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Dr Satyanarayan Hegde, Medical Director, University of Chicago Medicine, Pediatric Subspecialty

FUTURE TREND FOR HEALTHCARE IN INDIA DECEMBER 2017

Winning the War

PG Medical Graduates

Itâ&#x20AC;&#x2122;s a Munna Bhai MBBS

on NCDs with Technology

National Asset

Remake for Healthcare Investing

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DECEMBER 2017 EDITORIAL

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LOOKING AHEAD AT DETERMINANTS OF CHANGE IN HEALTHCARE IN THE past year strategic planning has become increasingly difficult for hospital administrators, with new risks cropping up thick and fast. From NPPA’s pompous approach to price control to uncertainties of government norms on taxation and regulation on private healthcare,(eg. Max hospital Shalimarbag), it has been harder than ever to set the right course of action for healthcare providers. Add to this the absence of credible data which often leads the healthcare provider to make non-optimal resource allocation, which affects outcomes. This is true in case of government’s efforts too. The rapid advances being made in the modern medicine along with the parallel ethical, legal, social and commercial issues require quick action to leverage the progress being made and facilitate availability and access to better health care. A group of experts are looking at these problems through a different lens, trying to constitute an advisory body on healthcare, which would function as a think-tank leading to a future filled with real-time, on-demand, efficient, and effective healthcare delivery.

The rapid advances being made in the modern medicine along with the parallel ethical, legal, social and commercial issues require quick action Our Cover story this issue, looks at all these efforts and presents a view of the future in healthcare delivery. Besides we have industry experts telling us how healthcare will shapeup in 2018. We have an interesting opinion piece about the state of infrastructure funding in healthcare. One of the highlights of the issue is an Interview with Dr Satyanarayan Hegde, Medical Director, University of Chicago Medicine, Pediatric Subspecialty, who talks about on building bridges from ‘Bench to Bedside and Bedside to Bench in Healthcare Delivery’. Hope you enjoy the read. Our subscribers are increasing steadily. Thank you for subscribing and supporting our initiative Your views and opinions make working on the magazine more meaningful so keep sending them to us. We are eager to hear from you.

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CONTENTS

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PULSE 14 What Changes will shape healthcare industry in 2018

16 Ten Thoughts of a Technology Driven Healthcare Enthusiast

OPINION

20 COVER STORY

LOOKING AHEAD 2018: FACTORS THAT WILL SHAPE HEALTHCARE DELIVERY IN INDIA

A glance at determinants that will help providers create more accessible, affordable and equitable health care for all in 2018

IMPACT

IT’S A MUNNABHAI MBBS REMAKE FOR HEALTHCARE INVESTING India’s first healthcare real estate fund for underwriting exiting healthcare assets of private sector healthcare ventures is now in available.

18 Opportunities and Trends in Healthcare – 2018

UPFRONT 03 Editorial 05 Letters 06 News roundup 46 Events 49 Ask the expert

APPROACH

PG MEDICAL GRADUATES: NATIONAL ASSET

Low PG/UG ratio drives young talent abroad to serve other countries despite all hard work done at basic medical education level

FEATURES 42 Health - IT

The Power of Healthcare is in Consumer’s Hands

INTERVIEW

WINNING THE WAR ON DR SATYANARANCDS WITH TECHNOLOGY YAN HEGDE Use of simple, inexpensive and effective technology innovations that focus on prevention and management of NCDs - especially cardiovascular disease, diabetes, and mental health - offers the greatest opportunity to avert millions of premature deaths and even greater unnecessary suffering

39 4

December 2017

Medical Director, University of Chicago Medicine, Pediatric Subspecialty

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LETTERS

hearticle “Private Hospital Administrator Has A Difficult Pill To Swallow” underscores the huge challenges faced today by the corporate healthcare sector. Areas like accountability for failure of treatment or wrong diagnosis, price caps, mandatory treatment of accident cases and non-clearance of bills of patients who die, are a nightmare for hospitals and doctors. Violence against both is not uncommon. Malpractice liability is a contentious issue today even in countries like the US where medical practitioners in some states stop working because of the high cost of liability insurance and litigation involved. Much depends on the credibility of the profession in the public mind -recall that in earlier times there was an almost childlike faith in the medical practitioner’s professional competence and integrity. With regard to price caps, perhaps the policy is aimed to prevent price gouging when human life is at stake. In ethical terms, do the rich have a stronger claim to survival than the poor which would justify charging of higher prices for life-saving drugs or equipment? Medical services are generally viewed as a ‘public good’ in India though as cited in the article, private healthcare provides 60% of health care services in the country compared to 5-10% at Independence. Has it become a purely commercial service because of the high costs and length of time invested in medical education? Are fiscal or monetary incentives possible to compensate for the public-good aspect of providing medical services in emergencies? I’m not sure there are any ‘right’ answers.Possible solutions being debated in the medical community to these problems outlined, would have made this interesting article even more thought-provoking.

Jayanto Narayan Choudhury Ex- Director General of NSG (Black Cats) Vice President, Operations & Coordination PHFI, New Delhi

IndiaMedToday is a good quality magazine with many thought provoking articles. Looking forward to the next issue. Dr. Gopalkrishnan Mumbai

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I would like to commend the team for bringing out an excellent quality magazine on healthcare business. It has many good reads and articles cover so many issues related to healthcare industry in India. Vikas Mishra Business Head Medical Device Distributor Ahmedabad

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NEWS ROUNDUP GE HEALTHCARE PARTNERS WITH UE LIFESCIENCES TO SCALEUP EARLY DETECTION OF BREAST CANCER IN 25 COUNTRIES UE LifeSciences Inc., a USA-India based medtech startup today announced a pivotal distribution partnership with GE Healthcare to commercialize iBreastExam (iBE) in 25+ countries across South Asia, South-East Asia and Africa. The partnership brings together UE LifeSciences’ skills to design and develop mobile health innovations, and GE Healthcare’s sales, marketing and distribution expertise in these markets to enable early detection of breast cancer in the developing world. “Large scale access to early detection is the key to lowering the burden of breast cancer in the developing world”, says Mihir Shah, Founder and CEO, UE LifeSciences. “Affordable, accurate and easy to use primarycare tool like iBreastExam is one aspect of the solution. There is also a need for experienced teams across geographies that can seamlessly connect the care pathway – from primary care and women’s health to radiology, diagnostics and oncology. Our partnership with GE Healthcare will combine the

power of innovation and scale to fight breast cancer in a whole new way.” Commenting on the partnership, Terri Bresenham, President and CEO, GE Healthcare Sustainable Healthcare Solutions said, “We are delighted to welcome UE Lifesciences as a partner in our efforts to improving healthcare outcomes for the world’s developing economies. GE Healthcare will begin selling iBE as part of its global portfolio of breast health and affordable care products, including mammography and ultrasound devices. The partnership provides a significant opportunity to commercially scale-up iBreastExam across India, South Asia, Africa and South-East Asia and improve breast cancer related outcomes in these regions.” IBreastExam- Impact innovation for Early Detection IBreastExam is an innovative, validated5 and affordable mobile breast health solution designed for use by primary health workers, obstetricians and gynecologists to identify breast abnormalities in healthy, asymptomatic women during a routine health checkup. Being a radiation-free and painless test further makes iBE suitable to women at primary care locations such as a doctor’s clinic, community health centers, health camps or a hospital’s out-patient department.  iBE is a “Made in India” device. It is USA FDA cleared and CE marked.

 With $1.3MM in grant funding from

Pennsylvania Department of Health (CURE Grant), University City Science Center (QED & DHA), Drexel University (Coulter Program) and Unitus Seed Fund (StartHealth grant), iBE was developed by a team of 20+ scientists, engineers and clinicians.  Three published clinical validation studies show 83-86% sensitivity and 88-94% specificity for iBE to detect clinically relevant breast abnormalities. 5  In partnership with 40+ private healthcare, government institutions, non-profits and CSR initiatives, UE LifeSciences has screened over 75,000 women to date and enabled 100+ breast cancers to get diagnosed. iBreastExam is currently commercially available in India, Myanmar and Botswana. Founded in 2012, UE LifeSciences has commercially designed and developed the iBreastExam device specifically for large scale use in the developing world. The sensor technology with multiple patents has passed stringent regulatory pathways, clinical validation and implementation studies. The project has been mentored and invested by Mrs. KiranMazumdar-Shaw of Biocon, Dr. Ranjan Pai of Manipal Education and Medical Group and Unitus Seed Fund, a social impact investor in affordable healthcare innovations.

1ST WORLD CONFERENCE ON ACCESS TO MEDICAL PRODUCTS AND INTERNATIONAL LAWS FOR TRADE AND HEALTH HELD IN NEW DELHI

Terri Bresenham, President and CEO, GE Healthcare Sustainable Healthcare Solutions and Mihir Shah, Founder and CEO, UE LifeSciences with iBreastExam (iBE)

December 2017

“India is deeply committed nationally and globally to achieving all public health goals and also focusing on developing India as a hub for affordable medical devices.” This was stated by J P Nadda, Union Minister of Health and Family Welfare at the inauguration of 1st World Conference on Access to Medical Products and International Laws for Trade and Health in the Context of the

2030 Agenda for Sustainable Development . The Health Minister further stated that there is a need for promoting industry and academia collaboration for developing affordable medical products such that innovations and advances in medical sector reach a vast population. Anupriya Patel, Minister of State (HFW), Dr. V.K. Paul, Member, NITI Aayog, Govt. of India, Preeti Sudan, Secretary (Health), Dr SoumyaSwaminathan, Secretary, Dept. of Health & Research (DHR) and DG, ICMR and Dr Jagdish Prasad, Director General Health Services also graced the occasion. Highlighting the importance of transparency between regulatory authorities and pharma sector, Nadda stated that the coordination between the National Regulatory Authorities and pharmaceutical sector will enable launch and registration of new health technologies. He further said that the dialogue on role of competition in competitive pricing and discussion on related WTO agreements influencing health should lead to a larger umbrella of suggested policy options for the government. Nadda stated that the 2015 National Medical Device Policy will enable local manufacture in the multiproduct, multidisciplinary industry. “In India, nearly 150 thousand orthopaedic knee procedures are done every day. More investments and more players in the medical devices sector will lead to lowering down of prices and access to medical products as most of the governments are sensitive to access and pricing of medical products,” he added. Addressing the conference via video link, Ashwini Kumar Choubey, Minister of State (HFW) said that research and development in public health should focus on two main aspects. To enable safe, effective and quality medical products for the diseases and rolling out the innovations and inventions along with the learning’s from the field to the people. He further stated that the research and development should focus on making the cost of medical devices/products affordable to the people and highlighted the issue of Anti-microbial Resistance (AMR).

Speaking at the function, Anupriya Patel, Minister of State (HFW), stated that India is committed to attainment of the highest possible standards of health for its citizens. She further said that at the national level, access to medical products (medicines, vaccines, medical devices & diagnostics) is an important facet in the health system as a whole and at the international level, access to medical products is a critical factor for the success of the 2030 sustainable development goals agenda that aims to ensure healthy lives and to promote well-being of people of all ages. Dr VK Paul, Member, NITI Aayog, Govt. of India stated that there is a need for investment in medical products for preventive therapy and treatment and highlighted the importance of affordability, quality, domestic production capacity and to create an ecosystem of policy and innovation for greater accessibility of affordable medical drugs and devices. Dr V K Paul further said that technology is an integral block for strengthening medical systems in any country and must also ensure timely maintenance of medical equipment by suppliers in remote and rural areas such that equipment functions effectively. Preeti Sudan, Secretary (Health) spoke about the issues of access of medicines and medical products. She said that safe medical products should be available at affordable prices. She further reiterated that the Health Ministry is committed to robust regulatory systems for ensuring safety, quality and efficacy of drugs. Dr SoumyaSwaminathan, Secretary (DHR) and DG, ICMR highlighted issues such as how to use TRIPs flexibilities; alternative models for affordable medicines and devices such as voluntary licensing; clear predictable regulatory pathways; more investment in R&D and publicly funded R&D; innovative healthcare service delivery models; anti-biotic stewardship; and collaboration between the public and private sectors including academia to reduce cost of production and delivery. The Conference was organized by the Ministry of Health & Family Welfare with the support of WHO Country Office for India and

in partnership with Indian Society of International Law. The objective of the Conference is to exchange knowledge and expand understanding on contemporary issues in international trade laws and research and innovation for access to medical products to achieve SDG 2030 agenda. Also present at the event were, Dr RK Vats, Addl. Secretary, Ministry of Health & Family Welfare; Dr. HenkBekedam, WHO Representative to India; and Dr. EMS Natchiappan, President, Indian Society of International Law, India along with other senior officers of the Ministry, delegates from various countries and representatives of development organisations.

