T cell activation in
APRIL 2017
COVER STORY
Decoding the National Health Policy
-by Abhishek Prasad
Priorities are changing, people are more aware of the health insurance, health laws and personal wellbeing in particular.
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he Union Cabinet chaired by the Prime Minister Shri Narendra Modi in its meeting on 15.3.2017, has approved the National Health Policy, 2017 (NHP, 2017). Prime Minister Shri Narendra Modi called it a “historic moment…to create a healthy India where everyone has access to quality healthcare”. The primary aim of the National Health Policy, 2017, is to inform, clarify, strengthen and prioritize the role of the Government in shaping health systems in all its dimensions - investments in health, organization of healthcare services, prevention of diseases and promotion of good health through cross sectoral actions, access to technologies, developing human resources, encouraging medical pluralism, building knowledge base, developing better financial protection strategies, strengthening regulation and health assurance. HEALTHCARE TIMES
Now after the last 15 years context has changed. First, the health prorities are changing, people are more aware of the health insurance, health laws and personal wellbeing in particular. Second important change is the tremendous growth of the healthcare industry, according to IBEF 'The overall Indian healthcare market is worth around US$ 100 billion (as of 2017) and is expected to grow to US$ 280 billion by 2020, a Compound Annual Growth Rate (CAGR) of 22.9 per cent. Healthcare delivery, which includes hospitals, nursing homes and diagnostics centres, and pharmaceuticals, constitutes 65 per cent of the overall market. The Healthcare Information Technology (IT) market which is valued at US$ 1 billion currently is expected to grow 1.5 times by 2020.' The third major change is the catastrophic increase in the out of pocket expense on health services, 6
which according to some is one of the biggest reason for transient poverty. On the background of these realities, The National Health Policy 2017 seeks to reach everyone in a comprehensive integrated way to move towards wellness. It aims at achieving universal health coverage and delivering quality health care services to all at affordable cost. Key Stones The National Health Policy 2017, aims to attain the highest professional standards, integrity and ethics to be maintained in the entire healthcare delivery system, which would be supported by a transparent and responsible regulatory mechanism. Policy also aims to reduce inequity which would mean minimizing disparity on account of gender, poverty, caste, disability, other forms of social exclusion and geographical
APRIL 2017
COVER STORY This would imply greater investment in health care sector and increased financial protection of poor who suffer from the huge burgden of out of pocket expense. The policy is designed in a way to increase affordability, universality and accountabilty in the healthcare system. It also aims to increase transparency and eliminate corruption in the healthcare sector, both in public and private.
1000 population in golden time period or within one hour of the injury. What is uniques about the NHP2017 is that it aims to achieve its objectives through deployment of digital tools for improving efficiency and outcomes of healthcare systems. It also recommends the establishment of National Digital Health Authority (NDHA) to regulate, develop and deploy digital health.
The policy seeks to move away from sick-care to wellness, with a thrust on prevention and health promotion. Which is although not unusual but new to India when it comes to healthcare laws. With the main aim of achiving good health and well being through preventive care, NHP2017 have some very ambitious targets - of reducing under 5 motality rate to 23 by 2025, reducing maternal motality ratio from current rate to 100 by 2020, reducing infant motality rate to 28 by 2019. Policy also proposes to raise public health expenditure to 2.5% of GDP by 2025 and increase life expectancy at birth from 67.5 to 70 by 2025. It also aims to reduce Total Fertility Rate (TFR) to 2.1 by 2025 and increase the availability of beds to 2 per
Legal Framework for Health Care and Health Pathway
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One of the fundamental policy questions being raised in recent years is whether to pass a health rights bill making health a fundamental right- in the way that was done for education. The policy question is whether we have reached the level of economic and health systems development so as to make this a justiciable right- implying that its denial is an offense. Questions that need to be addressed are manifold, namely, (a) whether when health care is a State subject, is it desirable or useful to make a Central law, (b) whether such a law should mainly focus on the enforcement of public health standards on water, sanitation, food
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safety, air pollution etc, or whether it should focus on health rights- access to health care and quality of health care – i.e whether focus should be on what the State enforces on citizens or on what the citizen demands of the State? Right to healthcare covers a wide canvas, encompassing issues of preventive, curative, rehabilitative and palliative healthcare across rural and urban areas, infrastructure availability, health human resource availability, as also issues extending beyond health sector into the domain of poverty, equity, literacy, sanitation, nutrition, drinking water availability, etc. Excellent health care system needs to be in place to ensure effective implementation of the health rights at the grassroots level. Right to health cannot be perceived unless the basic health infrastructure like doctor-patient ratio, patient-bed ratio, nurses-patient ratio, etc are near or above threshold levels and uniformly spreadout across the geographical frontiers of the country. Further, the procedural guidelines, common regulatory platform for public and private sector, standard treatment protocols, etc need to be put in place. Accordingly, the
APRIL 2017
COVER STORY management, administrative and overall governance structure in the health system needs to be overhauled. Additionally, the responsibilities and liabilities of the providers, insurers, clients, regulators and Government in administering the right to health need to be clearly spelt out. The policy while supporting the need for moving in the direction of a rights based approach to healthcare is
conscious of the fact that threshold levels of finances and infrastructure is a precondition for an enabling environment, to ensure that the poorest of the poor stand to gain the maximum and are not embroiled in legalities. The policy therefore advocates a progressively incremental assurance based approach, with assured funding to create an enabling environment for realizing health care as a right in the future.