FIRST UNIQUE STUDY OF COST-COMPARISON OF 20 COMMON TREATMENTS IN INDIA

For the first time a government approved study to look at the cost of medical procedures in Karnataka has been conducted by IIM, Bangalore, NABH , AHPI,CAHO, CMC Vellore, the Medical Department of ISRO, the Health and Family Welfare Department of Government of Karnataka, the General Insurance Council of India along with community representatives. The study looks at the actual cost of 20 common procedures carried out in private, non-profit and government hospitals. Most importantly, the costing was done as per clinical pathway endorsed by the respective associations and validated on ground by IIM-B and NABH. The Government of Karnataka has always been at the forefront, pioneering ways and means of improving the health status of its citizens. The Karnataka JnanaAayoga (KJA) through its Task Force on Health has been responsible for carrying out this unique, indicative, systematic and scientific study on procedural costing, in order to understand the actual cost involved in carrying out a set procedure in the hospital empanelled under various Government Health Schemes of Government of India and Government of Karnataka.

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NEWS ROUNDUP The Task Force sub-committee on procedural costing was co-chaired by the Dr P L Natraja, Director of Health, Government of Karnataka. The technical committee felt that there is a need to approach the issue of costing in a very systematic and scientific manner. “This is a prototype study based on available data, incorporated into the approved clinical pathway, and aimed at comparing the cost incurred with the reimbursement being made by the Government Schemes,” said Dr Alexander Thomas, Chair of the Committee. “It is critical that Government and private players work closely to provide quality healthcare cantered around patient safety,that is realistic and sustainable for the scheme,” he added.

P.D. HINDUJA HOSPITAL CONFERRED WITH GREEN AND CLEAN HOSPITAL PLATINUM CERTIFICATE

P.D. Hinduja Hospital & MRC, became the first hospital in India to be conferred the ‘Green and Clean Hospital Platinum Certificate’ by Bureau Veritas, a renowned international certification and assessment agency. The prestigious Platinum certificate is the highest in its category and signifies an organization’s sustained effort towards working together

in harmony with the environment, along with the implementation of various control mechanisms that focus on a clean and hygienic system within the hospital. The hospital was audited on standards for leadership & commitment; legal compliances like statutory regulations; biomedical waste management; environmental sustainability by meaning of water / energy/ carbon footprints; hospital infection control; hygiene &sanitaization; food hygiene / safety; health & safety to name a few. the internal audits were also measured. On receiving the certification, GautamKhanna, CEO, P.D. Hinduja Hospital & MRC said, “It brings me tremendous pleasure to see that the combined effort and dedication of our employees being acknowledged. I would like to congratulate our employees for contributing to our vision of providing quality healthcare to all that come to our hospital. I am grateful to Bureau Veritas for this prestigious certification.” The hospital first underwent the training for these standards by Bureau Veritas& AHPI, then worked towards the compliance of these standards and the audit was conducted in the month of September. The outcome of the audit is that the hospital is the 1st in India to receive this Platinum Certification Joy Chakraborty, COO, P.D. Hinduja Hospital & MRC said, “This certification marks an

P. D. Hospital became the first hospital to be conferred the Green and Clean Platinum certifcate

December 2017

important benchmark for Hinduja Hospital and it’s strive to reach and provide quality healthcare services to our patients. It is a testimony of our hard work and commitment to provide outstanding patient care and a motivation to continue striving to achieve our founder’s vision of providing quality healthcare for all.”

NORTHEAST TO GET INDIA’S FIRST EVER ‘AIR DISPENSARY’ Northeast is all set to get India’s first-ever “Air Dispensary” based in a helicopter and the Union Ministry of Development of Northeast (DONER) has already contributed Rs. 25 crore as part of the initial funding for this initiative. Disclosing this after a meeting with the representatives of Aviation Sector and helicopter service/Pawan Hans, Union Minister of State (Independent Charge) for Development of North Eastern Region (DoNER), MoS PMO, Personnel, Public Grievances, Pensions, Atomic Energy and Space, Dr Jitendra Singh said, for quite a few months, the DoNER Ministry had been exploring the idea of introducing a helicopter based Dispensary/ OPD service in such far flung and remote areas, where no doctor or medical facility was available and the patient, in need, also did not have any access to any medical care. The proposal put forward by the Ministry of DoNER, he said, has been accepted and is in the final stages of process in the Union Ministry of Civil Aviation. The Union Ministry of Northeast/DoNER, Dr Jitendra Singh said, is keenly pursuing the proposal so that by the beginning of 2018, this could be the Union Government’s gift to the people of Northeast. Dr Jitendra Singh said that even today, nearly 1/3rd of India’s population did not have access to proper hospital bed care, as a result of which, poor patients living in remote areas remained deprived of crucial medical care. The experiment being introduced in the Northeast, at the behest of the Ministry of Northeast/DoNER, can also

be emulated in other hill states having difficult topography like Jammu & Kashmir and Himachal Pradesh, he added. As per the envisaged plan, Dr Jitendra Singh said, to begin with, helicopter will be based at two locations, namely Imphal in Manipur and Meghalaya in Shillong. Both of these cities have premier postgraduate medical institutes from where specialist doctors, along with the necessary equipment and paramedical staff, would be able to move into the helicopter and hold a dispensary/ OPD in different locations across the eight States of North Eastern Region. On its way back, he said, the same helicopter can also transport a sick patient, requiring admission, to a city hospital. Giving an account of other new helicopter service plans for Northeast, Dr Singh said, three twin-engine helicopters are planned to be placed for initial operation on six routes in the region around Imphal, Guwahati and Dibrugarh.

HSSC AND 3M COLLABORATE TO UPGRADE SKILLS OF HEALTHCARE PROFESSIONALS IN INDIA With the aim to create a robust and vibrant eco-system for quality vocational education and skill development in Healthcare, 3M India Limited and HSSC (Healthcare Sector Skill Council) signed a Memorandum of Understanding recently in Delhi. Debarati Sen, Managing Director, 3M India Region and Ashish Jain, Chief Executive Officer, HSSC, signed the Memorandum of Understanding. The Healthcare Sector Skill Council (HSSC) is under the ambit of Ministry of Skill Development and Entrepreneurship working toward ‘Skill India’ mission. Multiple studies have documented the high incidence of infection amongst patients from the use of improperly ‘processed’ surgical instruments. This makes it imperative for hospitals to have a trained work force in sterilization function thereby ensuring reduction in post-operative infections and sub-

Debarati Sen, MD 3M India Region with HSSC officials during the signing

sequent complications. To address this need, 3M Health Care, a global leader for quality monitoring in the device reprocessing space, will be partnering with HSSC to train the CSSD (Central Sterile Services Department) personnel across India. Speaking at the event, Jain said, “HSSC aims to facilitate skill development in Healthcare benchmarked to global standards ensuring quality and standardization. It is our endeavor to train and skill Indian youth making them employable not only for India but for the world. This partnership between 3M and HSSC is a step in this direction.” Talking about the partnership, L C Das, Executive Director, Healthcare Business Group, said, “3M in India has been present in the healthcare industry for nearly 3 decades and we recognize the need to create standardization which can change the existing practices around hygiene in hospitals.” As knowledge partners to HSSC, 3M India with its global expertise endeavor to provide tools and best practices that help individuals, healthcare organizations and trainers to improve performance, productivity and efficiency. We are confident that this synergistic collaboration between HSSC & 3M will deliver impactful results in reducing post-operative infection.”

INDIA AND ITALY SIGN MOU FOR ENHANCED COOPERATION IN THE HEALTH SECTOR India and Italy signed a Memorandum of Understanding (MoU) for enhanced cooperation in the health sector, in New Delhi. J P Nadda, Union Minister of Health & Family Welfare and Beatrice Lorenzin, Health Minister of Italy signed the MoU in the presence of senior officers from the Health Ministry and a high level delegation from Italy. J P Nadda stated that both the countries share a strong and rich traditional relationship which has been enhanced by high level visits. Also, there is a mutual interest in the promotion of stronger ties in the health sector, he added. The MoU recognizes the potential for exchanges in the health sector between the two countries and the need to tap the capabilities and opportunities in a focused and comprehensive manner, Nadda stated. The objective of this MoU is to establish comprehensive inter-ministerial and interinstitutional cooperation between the two countries in the field of health by pooling technical, scientific, financial and human re-

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NEWS ROUNDUP sources with the ultimate goal of upgrading the quality and reach of human, material and infrastructural resources involved in health care, medical education & training, and research in both countries. The main areas of cooperation include:  Exchange & training of medical doctors, officials, other health professionals and experts;  Assistance in development of human resources and setting up of health care facilities;  Short term training of human resources in health;  Regulation of pharmaceuticals, medical devices and cosmetics and exchange of information thereon;  Promotion of business development opportunities in pharmaceuticals;  Procurement of generic and essential drugs and assistance in sourcing of drug supplies;  Procurement of health equipment and pharmaceutical products;  Collaboration in the prevention of NCDs of mutual interest, such as neurocardiovascular diseases, cancer, COPDs, mental

December 2017

health and dementia, with an emphasis on SDG3 and related factors;  Collaboration in the field of climate



  

change impact on communicable diseases and vector borne diseases; Nutritional aspects of food intake, including malnutrition (over-nutrition and under-nutrition) in the light of the SDG2 and organization of nutritional services; Safety of production, transformation, distribution and food delivery; Research and training of food industry operators; Information and communication to citizens on hygiene and food safety and healthy eating habits.

BOOST TO IVD MANUFACTURING IN INDIA, WHO ESTABLISHES PRE-QUAIFICATION CELL World health Organization (WHO) has selected Andhra Pradesh MedTech Zone Limited (AMTZ) to host their Pre-Qualification cell for In-Vitro Diagnostics, which is a first of its

kind in South East Asia. The cell at AMTZ was officially announced by WHO during the 1st World Conference on Access to Medical Products and International Laws for Trade and Health in New Delhi today. A citation plaque was presented by WHO to Dr PoonamMalakondaiah, Principal Secretary Health Medical & Family Welfare Govt of AP and Dr Jitendar Sharma, MD and CEO, AMTZ to commemorate the occasion. The In-Vitro Diagnostics segment has an estimated market value of INR 3.54lakh cr. globally out of which India contributes an estimated INR 2550 cr. Exports from India in the In-Vitro Diagnostics segment were at INR 254 cr in FY- 16 which leaves a huge export opportunity of approximately INR 3 lakh cr for Indian manufacturer to tap into. This pre-qualification cell, which will provide guidance to Indian manufacturers on the who pre-qualification of In-Vitro Diagnostics program is an important addition to India’s medical device ecosystem as it enables manufacturers to match global quality standards and also participate in UN procurement process for In-Vitro Diagnostics devices enabling export. WHO will provide the required training to the support cell staff to guide the manufacturer about WHO prequalification expectations while AMTZ will handle day to day operation. The WHO pre-qualification of In-Vitro Diagnostics programs aims to promote and facilitate access to safe, appropriate and affordable In-Vitro Diagnostics of good quality in an equitable manner. The program focuses on IVD for priority diseases such as HIV malaria hepatitis B and Hepatitis c and their suitability for use in resource-limited setting. It undertakes a comprehensive assessment of In-Vitro Diagnostics through a standardized procedure aimed at determining in the product meets who pre-qualification requirements. “We are delighted with the announcement. This is a big boost to making India a manufacturing hub for medical devices including IVD,” said Rajiv Nath, Forum Coordinator, AiMeD.

NEWS ANALYSIS

FIRST COMPREHENSIVE ANALYSIS OF HEALTH IN INDIA REVEALS VAST INEQUALITIES BETWEEN STATES RECENTLY, The Lancet published the first comprehensive analysis of the health of India’s 1.34 billion citizens—encompassing almost a fifth of the world’s population. The analysis aims to equip the government with evidence to identify specific state-level health challenges and priorities for intervention. This massive effort brings together over 200 leading health scientists and policy makers from more than 100 institutions across India as part of the India State-level Disease Burden Initiative. The India State-level Disease Burden Initiative is a collaboration between the Indian Council of Medical Research, Public Health Foundation of India, Institute for Health Metrics and Evaluation at the University of Washington, and experts and stakeholders from 100 institutions across India. For the first time, the study estimates the key drivers of ill health, disability, and premature death in all 29 states, many of which have populations the size of large countries, and include people from over 2000 different ethnic groups. It analyses 333 diseases and injuries and 84 risk factor trends for each state in India

between 1990 and 2016 as part of the Global Burden of Disease 2016 study. The researchers divided India’s states into four groups according to their level of development or epidemiological transition, using the ratio of illness and premature death caused by communicable, maternal, neonatal, and nutritional diseases (CMNNDs) versus noncommunicable diseases (NCDs) and injuries as an indicator. “Individual states in India are in different phases of epidemiological transition, and this has resulted in wide inequalities in the magnitude and progress against various diseases and their causes”, explains Professor LalitDandona, Public Health Foundation of India, Gurugram, India, who led the study. “This has major policy implications for national and local governments. Rather than taking a more generic approach, these new estimates will be crucial to steering health policy to take account of specific health problems and risks in each state, and ultimately achieving the government’s vision of assuring health for all.”

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NEWS ANALYSIS Significant improvements in health, but major inequalities between states The Indian population has gained nearly a decade of life expectancy since 1990, rising to 66.9 years in men and 70.3 years in women. But there are wide inequalities between states, with life expectancy for women ranging from 66.8 years in Uttar Pradesh to 78.7 years in Kerala. Since 1990, India has made substantial gains in health, with the overall health loss from all diseases and conditions about one-third less per person in 2016 than in 1990. But progress has been mixed, with greater improvements in states at the most advanced phases of development (eg, Kerala and Goa), compared to those in the earlier stages (eg, Assam, Uttar Pradesh and several other poorer north Indian states). Child health remains a particular concern, with high levels of neonatal and under-5 disease relative to other age groups (figure 5). The under-5 mortality rate has reduced substantially since 1990 in all states, but rates in As-

First comprehensive analysis of the health of India

December 2017

sam (52 deaths per 1000 livebirths) and Uttar Pradesh (48 deaths) are four times higher than in Kerala (13 deaths), indicating major health inequalities. Slow progress in reducing infectious, maternal, neonatal, and nutritional diseases in many states By 2003, the total burden of ill health, as measured by DALYs, had shifted from CMNNDs to a dominance of disabling NCDs and injuries. But the extent of this dominance varies widely between statesâ&#x20AC;&#x201D;with about half of the total disease burden due to NCDs in Bihar, Jharkhand, Uttar Pradesh, and Rajasthan, and around three-quarters in Kerala, Goa, and Tamil Nadu. Overall, the burden from CMNNDs has decreased. Yet, diseases that primarily cause illness and death in children and mothers continue to dominate in the country. Lower respiratory infections and diarrhoeal diseases were the 3rd and 4th leading causes of health loss in

2016, accounting for about 9% of all premature death and ill health (figure 3). Moreover, there are wide differences between states in terms of overall progress. For instance, Jharkhand has rates of death and illness due to diarrhoeal disease 9 times higher than Goa, while Rajasthan has rates due to lower respiratory infections 7 times higher than Kerala (figure 4). Despite signs of progress, several CMNNDs including diarrhoeal diseases, iron-deficiency anaemia, and tuberculosis still cause a disproportionate amount of ill health, and claim more lives, than is expected for Indiaâ&#x20AC;&#x2122;s stage of development, particularly in states in the early stages of epidemiological transition. For example: the rate of premature death and illness from irondeficiency has not improved since 1990, still causing 3.5% of the total disease burden in 2016; has a disease burden that varies more than 3-fold between the states; and is 3 times higher than expected based on Indiaâ&#x20AC;&#x2122;s level of development.

NCDs a major cause of disease burden like never before As a result of urbanisation and ageing, the burden of NCDs is large and rapidly rising in all states. The fastest-growing causes of ill-health over the last 26 years were diabetes (increased by 174%) and ischaemic heart disease (up 104%). Ischaemic heart disease (responsible for 8.7% of the disease burden in 2016) and chronic obstructive pulmonary disease (COPD; 4.8%) were the leading causes of premature death and ill health in 2016, overtaking lower respiratory infections and diarrhoeal diseases. More than 60% of deaths (6.1 million) in India in 2016 were due to NCDs, up from about 38% in 1990. Even states in similar levels of development showed striking differences in the burden of death and illness from some leading NCDs. For instance, Punjab has much higher rates of premature death and ill health due to diabetes and ischaemic heart disease, but lower rates due to COPD compared to neighbouring Himachal Pradesh, despite the two states both being at an advanced level of epidemiological transition. Similarly, Uttar Pradesh has much higher rates due to COPD, but lower rates from stroke compared to Madhya Pradesh, despite both states being at a similarly early stage of epidemiological transition (figure 4). Rapid urbanisation is responsible for rising deaths and health loss from road injuries in most states since 1990, highlighting the lack of a comprehensive national policy for injury prevention. The burden of road injures was highest in Jammu and Kashmir, with rates of premature death and illness three times higher than in Meghalaya; the burden of self-harm was highest in Tripura, with rates six times higher than in Nagaland (figure 4). The authors warn that a bigger and more organised effort, supported by better financial and human resources, is needed to control the growing burden of NCDs. Child and maternal malnutrition still leading risk factor, whilst diet, obesity, and air pollution an increasing threat Despite decades of investment in preven-

tion and treatment programmes, child and maternal nutrition remains the leading risk factor for poor health in India, responsible for 15% of all ill health and premature death in 2016, whilst unsafe water, sanitation, and handwashing accounted for 5% (figure 8). The burden of malnutrition remains three times higher among states in the earlier stages of development (eg, Bihar and Rajasthan) compared to the most advanced (eg, Goa and Kerala). The authors warn that these ‘unacceptably high risks’ should be key priorities for health improvement in India, with a focus on behavioural change alongside provision of better nutrition and safe water and sanitation. Other highly preventable risks such as poor diet (eg, diets high in salt and low in vegetables and fruit), high blood pressure, high cholesterol, and high body mass index are contributing to the growing burden of NCDs. Together they accounted for almost a quarter of poor health in 2016—over two times more than in 1990. Worryingly, the burden of these risks has increased in every state since 1990, with generally higher rates in states in more advanced stages of epidemiological transition (eg, Punjab and Tamil Nadu; figure 7). One area that needs special attention is exposure to air pollution which is among the highest in the world. In particular, the exposure to ambient outdoor air pollution has increased by around 17% since 1990. Ambient outdoor and household air pollution together are responsible for almost 10% of the total disease burden in 2016, highlighting the need to increase the use of cleaner technologies to reduce air pollution from various sources. The burden is highest in the northern states, with Rajasthan, Uttar Pradesh, and Bihar having levels of premature death and ill health due to air pollution around three times higher than Kerala and Goa (figure 7). The researchers say that the risk factors included in the report only explain about half of the disease burden in India, emphasising the need for understanding the additional broader determinants of health such as income and education. According to Professor Dandona, “India has come a long way. But these individual state

estimates reveal major health inequalities between the ‘nations’ within this nation. Over the past two decades the Government of India has launched many initiatives and programmes to address a variety of diseases and risk factors. However, these data show that what we have being doing up to now is not enough. With the availability of state-specific findings now identifying the diseases and risk factors that need most attention in each state, we can act more effectively to improve health in every state of the country. This has the potential of reducing the major health inequalities observed currently between the states, and this would also help achieve better health outcomes for India as a whole.” Finally, the authors note that the cause of death data in India should be improved, and the data gaps for some risk factors and diseases across the states should be addressed, in order to have even better estimates in future. They call for the development of a comprehensive health information system to improve data collection and quality in many states. According to Lancet editorial, “Encouragingly, a flourishing era of innovation in the way health care is being designed and delivered is being invested in and led by the states themselves. For example, Kerala, Tamil Nadu, and the Punjab are strengthening health systems in pilot projects for UHC. However, these state level actions should not diminish the responsibility of the federal government for increasing public investment in health care. We are disappointed by the lack of ambition of President Modi’s Government to invest only 2.5% of its GDP into health care by 2025, when the global average for countries is about 6%. The rise in India’s economic fortunes and its aspiration to progress to the same level as its neighbour, China, is something of an embarrassment, given how improvements to health trail so far behind. Until the federal government in India takes health as seriously as many other nations do, India will not fulfil either its national or global potential.” This study was funded by the Bill & Melinda Gates Foundation; Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India; and the World Bank.

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PULSE

WHAT CHANGES WILL SHAPE HEALTHCARE INDUSTRY IN 2018

Guruprasad S, Senior General Manager – Healthcare Business (India), Director - Medical Screening Solutions (Germany)

THE WORLD is changing. Changing at a much rapid rate than we would have ever foreseen. At the heart of this change is technology. Healthcare industry around the world is undergoing a tectonic shift- from traditional care to transformative care, backed by a strong support of technology. Key pivots which would be major tenets for this change in 2018 and in the years to come: People With increasing consumerism, patients will take the driver’s seat of their own health, and will be at the center of the healthcare ecosystem. Healthcare would come to the doorstep of a patient rather than the patient goingto the doorstep of a healthcare facility. The load of increased population across the world would as well enable this “Patient” / “People” centricity. Data With devices and sensors relentlessly acquiring patient information on a continual basis, Data will be one of the key healthcare drivers in the years to come. Comprehensive Health Records (CHRs) will soon be the norm replacing traditional Electronic Medical Records (EMRs) to accommodate multi-dimensional data from diverse sources including remote health and

December 2017

social determinants of healthcare. Clinical decision making would increasingly be based on such acquired data. Technology Emerging technologies like Artificial Intelligence (AI), Cognitive systems powered by Machine learning will unlock the value of the thus captured data. Clinical practices worldwide would start adopting technology as an enabler rather than a threat. Open source technologies like blockchain, will help to address pertinent challenges related to data security, data integrity and data privacy. In India, we find that healthcare needs are diverse spanning from primary care all the way up to tertiary care. Though healthcare anywhere is a necessity,in India, it comes packaged as a luxury in most cases. To combat the dual disease burden of India, innovative solutions, unconventional business models and unorthodox care delivery systems would be the key drivers in healthcare. Indian healthcare is on the cusp of a digital transformation – many a time leapfrogging the accepted models of even developed countries. India’s digital connectivity is poised to grow at an accelerated rate from 30% in 2017 to 80% in 2034 thereby driving the following key trends:

Flipped Care: Similar to trends around the world, focus is shifting from the provider to the patient. There will be an increasing power to digital technologies for remote patient monitoring at extended care facilities using Internet of Things (IoT), Connected devices and Wearables.  Health on the Move: Mobile health is a major segment, with an estimated market size of 2083 crore INR in 2015 and set to rise to 5184 crore INR by 2020. Mobile solutions especially doctor-patient connects and those centered aroundthe “Quantified self ” will be a major growth segment.  Front line innovations: Low-cost portable innovations to cater to the needs of our vast rural population will continue to be a major trend in 2018 and beyond. These products will help increase access by providing Point of Care diagnostics, tele and remote consultations. We are focussing on addressing some of the burning healthcare issues in Indiaby providing the latest technology enabled care to the masses. We specialize in bringing IoT to the foreground of the healthcare ecosystem, thereby generating true value of Connected Health services. Our primary focus is on Healthcare Screening Solutions to enable affordable, qual

India’s digital connectivity is poised to grow at an accelerated rate from 30% in 2017 to 80% in 2034 ity screening and early detection of risk factors, in a non/minimally invasive way. Our innovations are centered on compact, portable, noninvasive and point of care solutions that are anchored on Digitization, Connectivity and Monitoring. We are working on technologies of tomorrow like AI, machine learning, deep learning, blockchain to bring about a revolution in the Indian healthcare. We endeavor to leverage technology as an enabler to defragment the healthcare industry, and facilitate the transition of passive healthcare recipients to active value seeking customers. Our products and solutions would re-imagine healthcare delivery by being:  Preventive: Our Point-of-Care screening solutions, would help flag first signs of abnormalities that could potentially be halted via early interventions.  Predictive:Our data driven diagnosis, will



enable in early and effective detection of key trends in the health of a patient. Artificial intelligence based machine learning systems would enable in a more accurate prognosis. Personalized: Our virtual solutions would create additional “technology avatars” of care givers with linked force multiplier effect to cater to individual patient needs. Scarce resources would be better deployed at an optimal and efficient way to take care of individual needs of patients than a one care model for all. Participatory: Our integrated healthcare delivery system would connect rural areas to point of care there by democratizing the way healthcare is delivered. Population health management would get a boost via such solutions thereby enabling an overall improvement in societal health and wellbeing.

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PULSE

TEN THOUGHTS OF A TECHNOLOGY DRIVEN HEALTHCARE ENTHUSIAST

S.Premkumar, Executive Vice Chairman & Managing Director, HCL Infosystems Ltd.

EVEN AS Indian healthcare industry grapples with the problem of accessibility and affordability, the opportunity it provides, continues to marvel both healthcare providers and industry enthusiasts alike. The healthcare industry in India is expected to grow from $ 145 billion in 2018 to $ 280 billion by 2025. Here are the 10 trends that will have a major impact on healthcare industry in 2018. Growth would be toughest challenge for providers Yes, the greater fragmentation of the care continuum that disintegrates the entire care process instead of integration is clearly an area that would see attention. Leakage is the term used and over time a positive movement to a regime of ‘Comprehensive Care Plans’ becomes imperative. Irrespective of fragmented care across primary physician, diagnostics, tertiary care, continuing monitoring and wellness, a “partners in care” model would surely emerge with technology at the core of this workflow. Retail Healthcare would see momentum despite fragmentation The rather slow level of consolidation in the

December 2017

retail space will see some early innovative aggregation leveraging technologies. These are early days but clearly the direction of the future. Wearable technologies and digital leverage would be “par for the course” in this space and would act as the catalyst to usher change. Continuing growth opportunities for Insurers. But! There does not seem to be any head winds in growth for health Insurance and maybe some of the policy interventions on costs augurs well, however, Indian Insurers would have to innovate and participate more deeply into the care continuum to keep their ratios in the green. This will be imperative. Technology investments would start growing exponentially It would suffice to just list out areas of technology influence as a reiteration rather than elaboration given that much is written about it. Personalised medicine, roboadvisors, chat bots, AI, AR, cognitive computing, digital services, digital clinical pathways and the list goes on. I see this to be ‘Liquid Expectation’ as the art of the possible meets smart solutions.