KAYAKALP SCHEME
A policy is only as good as its implementation. The National Health Policy envisages that an implementation framework be put in place to deliver on these policy commitments. Such an implementation framework would provide a roadmap with clear deliverables and milestones to achieve the goals of the policy.
DRAFT GUIDELINES FOR KIDNEY DONORS ISSUED
To recognise efforts of ensuring Quality Assurance at Public Health Facilities, the Ministry of Health & Family Welfare, Government of India has launched a National Initiative to give Awards ‘KAYAKALP’ to those public health facilities that demonstrate high levels of cleanliness, hygiene and infection control. The Objectives of award scheme are to promote cleanliness, hygiene and Infection Control Practices in public Health Care facilities; To incentivize and recognize such public healthcare facilities that show exemplary performance in adhering to standard protocols of cleanliness and infection control ;To inculcate a culture of ongoing assessment and peer review of performance related to hygiene, cleanliness and sanitation and to create and share sustainable practices related to improved cleanliness in public health facilities linked to positive health outcomes
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Implementation Framework and Way Forward
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The National Organ and Tissue Transplant Organisation (NOTTO) under the Ministry of Health & Family Welfare issued draft guidelines for Allocation Criteria for Deceased Donor Kidney Transplant. This will be a major step towards easing rules and procedures to encourage organ donation among the masses. The draft guidelines have been posted on the website of NOTTOwww.notto.nic.in This initiative will promote organ donation in the country. The guidelines will be finalised after Ministry reviews various suggestions & comments regarding the same" The draft guidelines include issues like = recipient registration, listing and scoring system in the waiting list scoring system for making priority, allocation principles, allocation algorithm, including criteria for urgent listing, and interstate issues. A list of the government and non-government hospitals in Delhi along with those in the neighboring area of the NCR (Gurgaon, Ghaziabad, Faridabad, Noida) have also been listed in the draft guidelines. The hospitals in the NCR cities will be included in the networking along with hospitals of Delhi for the purpose of organ sharing and allocation with the concurrence and MoU with the respective State Governments and institutions in due course of time.
APRIL 2017
COVER STORY - by Kinkini Chakravarty, Rural Health Care Foundation (RHCF)
“Basic health care should be the immediate focus” Lack of Medical facilities in the vicinity of her neighborhood made the treatment almost inaccessible to her. She was unable to travel far as that would lead to a sacrifice of one day wage which she could not afford
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anita Bibi , age 40, has a family of 6 members to feed. She is the sole bread earner in her family who travels 10 km to and from her workplace, everyday. She works in a bidi making factory for the last 4 years , ever since her husband passed away. Lately she was suffering from low eyesight and the condition was deteriorating with each passing day. Lack of Medical facilities in the vicinity of her neighborhood made the treatment almost inaccessible to her. She was unable to travel far as that would lead to a sacrifice of one day wage which she could not afford. At this juncture, she came to know about the primary health care centres set up by
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Sanita Bibi (photo courtesy: RHCF)
Rural Health Care Foundation (RHCF) at the vicinity, where she could be diagnosed and receive treatment at a nominal amount of Rs. 60 (less than $1) only and weeklong supply of medicines,
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free of cost and a pair of spectacles free of costs as was funded by some anonymous funder through Give India from USA. When Sanita Bibi visited RHCF’s Namkhana centre, she received
APRIL 2017
COVER STORY immediate medical attention which came as a surprise to her. Being a member of the deprived and underserved community she was habituated to insensible, negligent and callous behavior of the doctors who she encountered previously. Unlike less qualified local doctors, the doctor at RHCF treated her with great care. The doctor not only advised on the prescribed medicines but also suggested her
The centres offer high quality health services at the most affordable cost to the low income group, rural population residing in the densely populated remote villages of West Bengal, India. Currently RHCF has 16 primary health centres (PHCs) spread across 8 districts of West Bengal including Kolkata. They are at Nadia, Bardhaman, North 24 Pargana and South 24 Pargana, Birbhum, and Hooghly.
low supply of medicines, lack of qualified and dedicated human resources and gross negligence in dealing with the patients. Though at various levels Government has come up with programs and policies but fell short of proper implementation. Hence in many places state run medical facilities are present only on papers but not in practice. Frequent mass health care awareness programs and medical camps should be organized. Mobile clinic should be launched to make the primary health care reach to the doorsteps of the poor.