Patient communication & transparency would draw significant attention This area has been under invested and under focused for ages. India is dealing with a new generation of educated millennials and their parents, thus, demand for education and the need to know more to compare, appreciate and align for this ‘search engine ready’ generation is a given. Many of the incumbent providers are missing the point that these customers value experience that would be of help to build positive correlation between experience and revenues. Here again, huge potential to leverage mobility and digital services. Quality Clinical talent would see innovative engagement models We are clearly bound to see some re-alignment in the traditional clinical talent engagement models and rewards. Outcomes aligned programs and fees will see some early adopters. Strategic partnerships would enable strengthening ‘Trust’ across the care continuum. Non -Clinical would see greater specialization and Per Capita

augmented earning potential On the non-clinical side, professional competencies and specialization will help create Third Party Providers of these services as shared services across providers. This will result in the emergence of domestic Healthcare BPO. Multi-tenant technology + clinical services These shared services units, much like the way independent diagnostic centres prevail, would become imperative given the ‘Asset Sweating’ that one is able to achieve. They would also include critical clinical services, like e-ICU’s that will see adoption in larger cities to start with but Tier II & Tier III will also see such adoption. Legacy providers would face significant viability issues There is a major generational shift coupled with economics that is forcing many legacy establishments to re-think their continuing presence. The phase of keeping the lights on is not helping and hence a call to monetise and exit, or transform through professional intervention or outsource (OMS) will be taken. Consulting in this space will mature with greater management and technology interventions.

The healthcare industry in India is expected to grow from $ 145 billion in 2018 to $ 280 billion by 2025 Government interventions around Care Cost mandates will continue The cost control regime that has been launched and debated in courts and outside, will continue and extend to newer areas but a broader institutionalization of certification based Tier system would emerge, either mandated or brand driven. A system of Star Rating, like in Hospitality backed by credible State Board or Council is imperative. NABH / JCI and their lighter version for smaller establishments would be table stakes to this rating. Over time, market and experiences will define the rating.

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PULSE

OPPORTUNITIES AND TRENDS IN HEALTHCARE - 2018 TODAY THE Indian healthcare industry is witnessing a major transformation, a transformation that has the capability to change the face of healthcare. Such are the healthcare challenges and the demographics in India that they pose a unique opportunity for innovation that will have global applications.

Srinivas Prasad, CEO Philips Innovation Campus

December 2017

Transformation inevitable The Indian healthcare market is expected to touch $280 billion by 2020. The environment has changed over the years with a paradigm shift towards value-based care. People are now more aware and concerned about their health than ever before. We see more democratization of healthcare and patients have a greater say in their care. The healthcare providers are starting to recognize this important shift and are

more open to explore opportunities. People are now more aware of the healthcare benefits and increasingly opting for health insurance now than before, even the government has initiated several schemes to support rural healthcare. Moreover, the recent approval by the union cabinet of the National Health policy 2017 should set this transformation rolling, where we will witness major changes in the years to come. Consolidation There will be an increase in mergers and acquisition activity in 2018. While the R&D activity will continue to increase, companies will also look to acquire smaller companies to accelerate and spread the reach of their business. Through partnerships smallerhealthcare companies, can accelerate their growth helping themselves re-

brand, reposition and increase their production and distribution capabilities. We will see more of this in the years to come. Research as in the previous few years will also see an increase in funding. In the years to come we will see more path breaking innovations that will help us in leading better and healthier lives. Technology innovation From an Indian perspective, tele-solutions leveraging connected devices and AI is the way forward to address the healthcare challenges. Point solutions that are not connected or scalable, will only add on to the existing problem by complicating it further, and increasing the cost of aggregating the data from the device into the larger solutions. Interoperability and Database Schema decisions will be important in the

scheme of things. IoT alone is not the answer to this, we need to derive meaningful insights from the data from these devices. Use of AI will help in providing those insights that are required. AI models developed for India would be relevant in other countries too if the model is trained using local data. The connected devices need to be medical grade if the global marketshave to be addressed and this requires quality time and investment. In 2018 we would see more startups leveraging AI to solve healthcare problems in India. An Enabler HealthWorks at PIC was set-up a few months ago to mentor startups in the ecosystem. This is a part of a global programme, and is the second accelerator across the globe, the first one being

Interoperability and Database Schema decisions will be important in the scheme of things at Cambridge in Boston. I believe that there is an opportunity for the next big healthcare unicorn to come from India and we want to help them get there.

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COVER STORY

October 2017

LOOKING AHEAD

2018

FACTORS THAT WILL SHAPE HEALTHCARE DELIVERY IN INDIA M Neelam Kachhap

A glance at determinants of change in 2018, will these help providers create more accessible, affordable and equitable health care for all?

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COVER STORY

his past year has been turbulent and unexpected for healthcare providers with changing dynamics of healthcare delivery in India. Of course price capping of medical devices, stringent regulation on private providers, increasing violence on doctors and hospital and widening trust deficit between the doctor and patient has only added to the omnipresent problem of accessibility, affordability and accountability of healthcare delivery in India. Going into 2018, a change in policy and perception will force healthcare providers to adjust their strategies to be cost-competitive and still be relevant to the industry. The main factors that will affect healthcare delivery are  Change in medical education  Cost containment  Legalities of medical practice  Need for quality and accreditation  Universal health coverage  Pluralistic approach to healthcare  Increased focus on NCDs Change in Medical Education The key to building an effective healthcare delivery organization is focus on people. Healthcare workers, be it the physician, nurse, technologist or the support staff will define the success of the organization, backed by robust process. Medical education and medical employment are interrelated so much so that one depends on the other. Less expensive medical education coupled with increased availability of medical seats seems to be the logical solution to counter the looming lack of healthcare workers in India. This has to be complimented with equalization of undergraduate and post graduate seats so that fresh and bright MBBS graduates do not spend precious man-hours preparing for an elusive PG-seat. Of course, the quality and the process of creating healthcare workforce in India needs an overhaul;where there is provision for a credible teacher, credible institution and an up-to-date curriculum. The idea should be to not only create clinical leaders for India but also for the world. In doing so we should not overlook the skewed metrics of healthcare workers who are concentrated around larger cities. India should focus on creating intermediate specialist to fill large specialist vacancies in both government and private establishments. Nurses and paramedics should be empowered and creating nurse practitioners is a welcome step in the right direction. However, there is a need to uplift the status of our paramedics and non-medical technicians who vastly contribute towards running a well-functioning healthcare organization. In all probability, training and skill development will be embraced by the industry in 2018, as healthcare progresses to become the largest employer and job creating industry across the globe. Hopefully the new education policy that is in deliberation and stated to release in

December 2017

early 2018 will take cognizance of and improve the current state of medical education in India. Cost Containment India offers world-class healthcare at a fraction of the cost available elsewhere in the world. However, a large chunk of our own population cannot afford quality healthcare at the present rates. We need business models and disruptive ideas to bridge this gap, but draconian policy and clamping industry practices will not provide the desired results. Cost-containment strategiesin healthcare delivery will be the most discussed topic in 2018. Additionally, in 2018, price capping will continue across segments. Talks are on to cap prices of Intra ocular lenses used in cataract surgery, heart valves used in valve replacement surgery and medical consumables like syringe, tubing etc. The government has also released an advisory for disposable medical consumables. In India, sterilizing and re-using medical consumables labeled for single use is a common practice, to cut down cost of surgery and subsidizing the cost to patient. While the Ministryâ&#x20AC;&#x2122;s step will make it mandatory to use new consumables with each surgery, the cost of each surgery will rise. This may bring more disdain among different stakeholders. We may be staring at a scenario where a doctorâ&#x20AC;&#x2122;s professional decision is based on economy and not on clinical judgment and a technology usage is driven by economics rather than clinical relevance. In India, how will any cost ever be low enough to be called low-cost or affordable when only a small population of the country is covered for health emergencies and majority of the cost of healthcare is out-of-pocket expense? Our policy makers have to think about this.Unless the government focus on outcomes and incentivises hospitals to keep patients healthy a dream of Swasthya Bharat will remain just that a dream!

and no healthcare provider is immune to extreme criticism. In 2018, more doctors will take to law schools and other course to understand the legalities of practicing medicine in India. While there are about 16 forums that a patient has access to, where complaints against the doctor or hospital can be filed there are no designated forums to address issues of violence against doctors or hospital property. In the years to come, liability insurance policies will become the norm for healthcare workforce and providers. Much has been said about vicarious responsibility for negligence or malpractice in healthcare delivery. A large section of providers both physicians and owners feel cornered by the law. There is no doubt that peoplesâ&#x20AC;&#x2122; right takes precedence amongst all other issues and safety of the patient is of utmost importance. But the sanctity of the doctor-patient relationship and the experience of years of learning should also hold some importance. It will be interesting to see how this saga unfolds and weather the medical community can improve upon the situation. No doubt, there is an urgent need to educate the healthcare providers on the legal liability of practicing medicine and there is a need to educate patients of their rights. While doing this, one should also make people aware of the limitations of modern medicine and debunk the ultimate healing and Godly status given to medicine. In this regard end-of-life care and palliative medicine become even more important and one cannot emphasize enough the role of counseling.

Legalities of Medical Practice Medical malpractice and medical negligence is not the same thing. To explain the difference between the two you need to have legal knowledge, but to not know the legal obligations of practicing medicine is not acceptable. Specially now when the conduct of doctors has become the object of intense scrutiny by the media and the public,

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COVER STORY Quality and Accreditation The year 2018, will see focused attempts to improve and sustain high quality health services. The recent incidents in Delhi have brought the conversation on quality and safety to the forefront. While the government is planning to implement and enforce Clinical Establishment Act across India, the government health services elude monitoring. Both the healthcare practitioners and patient groups have been demanding that there should be a monitoring and accountability of quality and safety at all institutions government or private. Will the government look at this suggestion in 2018? Only a handful of hospitals in India are National Accreditation Board for Hospitals and Healthcare Providers (NABH) accredited. There is a need for greater participation of healthcare organization for accreditation and bigger incentives for accredited hospitals. A welcome step in this regard is the governmentâ&#x20AC;&#x2122;s decision to provide incentives in their schemes for hospitals that areaccredited by NABH. The government can certainly do more and link accreditations to fund allocation to encourage voluntary accreditation. On the clinical front, there is a need to develop and follow uniform treatment protocols which should be India specific. We cannot aim to implement first world guidelines with third world infrastructure and expect costs to be nil and outcomes equivalent to first world. Quality has become the focused mantra to make or break a healthcare organization and the meaning of quality has traversed beyond clinical excellence. Empathy and consumer relation will dominate the healthcare delivery scene in India and in this regard effective communication will be the only key to success. Universal Healthcare In the recently released National Health Policy, the government has set a target of increasing the public expenditure as percentage of GDP from 1.15 - 2.5 percent by 2025. This hardly seems adequate but what is commendable is the fact that health

December 2017

has become a priority for the government and Universal health coverage is gaining momentum in India. Increased government investment on health is the first step towards achieving universal health coverage. This has to be followed by strengthening health system capacity and creating robust governance and accountability mechanisms to better manage healthcare delivery. In 2018, Karnataka will become the first state to roll out universal health coverage where all primary, secondary and emergency care will be provided free of cost. The AarogyaBhagyascheme, will be the amalgamation of seven different health care schemes presently available to the people of Karnataka. Hopefully other states will also follow suit. Pluralistic approach to healthcare Traditional medicine has been omnipresent in India and in 2018 there will greater efforts to integrate different forms of medicine with modern medical practice. AYUSH will get a larger share of the healthcare delivery pie as the government formulates new education and healthcare policies. Pluralistic approach to healthcare was envisioned by the National Health Policy 2017. In 2018, AYUSH health workers will get new opportunities to work in the formal health systems. Increased focus on Non-communicable diseases One of the biggest challenge for India is the rise of non-communicable diseases and ageing population, both of these will add substantial burden on financial and infrastructure resources. NCDs are emerging as the leading cause of deaths in India accounting for over 42% of all deaths.Most noncommunicable conditions are chronic and these chronic conditions cause significant morbidity and mortality both in urban and rural population groups, with a huge loss in potentially productive years (aged 35â&#x20AC;&#x201C;64 years) of life. In 2018, the focus on NCDs will take center stage as the government focuses more on prevention. The private providers will tailor their strategies to be able to address the needs of patients seeking treatment for NCDs. New technologies and disruptive models.

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COVER STORY What India needsâ&#x20AC;Ś Winning solution for affordable, accessible healthcare in the next 10 years Invest in infrastructure

Healthcare delivery

2.2

Emphasis on family physicians

million beds required

Shifting point-of-care from hospital to home

Disruptive financing model for drugs and consumables

Traditional hospital + PPP model New disruptive model of equipment purchase and use

Technology for healthcare delivery

Medical education Nurse practitioner

Intermediate specialist

Preventive care

Educate & advocate self-care model Empowered MBBS

Empower DNB and CPS certification

Educate & advocate prevention

Add

million doctors

December 2017

million nurses

Incentivise hospitals for better outcomes

Incentivise doctor to keep patient out of hospital

Indians do not have access to primary healthcare facilities.

30%

million Indians fall below the poverty line each year because of healthcare expenses.

30% people in rural India do not visit hospitals fearing the expenses.

The healthcare industry in India is one of the largest in terms of revenue and employment. According to Deloitte Touche Tohmatsu India the healthcare industry has registered a growth of 10% over the past few years and is expected to reach USD 145 billion by 2018 and over USD 280 billion by 2025. At present its value is pegged at around US$ 100 billion. As a result of urbanisation and ageing, the burden of NCDs is large and rapidly rising in all states. The fastest-growing causes of ill-health over the last 26 years were diabetes (increased by 174%) and ischaemic heart disease (up 104%). Ischaemic heart disease (responsible for 8.7% of the disease burden in 2016) and chronic obstructive pulmonary disease (COPD; 4.8%) were the leading causes of premature death and ill health in 2016, overtaking lower respiratory infections and diarrhoeal diseases. More than 60% of deaths (6.1 million) in India in 2016 were due to NCDs, up from about 38% in 1990.

70% of Indiaâ&#x20AC;&#x2122;s healthcare infrastructure is limited to the top 20 cities.

15 Fastest Growing Occupations -2014-24 SL NO

OCCUPATION

Wind turbine service technicians

Occupational therapy assistants

Physical therapist assistants

Physical therapist aides

Home health aides

Commercial divers

Nurse practitioners

Physical therapists

Statisticians

Ambulance drivers and attendants, except emergency medical technicians

Occupational therapy aides

Physician assitants

Operations research analysts

Personal financial advisors

Cartographers and photogrammetrists Source: Bureau of Labour Statistic, USA

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INTERVIEW

WE WILL BE A FORMIDABLE FORCE IN THE HEALTHCARE TECHNOLOGY FIELD Recently, The University of Chicago Center in Delhi invited Dr. Satyanarayan Hegde a pediatric pulmonologist for an interactive session on building bridges from ‘Bench to Bedside and Bedside to Bench in Healthcare Delivery’. He spoke to M Neelam Kachhap during his India visit and later about innovations that will solve healthcare problems of the future.

AN AVID researcher and educator, a lifelong learner and a fatherDr Hegde stronglybelieves in evidence based, cost effective, culturally sensitive and patient centered care. He currently works for the University of Chicago Medicine and its affiliated hospitals. Dr Hegde overseas pediatric subspeciality operations of University of Chicago Medicine, in his role as Medical Director. A known advocate of“thinking outside the box”,Dr Hegde co-invented patent pending internal airway percussion device that will be useful for clearing mucus plugs in the lungs. He is also the co-founder of healthcare technology start-up Virtual Medical Assistant (VMA) Inc. Upon experiencing collective frustration of electronic health records, Dr Hegde chose to solve the problem of making HER user friendly and truly meaningful by founding the technology company VMA Inc., which is ready to release version 1.0 in early 2018. He shares his

December 2017

thoughts on solving some of the healthcare delivery problems around the world with simple innovations. Give us a perspective on benchto-bedside and bedside-to-industry in healthcare delivery. What is the current status? Biomedical scientists used to work in silos for many years. This was impeding the translation of bench-side research (basic science research) to bedside. In the US, this situation is changing. Funding agencies such as National Institutes for Health are encouraging collaborative research between different teams. Physicians can play a key role in leading the efforts of translation of bench to bedside science. They can act as team leaders or anchors to bring together different disciplines to solve important problems.

I would like to build a blockchain based, decentralized form of EMR Contrast this with India. Why don’t we see more academicians’as innovators? There are two reasons why academicians in India are not innovating. First reason is the education culture and second reason is the misplaced incentive structure for academicians. The Indian education sectorencourages, ‘retain and recall of facts’ as opposed to ‘creative and logistical information’. This culture has to change. In the medical schools and universities, the promotion and salary increment of faculty are linked to the seniority as opposed to productivity. Also in India, either by policy or culture, there is lack of interdisciplinary or interinstitutional collaboration. For example, Bangalore has top research institutions such as Indian Institute of Science and DRDO, multiple medical schools, top business school (IIMB), thriving private sector but there is hardly any collaboration between these institutions. If these institutions were located in a major US city, there would be a ‘research park’ linking all of these institutions. The institutions would have financial stake in the research park, with mechanisms for grant making for collaborative multi-institutional research and training programs for faculties to develop research skills.

Dr Satyanarayan Hegde, Medical Director, University of Chicago Medicine, Pediatric Subspecialty

Would it be difficult for you to innovate in India? I don’t know at this stage. But I am confident that I can. There is vast pool of talent and enthusiastic younger generation in India. There are great institutions and a thriving startup culture. Certainly, during my recent visit I had productive meetings with academic leaders from Manipal University, St John’s Research Institute, IIMB and some private entrepreneurs. The next step is to build a multidisciplinary

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INTERVIEW and multi-institution team around a research theme to turn at least one idea into a product. Let’s talk about your innovations. What led you to work on Internal Airway Percussor (IAP)? It was in 2011 when I had just joined University of Florida as a faculty in pediatric pulmonology. I was looking for collaborative research opportunities relevant to my field. I happened to meet with Prof. Paul Davenport, PhD who is a great pulmonary physiologist. He had just built a device called High Frequency Oscillator (HFO) using a loud speaker, guitar amplifier, corrugated pipes and toilet flange all bought from a local DIY store. The device delivered sound waves to subject’s airways (bronchi or breathing tubes in the lungs) through a mouthpiece. Paul had tested it in dogs to note that by vibrating the lungs through these sound waves, he could get more protein in the exhaled breath sample suggesting that one could “clear” something from the lungs. He tested them in dogs undergoing anesthesia for surgeries in a veterinary hospital. As a pulmonologist, I took care of patients with cystic fibrosis (CF) – a genetic condition that results in mucus build up in their lungs. These patients needed some form of airway

December 2017

In India, either by policy or culture, there is lack of interdisciplinary or inter-institutional collaboration clearance therapy (also called as chest physiotherapy) on a daily basis. In the US the CF patients use some form of medical devices for this therapy. With the mucus build up, CF patients also develop infection in their lungs from a bad bacterium called pseudomonas. The surest way of diagnosing this infection early on is by doing a test called bronchoscopy (passing a camera down the lungs) to get washings from the lungs. The test is cumbersome, expensive and requires anesthesia. When I saw Paul’s device, I thought that it can help my patients if developed further. We could develop it into a breath

based diagnostic device to replace bronchoscopy for obtaining lung washings. I would like to call the technology as virtual bronchial lavage (VBL). It is a daunting research task but doable. On the other side, the device could also be used as a means of airway clearance therapy. Some data already existed to support the notion that IAP could easily be developed in to an airway clearance therapy device. This is how my work on the IAP began. University of Florida subsequently applied for the patent for our discovery. How does IAP work? IAP is a patent pending medical device that delivers vibratory sound waves at certain frequency and amplitude to the breathing tubes of lungs called bronchi. When we breathe, the air passes through our windpipe and several generations of branching bronchi (breathing tubes) before it reaches microscopic bubbles known as alveoli where oxygen is delivered to the blood. The branching system of windpipe and bronchi is akin to an upturned tree with its body corresponding to windpipe, branches corresponding to bronchi and the leaves corresponding to the alveoli. The bronchi can sometime get clogged with thick mucus in certain diseases such as bronchiectasis. The mucus can be unclogged by vibrating or shaking the chest either by gently beating the chest wall with a cupped hand (traditional or manual chest physiotherapy) or by wearing a specialized jacket called “Vest”. The same can also be accomplished by directly shaking or vibrating the windpipe and its branching tubes of bronchi. IAP vibrates the windpipe and its branching tubes directly by delivering high frequency soundwaves thereby loosening the mucus. Following any form of chest physiotherapy, the subject will have to cough and can easily spit the mucus out. During normal breathing, we produce tiny bubbles originating from the branching system of breathing tubes called “aerosol droplets”. These aerosol droplets often carry parts of the cells, bacteria or viruses that are attached to these cells lining the breathing tubes. Let us call them as biologically important molecules. These molecules are hard to detect in exhaled breath since they are in extremely dilute con-

dition. By cooling exhaled breath, it is possible to collect the water content of breath in to what is called as exhaled breath condensates (EBC). Researchers have attempted to measure biologically important molecules in EBC, without much success. The problem was that contents in EBC’s were extremely dilute varying anywhere from 10,000 to 30,000-fold when compared to direct lung washings obtained by bronchoscopy. With IAP, we are trying to develop diagnostic tool where we do not need to collect condensates thereby reducing the dilution factor. We have also shown that with the appropriate frequency and amplitude combination, we can increase the aerosol droplet output in exhaled breath by several folds. In other words, we may have developed a method to concentrate biologically important molecules in exhaled breath so that using currently available detection methods, we can diagnose bronchial infections. Of course, we have not tested this hypothesis yet. It is possible to test this hypothesis in TB patients in India. If the hypothesis turns out to be true, using IAP we can develop a new inexpensive and noninvasive diagnostic tool for Indian mass market. How difficult or easy was it for you to take this device from bench-to-bedside-to-industry? It has not been easy. In the US for everything, one needs to have funding. We have plenty of resources but we cannot use them if we did not have appropriate funds to pay for them. We have something called as ‘effort allocation’ in the academic sector in the US. If I am hired as a physician to see patients and I also want to do some research, I will have to take permission from my Chairman. A physician can bring in more dollars to the department through clinical revenue than by doing research. So unless one has dedicated research funding or holds lot of promises, the department chairman may not release a physician in his/her department for research efforts. Whatever we have developed so far is due to pure passion for science and with the help from a team of scientists from different disciplines. I will have to mention the names of Prof. CYWu and his post doc, Nima who conducted the

aerosol study for us. My role was to identify the expertise, build the team and design the study protocol. Prof. Wu is an engineer with expertise in bioaerosol. So, a passionate group of a physician, physiologist and engineers were able to get some early data on IAP. When I moved to University of Chicago in 2015, I happened to get introduced to Polsky Center for Innovation and Entrepreneurship – a startup incubator space sponsored by University of Chicago. Moreover, Chicago being home to 3 major research Universities, world-class business schools, collaborative opportunities has a vibrant entrepreneurial culture. It opened up new opportunities that I was previously unaware of. I learned that with good idea, business plan and right team members, there are angel investors and venture capitalists who are willing to take risks with their money that traditional academic depart-

4 hours of direct patient care, physicians spend minimum additional 2 hours of “charting” when they simply become expensive, highly qualified data entry clerks. VMA will cut down this charting time by at least 50%. Version 1.0 of VMA is set for release in early 2018. The future versions will have big data analytics, patient engagement platforms and population health management features inbuilt in to VMA. How will your efforts shape healthcare delivery in 2018 and beyond? It is a good question. We are an early stage startup. There are risks. If everything goes as we planned, we will be a formidable force in the healthcare technology field. Imagine a physician having to only use a purple color pen and a pink paper to create pa-

Using IAP we can develop a new inexpensive and noninvasive diagnostic tool for Indian mass market ments cannot. Moreover, my own employer University of Chicago provided me with lots of opportunities and training in this area. I have now learned some tricks of the trade and also have access to world class mentors who can guide me. Tell us about your other inventions? I am currently developing a technology solution to address the problem of physician burnout due to cumbersome electronic health records. I have founded a startup called Virtual Medical Assistant or VMA (http://www.virtualmedicalassistant.net/). VMA will interact with any type of EMR in the backend and provide an intuitive, customized user interface for the physician. By leveraging existing but disparate technologies in a single platform, VMA will automate key physician workflows and thereby reducing the charting time. In the US for every

tient notes, that are only obtainable from central store in the hospital. He can only use Century Gothic style in hospital A and Calibri style in hospital B. This situation is in the current EMR era. Now imagine a situation where he is free to carry his own pen and paper and write in his own style irrespective which hospital he is working in. This situation is in the VMA era. Whether the hospital has Epic, Cerner or some other form of EMR, the physician will have ONE portal to work with. VMA can significantly improve: History and Physical Examination, Order Entry, Prescription of Medications and Operation Reports by the surgeons. What is the next step for you? My focus is now to develop first version of VMA, refine it as necessary and find paying customers for it to become a successful product. Once we reached that milestone, we will approach institutional investors for scaling up and devel-

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INTERVIEW opment of future versions. I would like to build a team that can build value to VMA with minimal input from me. At that stage, I will move on to other projects. To give you an illustration of future versions of VMA, surgeons have to create a boring operative report after every surgery. They have to memorize all the surgical steps they took and

a telehealth platform, remote monitoring technology using wearable devices and physician decision support system. With these technologies, we can provide intensive care to some of the patients at their home. We can significantly reduce hospitalizations and length of stays, improve patient satisfaction and ultimately reduce the cost of healthcare delivery.