“PHCs in rural India are short of more than 3000 doctors�
Rural Health Care Foundation (RHCF) (photo courtesy: RHCF)
about basic sanitation and hygiene, which in turn would improve the quality of her living as well. Like Sanita bibi, thousands of patients are getting benefitted by the basic healthcare offered by a chain of primary health centres established by RHCF, in the remotest villages of West Bengal. HEALTHCARE TIMES
RURAL HEALTH SCENARIO Basic health care should be the immediate focus, since many rural places are devoid of any basic medical assistance within the vicinity. State government run medical facilities in these areas are practically dysfunctional due to limited medical resources, substandard equipments, 10
Rural population need to be educated about basic sanitation , health , nutrition and hygiene and have to be encouraged to visit doctors in order to address any health related issues. Timely treatment and intake of medicine will decrease the infant mortality rate and maternal deaths. Attempts should be taken to develop the quality of living for a healthy future. PHCs in rural India are short of more than 3000 doctors, with the shortage being 200% over the last 10 years, APRIL 2017
COVER STORY according to an analysis by India Spend. Lack of public medical professionals leads people to travel to far flung places and in the process compromise one day earning. Beside, private medical services are expensive in nature thereby making it practically unavailable to the rural poor. Government should make attempts to increase manpower in public hospitals. Women, children and elderly people are the most vulnerable among all. Majority people from the rural community are either farmers, peasants, daily wage earners or contract laborers . When the male folks go out to earn money, the women and the children are left behind with meager money to survive on. Health related issues are neglected out of the fear of spending. In many cases visit to doctors only happens when the matter is escalated to a great level. Hence focus should be related to Child and Women health and nutrition.
JOURNEY TO SUCCESS The initiative taken by two brothers , Late Arun Nevatia and Anant Nevatia to enable basic health care services reach the doorstep of poor have been appreciated by various quarters , time and again. It is due to their farsightedness that the rural healthcare in Bengal is scaling new heights. HEALTHCARE TIMES
Eyecare Department at Sabang (photo courtesy: RHCF)
“Private medical services are expensive in nature thereby making it practically unavailable to the rural poor.”
afford quality treatment. It was this realization which led to the opening up of the first health care centres at Mayapur in Nadia district of West Bengal, in 2007. Behind the success story today, goes a history of hard work, sacrifices, dedication and perseverance. In order to serve the underprivileged, both the brothers left their lucrative careers of Real Estate. They embarked into an unpredictable, unforeseen journey of philanthropy which very few from their fraternity, would pursue. Undeterred by the dirty politics played by the local quacks and private practitioners, RHCF was successful in building trust among people and serving them better. In no time, the centre witnessed heavy footfall with remarkable outcomes.
The inspiration behind such initiative was dated back to the days when Arun was diagnosed with Hodgekin’s Disease in 1975. He was 10 that time and since then he suffered through 3 relapses and finally was diagnose with Leukemia in 2008. His regular visit to the hospital coupled with expensive treatment, chemotherapy and medicines led to the realization of the true condition of healthcare sector prevalent in Bengal. In the era of expensive treatment, the brothers understood the predicament of the poor The initiative which started as people who often are unable to 11
APRIL 2017
COVER STORY a one-day clinic concept of eye care, dentistry and general medicine, soon became a fullfledged clinic running 6 days a week .All at a negligible cost , within the reach of the poor community. The exemplary services provided by the Mayapur Centre had to be replicated in other parts of Bengal. The Centres were built up in a self sustenance model which if implemented as planned, could be run without any external aid or donation. Harvard School of Business published a Research Case Study on RHCF in 2015 followed by another publication by NUS Singapore in 2016. IMPACT SO FAR Till February 2017, 1529568 patients have been treated in the 16 primary health care centres. Besides catering to varied basic healthcare problems, our centres arrange cataract surgeries in association with Rotary Eye Hospitals. 9493 Successful eye surgeries, 13535 blood sugar testing and 501 Cleft lip/palate surgeries for children have been conducted free of cost in association with renowned hospitals and clinics. RHCF is also involved with providing spectacles at extremely subsidized rates. Till date, 35514 spectacles have been distributed among needy patients. HEALTHCARE TIMES
Furthermore, to support the poor, needy and physically challenged patients, about 150 Wheelchairs have been distributed, along with 2000 blankets. Proximity of a primary health centre in the remotest villages would also mean people do not have to travel to far flung places to avail the basic health care facilities and also the money they would spend in travelling could now be utilized towards educating their children and generating nutrition for the family. Each centre offers weeklong supply of medicines, free of cost. The wor th of the medicine would amount to Rs. 300 -350, if they are to purchase from the market. 10 % of the visiting patients who cannot afford to pay Rs. 60 are treated, free of cost. Further, the centre would garner employment opportunities to the local people residing nearby especially to women who have limited job opportunities otherwise. They can now be employed by the centres as the support staff taking care of the day to day medical stock and ensuring proper distribution of the same to the patients. THE BREAKTHROUGH
“Each centre offers weeklong supply of medicines, free of cost. The worth of the medicine would amount to Rs. 300350, if they are to purchase from the market. 10 % of the visiting patients who cannot afford to pay Rs. 60 are treated, free of cost.� expecting to reach out to hundreds and thousands of needy patients who require affordable healthcare. Mobile van delivering treatment at the doorstep of the poor is also envisioned, which would save 80% out of pocket expenses (including traveling and medicinal cost). Centres are getting revamped with the purchase of new and medical equipment. Research is also been conducted to identify new places to open up new centres. It is only a matter of time now, when RHCF would spread its wings to other parts of the country and be a name to reckon with in the field of Medical Philanthropy.
The journey is yet to reach its crescendo. RHCF is also 12
APRIL 2017
COVER STORY EDITORIAL
Secret to India’s affordable healthcare How India manages to handle such a huge population and with such a little spending is quite interesting, the fact is when you have a very limited resources you use those resources to the maximum.
Dental health camp conducted in Indian village
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t the time when health care cost in U.K. and United States are threatening to bankrupt the government, U.S. and U.K. hospital administration should learn a thing or two from India, when it comes to providing health care at low cost. HEALTHCARE TIMES
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According to some estimates Uttar Pradesh, which houses close to 204 million people, spent less than 600 INR or less than $9 per capita on health care during the last financial year, this is ridiculously low when compared to the United States which spent $8000 per capita on healthcare APRIL 2017
COVER STORY
Doctors at Primary Health care Centre (PHC) conducting regular check-up at a government school in India
Though the healthcare system in India is neither the most efficient nor the best in the world, it is somehow managing the pressure of rising health care cost and serving 1.25 billion people. At first, low-cost health care may not seem surprising, after all, wages in India is quite low compared to developed countries, but even when you adjust for wages the health care cost is still significantly lower, according to a study published in Harvard business review, If Indian hospitals paid their doctors and staff U.S. level salaries, their cost of open heart surgery would still be one-fifth of that in U.S. How India manages to handle such a huge population and with such a little spending is quite interesting, the fact is when you have a very limited resources you use those resources to the maximum, this may not seem logical to few but when you have to look after 1.25 billion people with little access to health insurance you have to innovate. HEALTHCARE TIMES
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And when it comes to innovation in health care delivery, India has surpassed the top institutions in the world. The key to this fact is that Indian doctors and hospitals have to operate on a shoestring budget, consider this according to the economic survey 2016-17 public spending of health is just over 1% of GDP, which is well below the world average of 5.99 % (according to world bank 2014).
On the background of such facts hospitals in India have to operate creatively to serve a vast number of poor population. According to Federation of Indian Chambers of Commerce and Industry (FICCI) when nearly 62% of the total health care spending in India is from out of pocket expense, Indian health care system must deliver value. Consequently, affordable and value-based health care is a reality in India.
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COVER STORY Major practices that enable hospitals to reduce cost, while still maintaining quality of care: In order to serve a large number of people India health care system have come up with a system of hub and spoke, while such system has been existent in developed countries like US and U.K., it has reached a remarkable level of efficiency in India. Indian hospitals have created a hub of main or tertiary hospitals in major metro cities like Delhi, Mumbai, Chennai etc. and small or primary health care centres (PHC) in rural areas or villages. These PHC refers patients to such big hospitals depending upon the need of care a patient require. For example, under Rashtriya Bal Swasth Karakyram (RBSK), PHCs or CHCs are setup in rural areas, doctors from these PHCs and CHCs, conduct regular check-ups in government schools and refer patients to secondary medical centre at the district level.
District level hospitals are relatively better equipped to handle cases, but when the nature of ailment is serious they refer the patients to larger tertiary hospitals in metros. Thus forming a feeder system for larger hospitals in metros. This tightly coordinated web reduces the cost, by concentrating the expensive equipment and team of experts at the hub.
Specialists at the hub perform a high volume of focused procedures. Hospitals in U.S. follow a similar approach but they are far spread and uncoordinated, they have duplicated care at many places, but often have low volume thus increasing the cost of procedures. According to Harvard business review, an MRI machine is used for 5 to 6 times in a day in U.S. at a cost of $1080 per MRI whereas in Indian hospitals it is used up to 20 times at merely 1500 INR or $23 per MRI at AIIMS New Delhi.