India can leapfrog into the next stage of healthcare technology revolution incisions they made and document them at the end of the surgery in a written report. What if they wore a wearable camera and a mic? What if the mic recorded their voice during surgery and the camera took some pictures with annotations? What if VMA were to generate an accurate and timely media rich operation report that the surgeon could just review and sign off? This is what a future version of VMA will accomplish. What are your future plans? I would like to build a full ecosystem around VMA. VMA is not a full-fledged EMR but it is a layer on top of EMR. I would like to build a blockchain based, decentralized form of EMR,

December 2017

Any parting thoughts. The healthcare IT field is at the cusp of massive disruption. We are at a stage of dot. com era in healthcare. For IT companies, this is the best time to enter into healthcare. There is a lot of hype out there just like in the dot. com era. For example, a new Chicago based healthcare startup recently got an evaluation of $5 billion with about $800 million in private investment. Many new technologies are expected to hit the market in coming years. Healthcare delivery model is going to have a massive transformation. With big data analytics made possible by electronic medical records, new treatments will be discovered. With the widespread adoption of connected

wearable technologies, it will be possible to forecast events such as heart attacks or strokes in advance. Telemedicine in combination with remote monitoring technology will make it possible for most of patient care to be delivered at home or as an outpatient. Patients who are critically ill and those who require major surgeries will only need to travel to a hospital. India can leapfrog in to the next stage of healthcare technology revolution. It should learn from the mistakes and successes of the US before implementing its EMR platform. I see that India has been making policies to regulate medical industry. Of the three healthcare systems I have worked in (India, England and USA), Indian healthcare is the only true market driven system with price transparency. Although it needs some accountability in terms of measurable quality indicators, policy makers need to be careful while prescribing government mandates so as not to stifle the market driven innovation. Economic meltdown of 2007-08 has shown that UK’s healthcare system which is completely government controlled is not sustainable in the long run. In the US, the healthcare is heavily regulated through a convoluted system resulting in uncontrolled cost. There is no price transparency and the end user – the patients’ have no power in deciding their care. India shouldn’t make these mistakes.

OPINION

IT’S A MUNNABHAI MBBS REMAKE FOR HEALTHCARE INVESTING

Kapil Khandelwal, Managing Partner, Toro Finserve LLP and Director, EquNev Capital Pvt Ltd

OVER 2016-17, India has undergone the MunnaBhai MBBS movie phenomena between the private equity investors (the college Principal Dr. Asthana) with his deviant student (MunnaBhai) in the college of healthcare investing pot boiler. While the disciplinarian Principals (private equity investors) wanted higher stakes, exits, secondaries, and return of multiples on the other hand the truant MunnaBhais of healthcare (physician/medical entrepreneurs) were trying to coach their Principals that they need patient capital, higher valuation and their Principal who is not breathing down their neck in the classroom of healthcare ventures. Pretty tough to balance out the Principals and MunnaBhais of healthcare in India! The outcome of this ‘love-hate all’ MunnaBhai MBBS flick with the drying up of equity gravy-train is that the credit ratio for the private healthcare sector at an all-time high of 1.5 times in 2017! Investment Deadlock In 2018-19 our MunnaBhais on the streets of healthcare will touch `5.5 lakh crores in revenues and would require minimum of `5,500 crores (barely 1% of topline as capex for a country that needs 5% of topline as investment in capacity building) to build additional bed capacities. There is a latent fear that MunnaB-

hai’s father (the Government) may make a late entry into this movie and scold MunnaBhai for playing their extortion game to curb prices to win audience (vote bank in 2019) approval. In such a scenario would the Principal give away their priced daughter, Dr. Suman (aka Laksmi or investments) to MunnaBhai to fund `5,500 next year in holy wedlock? The MunnaBhais of healthcare will have to turn to their trusted goons, Circuit (investment bankers) to bring them the booty of dead bodies for conducting autopsies! Fairly a heady remake of MunnaBhai MBBS! Not yet? Let’s compare all the healthcare investment models and their issues in India. These financing options are fairly limited and include:  PE investment in operating company for future expansion. These are expensive with minimum-IRR of 25%, equity-dilutive and restrictive with the strings attached.  Loan against Property (Hospitals) from Banks. These are cheaper with rates ranging from 9% to 11% pa, limited amount, short tenure, not for debt averse healthcare entrepreneurs.  Land Acquisition / Development finance from a Financial Investor. These are expensive with minimum IRR of 25% to 30% at land stage and limited.

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OPINION

Can a new investment model save the day? In 2018-19, a new avatar of benefit is on the horizon in healthcare investing, which will debut Indiaâ&#x20AC;&#x2122;s first healthcare real estate fund for underwriting exiting healthcare assets of private sector healthcare ventures (hospitals, diagnostic centers, assisted living facilities, rehab and long-stay facilities) through a sale and lease back model at 100% loan to value (LTV). The key advantage of this model is that, it will allow players who have been burdened with debt and are unable to raise private equity funding for growth to raise capital for establishing newer facilities and making their business model asset-lite. Our fund has also some of the State Governments which will co-invest with us into the healthcare ventures in their relevant states.

December 2017

There is a pipeline of investments from 2016-17 funding opportunities of around `1000 crores which we are evaluating for investments in 2018-19. These are in healthcare facilities located in top-18 tier 1 and tier 2 cities of India. Healthcare real estate fund benefits Investment in making current healthcare players asset-lite apart, the need of the hour is to make healthcare delivery of our investee partner cheaper, better and faster! El-Toro provides these through its total solutions of partner ecosystems that it has built. Cheaper This fund provides funding which is half the rate of return expected by private equity from their investments in healthcare ventures.

Indiaâ&#x20AC;&#x2122;s first healthcare real estate fund for underwriting exiting healthcare assets of private sector healthcare ventures is now in available.

Better This investor becomes more of a partner than a mere financier for the healthcare ventures by providing perpetual capital without the hassles of equity dilution with tag-along rights and exits. There is independence for the healthcare entrepreneurs to maneuver their growth strategy and stabilize their new healthcare assets without undue pressure for exit valuations and profitability. We do not acquire equity into the healthcare venture. Faster This investment firm does not guarantee that all deals will be funded however we turnaround most of the investment proposals promptly. The key criteria that the healthcare assets need to qualify include location of existing healthcare assets has to be top-18 cities in India; the operations of the facilities have stabilized and is EBITA positive to sustain the sale and lease back model of servicing the investments and healthcare entrepreneur comes with a management track record. Other key issues in 2018-19 that need to be resolved

clinical stuff or a businessman running the chain of hospitals? This alter-ego phenomenon has not delivered focus in driving neither the clinical excellence nor business excellence in healthcare. People Supply Chain For the scale of investments expected to come up in the next year, the constraints of people supply chain need to be solved immediately. We have noticed that most healthcare facilities have slipped on their timelines to stabilize due to supply of inadequate skilled medical, para medical and support staff which is right trained and credentialed. Build-2-Operate Time Our analysis of the investment in healthcare facilities over the last 10-years has revealed that there is 15%-20% delay in build-2-operate time. This time not only increases the capex cycle but also affects the long-term break-even and profitability and return of the investments. Letâ&#x20AC;&#x2122;s see whether 2018-19 will be another MunnaBhai MBBS blockbuster year at the investment box office for the industry!

Our analysis of the investment in healthcare facilities over the last 10-years has revealed that there is 15%-20% delay in build-2-operate time.

Are you a Clinician or a Businessman? For the `5,500 crores investments to come to reality in the next year will increase the realization that the doctor-entrepreneur model for operating hospitals is not sustainable for the investors or the doctor-entrepreneur. Its time that the doctor-entrepreneur needs to decide where his heart lies. Either it is in doing the

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FEATURE

APPROACH

PG MEDICAL GRADUTES: NATIONAL ASSET

Dr Abhijat Sheth, President, National Board of Examinations

OUR HEALTHCARE system is at present going through a phase where shortages of doctors and specialist doctors are exceedingly interfering with delivery of healthcare. The GP (General Practitioner) Doctor to specialist ratio is dismal. The crisis gets further compounded by lack of standardization in under graduates (UG) and post graduates (PG) training of doctors. National Board of examination (NBE) is an examination conducting body with prime objective of establishing quality standards of post graduate medical examination. PG medical education The post graduate degree awarded by the NBE is called the Diplomate of National Board (DNB). The Board awards Fellowship of National Board (FNB) in various sub-specialties. The list of recognized qualifications awarded by the board

December 2017

in various specialties and super specialties are approved by the Government of India. The NBE conducts the largest portfolio of examinations in the field of Medical Sciences in the country which now includes NEET PG (National Eligibility and Entrance Examination) in post graduate medical course. Challenges of the current system The lack of uniformity in educational resources, low post graduate (PG) to under graduate (UG) medical professional ratio, differing requirements at state health care systems, increasing complexity in the current medical therapies with research and innovations and exponentially expanding technical expertise in the medical sciences all contribute to the difficulties faced by our current medical education system to achieve desired

governmental and societal goals to provide universal healthcare to all people. For example low PG/UG ratio drives our young talent abroad to serve other countries despite all hard work done by us at basic medical education level. The current medical education system faces big challenge with ever expanding private/ corporate health care system and marked shortage of teaching talent in the medical schools. Many specialist teaching faculties are lost to private sector in addition to low UG/PG ratio effects main stream medical teaching at medical school level. In line with recent advances in the medical fields we also need to revisit our current medical education curriculum to reach at par with the advances. We do observe conscious efforts from the Government and main medical regulatory board, the Medical Council of India (MCI)

Low PG/UG ratio drives young talent abroad to serve other countries despite all hard work done at basic medical education level but it requires strong participation from all fractions of medical fraternity. The NBE is going to be a vital partner and pivotal with its national presence and universal participation from all its stake holders including private/ corporate/charitable/NGO hospitals and other organizations which are not able to participate directly in our current conventional medical school education program. At the same time NEET PG and associated examination is a

step forward to address issue of quality and standardization of curriculum of teaching and training of post graduate courses. Positive Steps The NBE started NEET PG examination across the country first time in 2017 and this is a major step forward to achieve our goal to address diversity and bringing universal standards for medical education at the national

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FEATURE

APPROACH level. We are meeting with some unexpected difficulties but there is a strong consensus within NBE Board, Government and MCI/DCI to create a strong national platform for one PG examination which is a reality now. In coming time the NBE is committed to learn from any of its shortcomings and implement meaningful solution to create NEET PG, conduct smooth, objective and fair exams. To increase the post graduate medical graduates the NBE revisited its accreditation criteria to ensure proactive participation of teaching faculties from private and corporate sector and other institutions which are not attached with state run medical schools. It is a huge positive step forward and certainly helps NBE to achieve its short term goal to increase current PG seats from 6700 to 10000 seats in the next couple of years. The NBE is working

December 2017

closely with the state government and MCI to start more basic specialty DNB courses that helps regional hospitals and rural areas. This includes DNB Family Medicine. In addition the NBE is evaluating to start more super specialty fellowship courses in consultation with the specialist faculties in the relevant super specialties across the country. Increasing Medical Educator To ensure that the quality of medical education is maintained, NBE is looking forward to increase the medical educators by undertaking strategic planning, analyzing and improving systems and process for efficient and effective delivery of teaching programs with appropriate policies to help with recruitment and training workforce in all participating organizations.

Curriculum Revision While addressing increased need of post graduate medical seats, the NBE also realized to help participating organizations with existing curriculum. In2018 NBE is planning to introduce externship training program for DNB students and working with ANBAI (Association of National Board of Accreditation Institute) to get cost effective access to international/national peer review journal to participating organization. Way forward The NBE will continue its vision to build up truly expert medical professionals along the country, creating more opportunities for post graduate medical specialty training and integrating innovative approaches to create doctors for today and for the future need of the society.

IMPACT

WINNING THE WAR ON NCDS WITH TECHNOLOGY

Prof D Prabhakaran , Vice President Research, Kavita Singh - Research Scientist, Public Health Foundation of India (PHFI), New Delhi

THE NON-COMMUNICABLE diseases (NCDs) such as heart disease, diabetes, hypertension, cancer and mental disorders are the leading causes of death and disability in India, like most parts of the world today. The rapid rise of these chronic diseases in India is particularly concerning due to under-resourced health systems and consequent catastrophic social and economic impacts. Use of simple, inexpensive and effective technology innovations that focus on prevention and management of NCDs - especially cardiovascular disease, diabetes, and mental health - offers the greatest opportunity to avert millions of premature deaths and even greater unnecessary suffering. Where Technology Can Help Novel use of technology and task-sharingstrategies opens many opportunities to enhance the efficiency of care, speed the implementation of effective treatment plans, decrease the morbidity and premature deaths, and ultimately reduce the overall health care costs.

NCDs Screening, Detection and Care In India, a very large proportion of people do not know that they have risk factors (e.g., high glucose, high blood pressure, high cholesterol) for NCDs. Having a system that detects these conditions proactively is important, but that is the first step, and often effective without careful coordination of prevention and control after the detection is done. Detection of NCD risk factors requires simple, reliable, safe, and low-cost approaches, and once people are detected with risk factors, they need a continued care delivery system that provides effective behaviour change (e.g., smoking cessation, improvement in diet and physical activity) and affordable medications. Furthermore, these systems need in-built measures of ensuring delivery of and compliance with these medications on a long-term, most often lifelong basis, and regular monitoring of control of risk factors of early signs of disease, so that prevention efforts and treatment can be appropriately intensified. All of

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IMPACT

this is seldom achieved by focusing only on the patient alone or on the physician alone or assuming that the process of physician-patient interaction will be able to address all of these issues in a sustainable and effective manner: rather it requires a health system-level approach to quality assurance, conceptualized in a way that empowers the patient, eases the burden on physicians, and proactively coordinates and monitors control of risk factors and complications in a methodical and structured manner. New Technological Interventions Many technology innovations have been recently successfully demonstrated in disease surveillance, survey data collection, screening, diagnostics and disease management. For instance: use of geographic information systems, computerized cardiovascular risk assessment, portable diagnostic equipment (lab on chip, portable ECG), the use of biomedical sensors that are integrated with GPS (global positioning system) to provide accurate

December 2017

estimation of physical activity and electronic health records - decision support system. There are numerous advantages of using information technology (IT) as it enables real time data access, ensure data accuracy (with inbuilt checks), data security (back-up), big data analytics, improves timelines, and is ecofriendly (paper less and re-useable) and allow application of processes in multi-language mode. An example of innovative use of GIS (geographic information system) technology is in mapping clusters of high blood pressure and neighbourhood built environment. In a study conducted by the Public Health Foundation of India (PHFI), Centre for Chronic Conditions and Injuries (CCCI) has demonstrated that the neighbourhood systolic blood pressureis higher in areas with high traffic density (unpublished data). While the high blood pressure could be attributed to noise pollution, other potential reasons such as lack of physical activity and unhealthy diet need to be explored with adjustments for socio economic status of the individuals studied.

The rapid rise of these chronic diseases in India is particularly concerning due to under-resourced health systems and consequent catastrophic social and economic impacts

Effectiveness of Technology-enabled Health Interventions Furthermore, at the PHFI, CCCI, we have developed and evaluated the effectiveness of several technology-enabled health interventions to screen and identify populations at risk of NCDs and to effectively manage hypertension, diabetes, cardiovascular risk reduction, and depression. Notable examples include: mPower Heart study and the CARRS Translation Trial. m-Power Heart

The m-Power Heart study was carried out in the Solan District, Himachal Pradesh with primary objective of designing a feasible and sustainable evidence-based, decision support-enabled, health care delivery model for the management of hypertension and diabetes in the primary health care facilities. The mPower decisionsupport system (DSS) was used by Nurses at the NCD clinics of community health centers (CHCs) and had the key features like: screening for hypertension/diabetes and suggestions for diagnostic investigations; guidelines based management plan for hypertension and diabetes; longitudinal health records; lifestyle advices tailored to patient profile; and quality assurance checks. Trained nurses carried out opportunistic screening of 22,009 individuals (â&#x2030;Ľ30 years) with the help of mPower DSS at NCD clinics over a time period of 21 months and identified 6797 patients either with hypertension and/or diabetes. There was significant reductions in systolic blood pressure, diastolic blood pressure, and fasting blood glucose at 18 months of follow-up: -14.6 mmHg, -7.6 mmHg, and -50.0 mg/dL, respectively, and these improvements in blood pressure and blood glucose were statistically significant even after adjusting for age, sex, and CHCs.

with features to provide specific reminders to physician and patients), and ongoing measurement of processes and outcomes of care. This pragmatic implementation trial has shown that major improvements in diabetes quality of care and in control of risk factors (glucose, blood pressure, lipids) is imminently feasible even in resource-challenged settings with significant proportion of less educated patients. In fact, the levels of improvement achieved were far higher than those seen in similar trials in high-income countries. We are now in the process of scaling up and evaluating this intervention, via primary care, at the District level, leveraging ongoing NCD programs, and also developing and testing models to manage multiple conditions simultaneously (e.g., diabetes, hypertension, and depression; or diabetes and TB), as large numbers of people have more than one NCD-related condition.

Need-of-the-hour Technology like cell-phones or web-based approaches provide an important means of helping strengthen the system, and connecting the various interfaces (e.g., patient and physician; primary and secondary care). Digital and portable technologies offer the most exciting opportunities to leap-frog barriers to improving the coverage and quality of preventive, diagnostic and therapeutic interventions to effectively control the chronic disease burden in India. A partnership between the diverse technology innovators in the country with clinical and public health researchers is the need of the hour to harness the technology-enabled interventions and task-sharing opportunities to contribute to the improvement in health of the nation.

CARRS Translation Trial

The CARRS Trial at ten sites in India and Pakistan, among 1,146 patients with diabetes, evaluated a model combining patient education, a nonphysician care coordinator (to enhance patientâ&#x20AC;&#x2122;s adherence to therapy), electronic health records and clinical decision support system (to ensure consistent and continuous evidence-based care,

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FEATURE

HEALTH - IT

THE POWER OF HEALTHCARE IS IN CONSUMERâ&#x20AC;&#x2122;S HANDS

Suchismita B, Emerging Healthcare Leader in Digital / IoT Transformation across India, Europe, and North America

December 2017

HEALTHCARE COSTS are experiencing a very fast rise, and almost 17% of US GDP is spend on healthcare, the rate is expected to increase to 20% by 2020, making healthcare almost 4.6 Trillion USD1. On top of the estimate, 750 BUSD is estimated as waste in the US Healthcare system2.Coming closer to Indian organized Healthcare market size is estimated to be 100Billion USD (655,000 Cr INR), translating into technology spend of4000 Cr INR. The Indian healthcare ecosystem, faces an overall challenge of rising cost, diminishing returns, low customer satisfaction, challenge from new technology entrants, andprotecting health information from cyber-attacks. Patients in turn face a plethora of different issues, these range from the traditional long timelines, to make an appointment or to coordinate care. In addition, rising costs are an issue, while the new set of technology advances has not been totally harnessed to improve care delivery. India has a unique problem on hand. How to empower healthcare in the hands of its population? The growth of smartphone sector and internet connectivity is very closely connected with the growth of healthcare digital. India has a huge and growing smartphone base, with an annual growth of 36%. This translates into 6570% penetration in 2018 (85-90% penetration

level by 2020x). These imply two out of three adults have a mobile connection, and one out of three adults has a smartphone. There is a good prediction of the remaining mobile and nonmobile user getting a smartphone in the next couple of years8. Health coaching /mentoring through digitization of healthcare data Increasing the Digital Healthcare ExperienceDigital healthcare is becoming popular across multiple areas of healthcare in 2017. The rise in popularity of fitness wearables increases the scope of self-diagnosis. Additionally, the rise of smartphones also allows the user to be more involved in healthcare decisions.There is a huge potential for tele-medicine (virtual doctor), as it reaches remote patients, save costs and collect detailed data points. However, telemedicine, has not really taken off in India, but it is too early to cut it off. Initial investment in telemedicine is high, especially in connectivity infrastructure. With the advent of 4G across the country at the cost of a postcard (Thanks to RelianceJio!!), there is tremendous scope for telemedicine over 4G. The capital and operating costs would be very minimal. A success of telemedicine would also bring

a higher level of participation from members from rural and far-flung areas; additionally, multiple other stakeholders including pharmacy and insurance companies would then get into the telemedicine bandwagon.Though there has not been much groundwork laid for telemedicine revolution in 2017, but there are chances of renewed interest in this line, as the 4G costs start to drop. Mass adoption of technology is an ensuing success factor as well. Many smaller players are also coming up with a plethora of healthcare apps that measures exercise levels/ food and allows to record blood pressure or blood sugar reading. Additional healthcare coaching tips for nutrition effectively acts as healthcare mentor. Additional apps in payments or care coordination is under development or early stages. Avalanche in the Healthcare Technology Investing Digital Healthcare ecosystem – in 2017, Digital healthcare funding was to the tune of $3.67 Billion USD towards the end of May, 2017, in USA. This was an upstart from 6+Billion USD for 2016, across healthcare start-ups and VC world. The start-ups ranged from enabling easier access to healthcare to end users, additional data to users for self- healthcare decisions to data analysis and payment options across multiple levels.

One of the virgin areas of healthcare tech is the participation of Indian start-ups in the healthcare tech. There have been some startups in seed stage, but thereis no clear patterns or growth. There is no clear healthcare unicorn across the country as yet, there is no healthtech unicorn in sight in 2018 either! Indian healthcare is at a ripe stage for seeding healthcare tech startups, there is ample niche areas in healthcare across patient requirements, connectivity across care continuum or apps in local languages across the country. Of particular importance would of apps in local language, or apps ‘hyper-localized with global’ know-how. Additionally, there is a vast opportunity in this sector in terms of wearable ranging from fitness to specialized functions. Cardiac Design labs deploys a wearable device called MIRCaM which acts as Mobile intelligent device capable of providing cardiac diagnosis in remote setting9.

Linking the ‘Aadhar Card’ to the collection of healthcare data is very important for creating datasets

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FEATURE

HEALTH - IT

Indian and international VC’s are willing to invest in strategic start-ups; about 350-400 Cr INR are up for healthcare technology investment in 2018. There are some chances of startups in advanced stages, and some seed startups in healthcare tech emerging towards the latter half of 2018, as the healthcare policy, 4G and higher mobile proliferation becomes more wide-spread. “Practo’ – an online doctor appointment app was lauded as a Indian healthcare unicorn. However, a 100K doctor base is in urban areas across 25 M patients/year implies the application has a lot of scaling up to be done. Considering the healthcare ecosystem, there is a lot of growth that ‘Practo’ can target!!

December 2017

About INR 350-400 Cr are up for healthcare technology investment in 2018 Stakeholders come together to automate Data Analytics and Intelligent Agents –Clinical Decision Support Systems enables the decision making based on evidence based knowledge;data analysis is persistently used to diagnose chronic conditions, help public health surveillance and monitor drug-drug interventions in a larger public setting. Gates Foundation is running a pilot in some

Indian states targeting pregnant women/new mothers versus infant growth tracking. This is a combination of date from smartphones, metadata analysis and assessment for intervention strategies. 5 Medical Drone delivery is in nascent stages of commercialization, it is used in Rwanda to deliver HIV medication faster to far flung areas at a lower cost. This promises to be an interesting mode of last mile connectively for medication to Indian villages either in regular or disaster conditions. 7 The collection of data sets across the population is not very established, but is the need of the hour. The establish dataset are the foundation for genotypic datasets for analysis and reporting across various demographic parameters. Linking the ‘Aadhar Card’ to the collection of healthcare data is very important for creating datasets. This is not likely to happen in 2018, but likely in the horizon. Intelligent agents consist of multiple platforms to collect preferences, actions, transactions buying patterns to predict the preferences of a group of consumers under study.Shopkick Beacon technology can allow to flag and alert the users against a specific buying patterns. Per my understanding, this buying stratification is also likely to extend to healthcare buying and healthcare transaction3. There is a likely to be a retail-healthcare harmony along higher levels of stratification of buying patterns of consumers. Artificial Intelligence involves machine learning and deep learning; Google DeepMind, is developing software in partnership with NHS hospitals to diagnose kidney deterioration. Virtual reality companies allow medical simulation cases for teaching and therapy, augmented bots are being developed for delicate surgery.

In the Indian context, ForusHealthcare9, is an imaging platform connecting remote diagnosis across cloud. The imaging platform called 3nethra offers screening of eye problems, being portable, this spans across artificial intelligence and telemedicine. The extensive development of data analytics and intelligence artificial intelligence and augmented reality would enable the accurate prognosis and diagnosis of diseased conditions, enable targeted care to the population segment and reduce errors. Upward Mobilization of Healthcare Resource Pool India has a huge resource pool of medical doctors, nurses, para medicals and technicians. Changing requirements and advanced technology would bring about additional retraining of existing resources, and advanced training for new resources.

India is a said to be a young country with the average age being 29 years; India becomes a huge potential for digitally trained medical resources, as well as advances in technology to serve the population. Trained Indian resources has led technological economy across many countries in the world, and going forward, a well-trained digital healthcare workforce can also lead the way for many other countries. Conclusion The need of the hour for Indian healthcare is to remove geographic and socioeconomic barriers, enabling a higher level of access to multiple levels of services and additional educational and informational enablers for both members and providers to for faster uptake of healthcare technology. This in turn is likely to increase levels of self-diagnosis and preventive care, and lead to higher levels of quality healthcare and equitable outcomes.

Reference https://khn.org/news/health-care-spendingto-double/ 2 https://www.theatlantic.com/health/archive/2012/09/how-the-us-health-care-system-wastes-750-billion-annually/262106/ 3 https://www.shopkick.com/shopbeacon 4https://www.ibef.org/industry/healthcareindia.aspx 5 https://health.economictimes.indiatimes.com/ news/diagnostics/india-spends-less-on-healththan-any-country-with-middle-income-statusbill-gates/61698218 6 http://www.livemint.com/Consumer/zxupEDYD560LJrnoRxcn4L/Mobile-phone-penetrationin-India-set-to-rise-to-8590-by-2.html 7 https://www.technologyreview. com/s/608034/blood-from-the-sky-ziplinesambitious-medical-drone-delivery-in-africa/ 8 http://money.cnn.com/2017/09/26/technology/india-mobile-congress-market-numbers/ index.html 9 https://www.forbes.com/sites/ suparnagoswami/2017/02/22/3-healthcarestartups-tapping-into-indias-soon-to-be-booming-iot-market/#4e8e4ee55040 1

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EVENTS AHPI GLOBAL CONCLAVE 2018 Date: Feb 16-17, 2018 Organiser: AHPI Venue: Le Meridien City: Kochi Click: www.ahpi.in Contact: Shikhar Gupta, Assistant Director Shikhar.ahpi@gmail.com

ealthcare industry will play key role to make the economic growth inclusive all over the globe. On one hand it is key social sector contributing to Human Development Index of nation; on the other hand it provides employment to large segment of population per unit investment. Rightly therefore the healthcare is fast

NATIONAL CONFERENCE ON SAFE AND SUSTAINABLE HOSPITALS (SASH) Date: Jan 20-21, 2018 Organiser: NIMS, AHA, AHHA Venue: ShilpakalaVedika, Madhapur, City: Hyderabad, Telangana, Click: http://sash2018.com Contact: Dr. P.S. Rakesh Prabhu, Conference Co-ordinator secretariat@sash2018.com

ASH’ 18 Conference is a highly focused, two day event organized for doctors, hospital owners and administrators, hospital agencies, students of hospital administration and management, nurses, architects, Civil engineers, Interior designers, purchase/health insurance/IT professionals and suppliers within the hospital industry who are interested in promoting change through innovation in health. The objective of this conference is to provide frame work for understanding challenges in health care management, current research, educational and professional development for medical technology industry in India.