Luxury hospitals in India is a new thing, where cost of healthcare is relatively high
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COVER STORY According to FICCI India is dealing with huge shortage of doctors and have a 1:1700 doctor to patient ratio compared to 1:1000 recommended by WHO. So another innovative approach have to be devised in Indian hospitals and that is task shifting. Indian hospitals transfer responsibility for routine task to low-skilled workers leaving doctors to handle complicated procedures. By focusing only on technical part Indian doctors have become incredibly productive, according to some data an Indian doctor in PHCs get more than 100 patients per day. In another story according to Limca book of records "Dr. Ganesh Raj Shivnani, Senior Consultant and Chairman, Department of Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, has completed 446 consecutive coronary bypass surgeries without any death during hospitalisation from Feb 18, 2013 to Feb 15, 2015." (http:// www.limcabookofrecords.in/record-detail.aspx? rid=1181) and to take it further "Sankara Eye Foundation organised a massive vision screening program for 14,918 school-going children across India through its different units on Nov 13, 2014 on account of Children’s Day" (http:// www.limcabookofrecords.in/record-detail.aspx? rid=1168). Such records are proof of the sheer hard work and efficiency at which Indian doctors operate. This innovation has reduced the cost, and not to
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jobs for low-skilled workers in the health care sector. By contract in United States, the first cost cutting move it to lay of supporting staff and transfer their duties to doctors clearly under utilising their expertise. Finally, Indian hospitals are wisely using resources by sterlising and reusing many surgical products that are routinely discarded in U.S. and U.K. on top of that local manufacturing and cheap imports of surgical instruments from nearly south Asian countries have helped in reducing the cost of procedures. Indian hospitals have also been innovative in compensating doctors, instead of creating an incentive based pay model, many hospitals employ doctors on a fixed salaries regardless of how many patients visit the hospital. Innovation in India has not flourished in the field of new drug development or state of art medical procedures but in terms of service delivery Indian model has performed considerably well looking at the budget allocation, and level of education and awareness of Indian masses. While U.S. and U.K. are going through the crisis in health care due to repeal and replace of Affordable care act and NHS service breakdown, Indian health care has unique innovation
APRIL 2017
COVER STORY - By Santanu Mishra, Co-Founder & Executive Trustee, Smile Foundation
Bridging gap in Indian healthcare system How India manages to handle such a huge population and with such a little spending is quite interesting, the fact is when you have a very limited resources you use those resources to the maximum.
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ndia has made rapid strides in the health sector since independence. However, various eye opening data from NFHS (National Family Health Survey) clearly indicate that access to healthcare still remains a challenge due to the vast and diverse geography & population of India. According to a report by Forbes, India spends only around 1.2% of its national GDP towards healthcare and nearly 70% of the population lives in rural areas and has no or limited access to hospitals and clinics. Apart from this, an extremely low doctor-topatient ratio is a major concern. There is only one doctor per 1,700 citizens in India; the World Health Organisation stipulates a minimum ratio of 1:1,000. Further, the Union Health Ministry figures claim that there are HEALTHCARE TIMES
about 6-6.5 lakh doctors available currently in the country and India would need about 4 lakh more by 2020. Other obstacles in providing optimum primary healthcare services include low budget expenditure, sub-standard infrastructure, inadequate and under-trained staffs, lack of public and private collaboration and the worst of all insufficient incentives. As per a report by the UN, 25% of the health infrastructure in India that includes doctors, specialists and other health resources is unavailable in rural areas where 72% of India’s population lives. 75% of the health infrastructure is concentrated in the urban areas that are inhabited by only 27% of the population of the country. While the health statistics of rural India continues to be poor, the health status and access to 17
By Santanu Mishra, Co-Founder & Executive Trustee, Smile Foundation
health for the poor inhabiting urban slums has surfaced to be equally deplorable. Urban slum dwellers suffer from adverse health conditions owing to mainly two reasons – first the lack of education and thus lack of awareness; and second the unwillingness to lose a day’s wage in order to reach the nearest medical facility. Health for underprivileged which is a desperate need, thus remains unaddressed APRIL 2017
COVER STORY As a result, cases of poor health among women, malnourishment in children and deaths from preventable diseases in such areas are always high.
“The neglect in even the simplest preventive medical treatment usually leads to a more serious ailment and eventually to deaths.” The neglect in even the simplest preventive medical treatment usually leads to a more serious ailment and eventually to deaths. The need of the hour is thus a two pronged approach – first to bring quality health care services to doorsteps of the needy and second to promote healthcare awareness and a positive health care seeking behavior among the underprivileged. Innovative working model India is unable to cater to the rising demands of immediate medical facilities across the states as a major part of the population continues to reside in remote and hard-to-reach rural areas, suffering and fighting the worst kind of ailments. In such a scenario a mobile health care services delivery system is the most HEALTHCARE TIMES
practical mechanism. To address the situation, Smile Foundation came up with an innovative solution called ‘Smile on Wheels’. This is a unique mobile hospital programme that seeks to address problems of mobility, accessibility, affordability, awareness and availability of primary health care with a special focus on children and women, in urban slums and remote rural areas. Managed by specialised medical professionals including doctors, pathologists, pharmacists and nurses, Smile on Wheels are mobile units complete with advanced medical facilities like ECG, X-ray, pathological labs, etc. The model helps to provide free health facilities to the underprivileged at their doorsteps, with a special focus on mother and children. In addition to providing preventive and curative healthcare services, Smile on Wheels also focuses on generating health awareness on gamut of vital issues including ANC/PNC, institutional deliveries, immunization and vaccination, etc The Smile on Wheels programme aims to increase access to healthcare services, through demand based strategies and by providing a comprehensive