December 2017

emerging as ‘election agenda’ in all the developing nations. Governments accordingly are working on plans to provide ‘Universal Health Coverage’. Considering that private sector is playing key role in providing healthcare in general and tertiary care in particular, the mission of ‘Health for All’ can be possible only through joint collaboration between public and private sectors including the allied healthcare industry. Keeping above in view, AHPI has chosen the theme for its 5th Global Conclave as; “Is Quality Healthcare Sustainable? Issues, Concerns & Solutions”. The conclave will also encompass the unique blend of 4th edition of ‘AHPI Awards for Excellence in Healthcare’ which will be presented on the eve of 16th February 2018

SMART TECH HEALTHCARE 2018 Date: Feb 1-2, 2018 Organiser: Explore Exhibitions and Conference LLP Venue: JW Marriott Hotel City: Bangalore, Karnataka Click: www.exploreexhibitions.com/ healthcare/ Contact: Samantha, Conference Co-ordinator info@exploreexhibitions.com

n its 2nd year the Smart Tech Healthcare is one among the most dedicated conferences aimed at streamlining new horizons of technology in healthcare which provides a common platform for the industry and other stakeholders to come together to discuss the key challenges, learn from the best practices adopted across the country and ensure their firm is positioned to comply with digital health trends in the evolving industry.

INDIA HOSPITAL DESIGN & BUILD SUMMIT 2018 Date: Feb 22-23, 2018 Organiser: Quest Conferences, Quest on the FRONTIER Venue: Le Meridien

City: Gurgaon Click: http://www.hospitaldesignbuildsummit.com Contact: Upendra Joshi, Conference Co-ordinator upendra@questconferences.com

ndia Hospital Design & Build Summit 2018 is scheduled during 22-23 February, 2018 at Hotel Le Meridien Gurgaon Delhi NCR, India. The theme for the summit is “Transforming Hospitals”. The event is being organized in association with AHPI, IGBC, CIDC and HIMSS India. The aim of the summit is to Leveraging the latest innovations and best practices in Hospital Build in India to deliver cost-effective projects with effective Project management for timely completion of hospitals.

XI INTERNATIONAL CONGRESS OF THE INTERNATIONAL NEUROPSYCHIATRIC ASSOCIATION AND THE TS SRINIVASAN-NIMHANS KNOWLEDGE CONCLAVE Date: Feb 15-17, 2018 Organiser: International Neuropsychiatric Association Venue: NIMHANS City: Bengaluru Click: www.ina2018.com Contact: ina@target-conferences.com

he 3-day event has the contemporary theme “Neuropsychiatry- A Global Approach” the core of our effort being to identify and discuss important transcultural issues in Neuropsychiatry.This congress will be of great relevance to professionals across disciplines. Apart from those who practice, teach & research neuropsychiatry or have a special interest in the field, behavioural neurologists, biological psychiatrists, clinical neurologists and psychiatrists, psychologists, neuroscientists, rehabilitators, public health & epidemiology professionals, nurses, social work professionals, complimentary and alternative health professionals and all others in healthcare interested in mental health and neurosciences, will be warmly welcomed to this forum; to exchange ideas and contribute to the global knowledge pool at this expanding and exciting interface.

EVENT REPORT

HEALTH 2.0 INDIA 2017 Matthew Holt Co-Chairman of Health 2.0 Conferences

Akanksha Kapoor Startup India

Shrutika Girdhar Co-founder & CTO, Bodhi Health Education

HEALTH 2.0 and ISB co-hosted the 4th edition of Health 2.0 India Conference on November 10, 2017, at ISB Hyderabad campus. The event brought together students, healthcare professionals and dignitaries to discuss best practices and challenges faced by the healthcare industry in India. The daylong conference saw varied presentations and ideas discussing areas that required focus and the future of healthcare. The sessions were stimulating and held the interest of the audience culminating into thought provoking discussions. ISB’s Max Institute of Healthcare Management has been working through the integrated elements of research, education, and outreach in providing insights that can change and shape healthcare systems in India and globally. In addition, Health 2.0 is working with ISB’s Centre for Innovation and Entrepreneurship in setting up a Healthcare Accelerator that can foster and grow healthcare enterprises in the region. TIE, Hyderabad, Indian Angel Network and AMTZ were a few of the partners for the event. Rajendra Srivastava, Dean of the Indian School of Business, welcomed the delegates and speakers and set the tone for the day. He highlighted the journey of the institution and ISB’s Max Institute of Healthcare Management through the years and their commitment towards capacity building and enhancing strategic management in healthcare organisations. Matthew Holt, Co-Chairman of Health 2.0 Conferences, kicked off the 4th annual Health 2.0 India Conference with an interesting presentation on the future of healthcare delivery. The Highlight of his presentation was the trends and factors that will drive decentralised healthcare in future.

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EVENT REPORT

Shashank Nd CEO, Practo

Following this, Prof Sarang Deo moderated an interesting conversation with Shashank ND, Founder, CEO, Practo who spoke about his entrepreneurial journey and also talked about the next big thing in Indian Healthcare. He said that Internet of Things would drive the next wave in healthcare. The next -panel discussion topic was adopting new technologies through

December 2017

piloting, how hospitals measure success in pilots. The panellists from leading hospitals across India discussed provider’s perspective on the key factors that go into adopting new technologies in a hospital setting and how those hospitals measure pilot success. The panel was moderated by Associate Professor Deepa Mani from ISB. During the discussion RohitMA co-founder and MD Cloudnine hospitals, Bangalore announced the launch of incubator for healthcare start-upsat his hospital. This was followed by a presentation and demo by Ariel Beery,CEO, MobileODT and Malika Samuel, ExpertGynecologist& Primary Investigator, Apollo Hospital. They spoke about a successful innovation pilot by Apollo hospitals on expanding and improving early detection of cervical cancer. The next panel was moderated by Dr JagdishChaturvedi, Director, Clinical Innovations, and Partnerships at Innaccel. Affordable point of care technologies are an integral part of an effective healthcare system, but continue to be a critical unmet need for billions of rural consumers in emerging markets like India. The esteemed panel comprised of dignitaries like Guruprasad Seetharamaiah,Director, Medical Screening Solutions, Bosch Healthcare and Sivan Menon, CTO, GE Healthcare among others. They discussed the role and impact of point-of-care technologies which is set to be transformational over the next 10 years. Dr Chaturvedi kept the audience on their toes with live feedback and whatsapp interaction. The session concluded with presentation and demos by Meddiff Technologies and Sohum Innovation Lab. Post lunch session talked about Investment Trends in India’s Health Tech. The panel saw eminent personalities likeArun Venkatesan, Practice Lead - Health/ Chief Technology Officer, Villgro; Ramesh Byrapaneni, Managing Director, Endiya Partners; RadhaKizhanattam, Principal, Unitus Seed Fund, Pratik Poddar, Vice President, Nexus Venture Partnersamong others. The pannelist discussed the dos and don’ts of pitching a business idea and funding options available for start-ups. After this discussion MadhubalaRadhakrishnan, Founder, MCURA talked about her successful mHealth story. Controlling costs and achieving profitability is always a challenge for hospitals and hospital systems. The next panel explored the role of innovative technology solutions and address the challenges faced during the procurement, design, delivery and operation in healthcare facilities. Dinesh Seemakurty, Co-Founder & CEO, Stasis Labs and ShrutikaGirdhar, Co-founder & CTO, Bodhi Health Education Pvt Ltd presented a demonstration of their technology for the audience. The last session for day talked about global opportunities in India in the light of global organizations such as accelerator programs, grant funding platforms, and PE & VC firms that are focusing on Indian Healthcare sector. Pannelist includedAkankshaKapoor, Startup India; MukundhanSrinivasan, Inception Program Manager, nVIDIA; DhananjayVaidyanathanRohini, India Lead, Surgo Foundation andSateeshAndra, Managing Director, Endiya Partners among others. This session was moderated by Matthew Holt, CoChairman, Health 2.0. The day ended up with a Special Comedy Show by Dr JagdishChaturvedi, an innovator and a renowned stand-up comedian.

Q&A

ASK THE EXPERT

Running a private medical practice in India comes with the risk of lawsuits and property damage. As a medical professional, you are probably well aware of the devastating effects of legal cases and security threats that await doctors who face the blunt of an angry patient. We encourage you to share your queries and concerns regarding legalities of practicing medicine in India to learn more about legal framework, legal cases and the experience of fellow doctors

Prof ( Dr ) R K Sharma, President, Indian Association of Medico-Legal Experts , New Delhi will answer questions from our readers. Please send in your queries to editor@indiamedtoday.com

Q: I am a practicingorthopedic surgeon.Weare starting a multispecialty hospital. As you know, we get many trauma and assault injury cases in such hospitals. Many a times we have to attend court as a witness or expert. My question is can we as a hospital appoints a MLC officer, who will be a MD in forensic medicine who can take care of court matters? Dr PareshPandya, Rajkot Ans: It is a nice idea to put a separate doctor for MLC work especially if he is MD Forensic Medicine. But I really doubt that you would get one as there is severe shortage of MD Forensic Medicine. I suggest that you put a plain MBBS doctor for it. Even getting MBBS doctor purely for MLC work is difficult.

positive. On probing his history I found that his mother also had HBsAg positive indicating a perinatal transmission.As far as I know this does not seem to be a valid reason for rejection as a pediatrician will not be involved in invasive procedures. I would like to know, what are the medicolegal aspects involved in healthcare worker being HBsAg positive and can he be denied job on the basis that heâ&#x20AC;&#x2122;s HBsAg positive? Name withheld Ans: Any person with HbsAg cannot be denied job as most of the persons with HbsAg are healthy and can do a job. Your friend should complain regarding this to health Ministry / inform press and seek other remedial methods.

Q: I have come across a very sad incidence. One of my old college friend who is a pediatrician and Intensivist applied for a jobpost of specialist at a corporate hospital. He was denied job on basis that his HbsAg was

Q: According to MCI and Honâ&#x20AC;&#x2122;bleSupreme Court, can an internist, MD Medicine treat acute MI or stroke or diabetes or UTI or hepatitis or cirrhosis or hypertension or pneumonia or COPD or asthma or any other disease of any

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organ in the body. Why I’m asking is because, if one does attempt to do so, and fails, and is sued by the patient, he can be punished because he is not a MCI recognised ‘super-specialist’ in the field of cardiology, gastroenterology, hepatology, or pulmonology?Is this really true? What is the logic behind this? And what of the millions of patients in government hospitals who are being treated and cured, of the very diseases alluded to above, at the hands of generalists.Is it all illegal? What did the Supreme Court say exactly in this regard? Please elaborate because I’m sure many like me would like to know can MD Medicine internist treat patients’ without risking jail or litigation or hefty fines or MCI de-recognition. Dr Sumeet Singla MD, DNB, MNAMS, FIACM, FICP Associate Professor of Medicine Maulana Azad Medical College New Delhi

December 2017

Associate Editor, Journal, Indian Academy of Clinical Medicine Ans: Please understand that Supreme Court and MCI has never stated that internist, MD Medicine cannot treat acute MI or stroke or diabetes or UTI or hepatitis or cirrhosis or hypertension or pneumonia or COPD or asthma or any other disease of any organ in the body. The only question here is calling oneself a super specialist. With just an MD medicine one cannot call themself cardiologist, nephrologists, or endocrinologist. Please understand that in most instances MCI creates problems for us, and not courts. Specific guidelines are missing in this regard as MCI has never elaborated on it. On the other hand, 90 percent of government healthcare is provided by MBBS doctors; who are treating all typescases. Q: I am an orthopedic surgeon working at private hospital.I had an RTA patient ,15yr old

school going boy,MLC filed.He had suspected knee ligamentous injury for which MRI was advised. His parents refused to take MRI and got discharged 2 days later (againstMedical advice). My query is can wound certificate be given for this patient? Since I don’t know the exact nature of injury should I mention it as grievous or non-grievous? Ans: Do not give any wound certificate stating whether the injury is grievous or non-grievous. Just mention that it would be given after report of MRI which has been advised. Going out of way to help patient may be risky.

Disclaimer: This material has been prepared for informational purposes only, and is not intended to replace, and should not be conveyed or constitute legal advice. You should consult professional lawyer and legal advisors before engaging in any legal matter.

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