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The Smile on Wheels programme has so far provided healthcare services to more than 10 lakh children and families. combination of health services which meets the needs of the impoverished communities. Journey
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Healthcare Since the last three years, Smile on Wheels has worked extensively in the disasterprone state of Uttarakhand. The Mobile Hospital programme works extensively in 23 villages of the Rudraprayag district, benefitting more than 24,500 people every year. Even after marked progress in provision of medical infrastructure and facilities, healthcare remains a challenge in the difficult terrains of Uttarakhand. Internationally known for its Kedarnath temple, situated near the Himalayas, the state of Uttarakhand is famous for its natural beauty. The state receives frequent rainfall but in the last couple of years it has experienced inundate rainfall. In 2013, Uttarakhand faced one of its worst disasters. Heavy rain swept away APRIL 2017
COVER STORY villages in many districts, notable in Rudrayapag, situated at an elevation of 2,936 feet, and inhabited by over 2.3 lakh people. A major setback that the district faces is healthcare. Healthcare had long been an acute problem in the district. It has only one government run hospital that lacks adequate health facilities. With lack of proper infrastructure and medical aid the residents often have to travel to other districts to get treatment. During calamities the condition is even worse. The entire district was left to ruins by the heavy floods in 2013, leaving the health system of the region ineffective at a time when the inhabitants needed it the most. The remoteness and undulating terrains made the delivery of the available medical resources difficult. This was when Smile on Wheels started its operations in the Ukimath Block, with support from the Union Bank of India, at first addressing the immediate medical needs of the flood affected families. Adding to the inaccessibility of healthcare was the extreme poverty in villages of the district. The cost of travelling to a distant medical facility, in addition to losing a day’s wage, is a significant burden HEALTHCARE TIMES
for the poor people. Lack of awareness has been paramount as extremely low education levels translate to lower appreciation of medical symptoms and benefits of modern medical procedures. All this meant that the villagers had been living with debilitating illnesses for years hence, enduring the pain either without understanding their health problems or by ignoring them. Since the people could not reach the medical facilities, Smile Foundation decided to take healthcare services to their doorstep by initiating Smile on Wheels mobile hospital programme in the district. However, this was just the beginning of a challenging journey. The project team had to go on door to door visits in every village and conduct rigorous mobilization sessions to encourage villagers to come for a medical checkup and get treated To promote preventive action awareness sessions were conducted combined with behavioral change classes to actively involve the community. The results have been satisfying. Once the people started visiting the mobile hospital, some only out of curiosity, some hearing about people who had got cured, the project was successful in the 19
state. The news spread quickly in adjoining villages and demands were made to make the healthcare services available in other blocks too. Last year healthcare services were provided in eight villages which are outside the coverage of the project but were in dire need. During the recent cloudburst incidents in Pithorgarh district, the Smile on Wheels team carried all their equipment and went on foot where vehicles had no access, to reach the unreached. The project has been functioning in close coordination with the district and blocklevel hospitals, and cross referrals are made as per requirement. Further government community health workers including ASHA, ANM and Anganwadi workers are engaged and trained from time to time to ensure a long-lasting change in the community. The Uttarakhand floods brought to light the limitations of healthcare facilities in the state, and now our efforts are directed towards supplementing the government health services and bridge the gap between the needs of the villagers and the medical infrastructure in the area, helping build a robust, sustainable and inclusive healthcare system.
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SPECIAL SURGERY
Pain Management after Surgery Dr. Shahverdi E - Blood transfusion Research Center, High Institute for research and Education in Transfusion Medicine, Tehran, Iran Khani MA - Department of Medicine, Najafabad Branch, Islamic Azad University, Najafabad, Iran
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cute pain following surgery known as the issue that most patients suffer from it; but chronic pain after surgery is a problem that has needed a little more attention. Depending on the type of surgery, 10% to 68% of surgical patients may be suffering from chronic pain that 2% to 10% of them suffer from severe pain. There is no exact definition of chronic pain after surgery, and also differences in diagnostic procedures and questionnaires used for evaluation of pain after surgery, may explain the differences in prevalence rate in various studies. Currently it is accepted that duration of pain after surgery should be lasting at least two months after the operation time to make a trustworthy diagnosis. Risk factors of chronic pain After surgery divided into three periods: before surgery, during surgery and after surgery. Pathophysiological processes that occur after tissue damage indicate that acute pain may become persistent. Inflammation at the site of tissue damage creates a barrage HEALTHCARE TIMES
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of afferent nociceptors activity that causes peripheral and central nervous system sensitization and creates functional changes in the peripheral nerves, spinal cord, higher routes pain center and the sympathetic nervous system It seems that specific receptor sites such as N-methyl-D-aspartate receptor is particularly important in chronic pain following acute injury and descending pathways pain control also probably the decisive factor in chronic pain. In another systematic review it has been shown that administration of Gabapentin consumption before surgery cause more reduced pain after surgery compared to the control group and also may decrease the dose of opioids and side effects. Chronic pain after surgery often has a neuropathic component. Even in the early stages, it can be seen as a neuropathic pain after surgery. Therefore, drugs for treatment of chronic neuropathic pain are used as the adjuvant drug for pain ante surgery increasingly. It has been shown in numerous studies that some drugs such as Gabapentin and Pregabalin, not only can reduce the severity APRIL 2017
of acute pain after surgery and reduce the analgesic dose but also may contribute to the prevention of chronic pain after surgery. In a metaanalysis of Clark and colleagues, it was found that the use of Gabapentin and Pregabalin improved the patient functional outcomes in long-term.
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Various mechanisms have been suggested for these drugs, but it is still not entirely clear that what extent involve these mechanisms the analgesic effects of this drug, dose, metabolism and drug interactions, but now evidence-based data revealed that there is no report of the duration of optimum consumption time and need for further investigation.
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IN CONVERSATION TELEMEDICINE
“Telemedicine will disrupt the status quo of Indian healthcare system” Interview with Amit Munjal CEO of Doctor Insta BY ABHISHEK PRASAD
Doctor Insta strives to bridge this gap between doctors and patients through a digital channel of primary healthcare delivery anytime anywhere. Doctor Insta endeavors to provide the best-in-class telemedicine experience to empower people to lead healthy lifestyles, enhance productivity, reduce infection rate and improve operational efficiency of Doctors. AMIT MUNJAL:
How difficult is it to achieve the desired level of acceptance of telemedicine by society, patients, family physicians, specialists, administrators? The telemedicine Healthcare Market in India is still in its nascent stage and has great potential to address serious health care concerns. The two main challenges faced in India is the access to good healthcare and the affordability of such services and Doctor Insta and other telemedicine company can tackle this problem One major roadblock is the adoption and engagement of telemedicine in India. Although a) PM Modi and the Indian government strongly
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“We are striving to fix the current problem of Accessibility, Reliability and Consistency”
support telemedicine and b) Independent research studies show us that 70% of the OPD cases do not require any in-person visit, yet people in India may feel the need of going to OPD. Slowly and steadily people are accepting this fact and soon Telemedicine will disrupt the status quo of Indian healthcare system. One of our customers who is a 50 year Old Daughter got her 80 year old Diabetic Mother’s consultation with Doctor at Doctor Insta. She was very happy with the services and thanked us for having them saved half a day every mon-
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IN CONVERSATION every month when the Daughter as the only care taker will have to take her mother to a Brick & Mortar Clinic.
Our Health Caregivers are available round the clock on 24 x 7 x 365 basis and can be consulted through Web, iOS and Android Apps.
Tell us about the initiatives which will be undertaken by Doctor Insta to strengthen the mHealth system in rural and urban India?
What are the key issues in designing costeffective appropriate hardware and software connectivity?
Doctor Insta believes in growing on the lines of serving the society by the means of providing consultations at subsidized costs. Under our ‘Buy 1 and Give 1 Consultation’ program, we provide 1 free consultation to the weaker section of the society for every paid consultation. Under this initiative our team visit slum clusters with screens and gadgets and help people consult Specialist Doctors. DII (Doctor Insta Inclusion) - For the rural areas of India,we are working in collaboration with companies running e-Kiosks. We also have a subscription plan in which we provide our customers access to unlimited consultations for an entire year at a highly subsidized price. This offer extends to the user’s dependents as well. How will they help to negate or at least lessen the current public health challenges caused by years of neglect? We are striving to fix the current problem of Accessibility, Reliability and Consistency in India’s $100 Billion Healthcare Market and to bring quality healthcare to everyone’s finger “taps” – Anytime, Anywhere. 70% of the total OPD cases do not require in-person visits. These mild to moderate issues can easily be resolved through Telemedicine. . With Video, phone and chat, our Specialists can engage with the patients to diagnose their issues and provide
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One of the major issues in the Indian market is the lack of high speed internet at a large scale. Also, low rate of literacy makes it difficult for users to use the app, and book an appointment. We are dealing with this problem by providing a toll free number to our users, through which they can get connected to our call center where our operator redirects them to a doctor for a particular specialty. How important is adequate reimbursement to teleconsultants to make the scheme attractive and viable? And how Doctor Insta dealt with this issue? It is very important for good quality doctors to work and stay with Doctor Insta. We typically have two types of Doctors, the first being the ones who’ve been associated with various hospitals across the country and practicing on Doctor Intsa increases their catchment area. They get to talk to patients across India, and a wide spectrum of cases which helps in their continuous development. The second type are the ones who wish to cut down on their commute time, have flexible hours, etc. and are able to provide a few hours to Doctor Insta on a daily basis. Supply is not a problem for us, since Doctor Insta provides flexible hours, option to work from home and in their own time to the doctors without any restriction in the patient’s demographics. The selection rate for Doctors is around 3%, and we make sure that only the best of them practice on Doctor Insta. APRIL 2017
IN CONVERSATION TELEMEDICINE: MENTAL HEALTH
“Mental healthcare is largely unaddressed worldwide ” Interview with Sushil Eapen Founder and CEO of Silver Oak Health BY ABHISHEK PRASAD
Launched in 2015, Silver Oak Health is an innovative product firm founded by Sushil Eapen, Saravanan Neel and Paul McKeown (UK) to deliver online mental health ser vices using evidence-based digital intervention products. The company strives to be a global provider of online mental health services using online therapy and digital Cognitive Behavioral Therapy (CBT) products. What makes Silver Oak Health a preferred choice for Cognitive Behavioural Therapy program? Silver Oak Health uses research in Cognitive Science to solve mental health, behavioural, learning and neuropsychological problems. The company has developed an innovative and scientifically-proven online program called Stress Control Online www.stresscontrolonline.com that helps people develop coping skills to solve behavioural challenges like anxiety and depression. Using cognitive science and technology,
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SUSHIL EAPEN:
“Mental health problems affect people of all ages “
the company aims to be a world leader in helping people achieve their full cognitive potential. Silver Oak Health uses intellectual property from best known Clinical Psychologists and research institutions around the world to develop digital products in India, and provides affordable solutions to customers worldwide. Silver Oak Health hopes to touch the lives of millions of people in India and rest of the world and help them achieve high quality of life. Mental healthcare is largely unaddressed worldwide, particularly in developing countries. Depression is ranked only next to heart
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IN CONVERSATION disease as the leading healthcare challenge in most countries, including India. These challenges are likely to increase over the years due to pressures related to job, relationships, finances and urban migration. Mental health problems affect people of all ages – from children, adults and geriatric population. While treatments are available for mental health problems, due to social stigma and lack of awareness, many do not reach out to professionals. In India, there is a severe shortage of mental health professionals, and most of the trained professionals in clinical psychology, speech and language therapy as well as occupational therapy are concentrated in urban areas, leaving a shortage in other parts of the country. Online psychological services market is expected to do well in the coming years due to the discreet nature, convenience and affordable delivery of services. Silver Oak Health has taken the route of creating digital products like the Cognitive Behavioural Therapy (CBT) that people can use to learn the skills required to cope with behavioural challenges like depression. Therapist services are wrapped around the product to ensure that people take the program to completion, at the convenience of their homes. This type of solution offers scale, where one therapist can assist hundreds of patients, as opposed to the current face-to-face therapy model that can cater to a limited number of people in need of assistance. In India, Silver Oak Health is offering an 8week therapist assisted program at an affordable price of Rs. 4000. The company will initially focus on the emerging markets where there is significant need for such solutions.
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Tell us about the Stress Control Online Programme. What makes Silver Oak Health stand out of the competition? Stress Control Online is India’s first Online Cognitive Behavioural Therapy that was specifically designed for our population. The company signed an agreement with Dr. Jim White, one of UK’s best known Clinical Psychologist to convert a proven, evidence-based Cognitive Behavioural Therapy program called Stress Control into a digital product to help people that are facing mild to moderate stress, anxiety, depression, and sleep disorder. This is an 8week online program that people would log in and experience at home with the support of trained therapists using phone communication. The cloud based CBT product that we have developed is available for use on computers and various mobile devices. The product is designed for use with normal internet speeds that are typically available in India. The solution has been localized to suit the urban India population. The product is designed for easy localization into other languages worldwide. How difficult it is to achieve a desired level of acceptance of online program by society, patients, specialists and administrators? There are major challenges in educating customers in countries like India about intervention programs like the online Cognitive Behavioural Therapy when most people would not even realize that they are experiencing a behavioural health challenge. With sustained marketing effort, we will educate the market, and show value in the form of convenience, afford-
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IN CONVERSATION affordability and discreet nature of online services. More and more people in India are reaching out to professionals for help but with limited numbers of trained mental healthcare professionals in the country, people will consider online services as a convenient alternative. We also believe that corporate employees will be the early adopters of online solutions. Employee usage will help spread the positive message about the ease and quality of the online CBT that would further fuel the demand for products across the country. Lack of consumption of mental healthcare is the leading issue in this business and there will be challenges for the early movers. Face to face therapy for behavioural health challenges have been in existence for decades, but it has not solved the challenges of large section of the society, even in developed countries. We believe that digital transformation that changed many other businesses will also change healthcare where people will accept digital solutions that offer many advantages like convenience, lower prices and access to better solution and services, wherever they are located. As part of educating the general public of stress and its reactions, Silver Oak Health has launched a free Health related Quality of Life assessment (silveroakqol.org) in India. A large number of people across the country have taken this assessment, and we are engaging and educating them about stress and how to cope with it. The assessment provides overall score and a percentile score of their health related quality of life in relation to others that have taken the assessment in the country. In addition, the users will be given feedback about the impact of stress on health in general. As the data increases we will be able to perform analytics and predict who among these people are likely to be at
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risk for health issues due to stress. By providing early warning to such high risk candidates, we are able to recommend changes in lifestyle as well as suggestions to improve coping skills through Stress Control Online. Mental illness is not covered by health insurance. What are your viewpoints on this? Despite the fact that the cost of untreated mental illness, when measured against the loss of productivity is relatively small, mental health is widely left out of most health insurance coverage in our country. It is widely accepted that some of the leading causes of disability worldwide are because of mental health challenges. A recent study by NIMHANS has revealed that nearly 150 million people in India need mental healthcare interventions out of which less than 30 million people receive care. While there are other factors, affordability is an important reason people cannot access mental healthcare. On a positive note, the Mental Healthcare Bill that was passed in the Rajya Sabha in 2016 guarantees a right of affordable, accessible and quality mental health care and treatment from mental health services run or funded by Central and State governments. This is a welcome step in the direction of eventual coverage by insurance companies. Insurance coverage will facilitate medical care for people facing various mental challenges, and benefit the society in the long-term.
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