VOL.8 NO.2 PAGES 94
Cover Story PE funding: Fuelling growth in healthcare Strategy mHealth: The next game changer Radiology Dose management: An urgent need
www.expresshealthcare.in FEBRUARY 2014, `50
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CONTENTS MARKET Vol 8. No 2, FEBRUARY 2014
Chairman of the Board Viveck Goenka Editor Viveka Roychowdhury*
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LVPEI LAUNCHES 100TH PRIMARY CENTRE
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GE ACQUIRES OF STRATEGIC ASSETS FROM THERMO FISHER SCIENTIFIC
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FORTIS LAUNCHES MULTI SUPER-SPECIALITY HOSPITAL IN LUDHIANA
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VIRTUS HEALTH SERVICES FORAYS INTO INDIAN HEALTHCARE SERVICES MARKET
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PD HINDUJA HOSPITAL & MEDICAL RESEARCH CENTRE HOST REDX: MIT INDIA HEALTH TECH 2014
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BD DIAGNOSTIC SYSTEMS INTRODUCES MEET THE GURU SERIES FOR ITS CUSTOMERS
Assistant Editor Neelam M Kachhap (Bangalore) Mumbai Sachin Jagdale Usha Sharma Raelene Kambli Lakshmipriya Nair Sanjiv Das Delhi Shalini Gupta DESIGN National Art Director Bivash Barua Deputy Art Director Surajit Patro Chief Designer Pravin Temble Senior Graphic Designer Rushikesh Konka Layout Vivek Chitrakar Photo Editor Sandeep Patil
mHEALTH: THE NEXTGAME CHANGER With potential applications which could enhance the value proposition for all players in the ecosystem i.e.from improving productivityin hospitals,creating opportunities for pharmaceutical companies to differentiate and adding functionalityto medical technologyofferings, mHealth could be a potential game changer.It is time to take action urge Bart Janssens,Partner and Director,BCG and Rahul Guha, Principal,BCG | P49
TRADE & TRENDS
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DEXACT-F: DESTROYING DIARRHOEA
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BLUESTREAM@ HBII 2013
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MEDISYSTEMS OPD PATIENTCALL AND QUEUE MANAGEMENT SYSTEMS
MARKETING Deputy General Manager
KNOWLEDGE
RADIOLOGY
Harit Mohanty Assistant Manager
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CHANGING PARADIGM IN CANCER CARE
45 47
A MATTER OF INHERITANCE
Kunal Gaurav PRODUCTION General Manager B R Tipnis Manager Bhadresh Valia Sr. ExecutiveScheduling & Coordination Rohan Thakkar CIRCULATION Circulation Team Mohan Varadkar
DRUG RESISTANCE TESTING: MAKING ANTI RETROVIRAL THERAPY MORE EFFICACIOUS
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DOSE MANAGEMENT: AN URGENT NEED
LIFE
58
MY TRYST IN RURAL INDIA
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IT@HEALTHCARE
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CLOUD POWER FOR HEALTHCARE
STRATEGY
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MAHARASHTRAS ELDERLY SHOW HIGHER LEVELS OF ABUSE: UNFPA REPORT
Express Healthcare Reg. No. MH/MR/SOUTH-252/2013-15 RNI Regn. No.MAHENG/2007/22045. Printed for the proprietors, The Indian Express Limited by Ms. Vaidehi Thakar at The Indian Express Press, Plot No. EL-208, TTC Industrial Area, Mahape, Navi Mumbai - 400710 and Published from Express Towers, 2nd Floor, Nariman Point, Mumbai - 400021. (Editorial & Administrative Offices: Express Towers, 1st Floor, Nariman Point, Mumbai - 400021) *Responsible for selection of newsunder the PRB Act.Copyright @ 2011 The Indian Express Ltd. All rights reserved throughout the world. Reproduction in any manner, electronic or otherwise, in whole or in part, without prior written permission is prohibited.
EDITOR’S NOTE
A ‘healthy’ bet ?
T
he healthcare sector has been one of the few to attract decent investments in the past year and going by the annual predictions put out by most analysts, market sentiment should pick up this year too. Express Healthcare's February issue thus trains the spotlight on finance. Our cover story (pages 22-27) analyses PE funding activity over the past few years and gets industry experts to predict some opportunities for investors in the year ahead. But is this more hype and hope and the fact that healthcare seems a safer bet than other sectors? As one set of numbers proves, while 2013 did see decent PE fund flows, investors are still risk averse. While the number of deals might have increased, deal value has decreased. So we still have to wait for this story to play out. In terms of financing options available to the consumer/patient, health insurance and patient financing are the mainstays. But experts from FICCI analyse that health insurance suffers a trust deficit and many kinks in the insurance distribution need to be solved (page 31). At the bottom of the pyramid, the patient financing model is slowly picking up traction, thanks to initiatives like Arogya Finance , according to its co-founder (interview on page 37). There are also welcome signs that deserving healthcare entrepreneurs are finally getting noticed and bagging the funds to scale up their ventures. For instance, social venture fund Aavishkaar Venture Management has chosen to give Series A funding to Mera Doctor, which has a unique model of taking healthcare to the rural areas through prepaid mobile cards. Startups generally choose to address niche needs which existing players ignore; either because they deem it too small or too time consuming. But these pioneers sometimes find the equivalent of a vein of gold. For example, haven’t most of us experienced the exasperating experience of parenting our parents, when it comes to their healthcare? The dilemma is: how do we monitor without inter-
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Startups generally choose to address niche needs which existing players ignore; either because theydeem it too small or too time consuming.But these pioneers sometimes find the equivalent of a vein of gold
fering? Especially if they insist on staying close to their roots, living continents away, alone with their ailments. NRIs living in the US have seen a continuum of care in geriatrics, chronic care and post operative cases but there are few examples of the same in India. Which is why the $3 billion dollar home care segment in India attracted the interest of serial entrepreneur husband-wife duo Ganesh K and Meena Ganesh. Scanning the landscape, they found an interesting model in a venture set up by two young NRI entrepreneurs: Karan Aneja and Zachary Jones. Replicating the US home care system in India might seem like a recipe for failure but they were canny enough to quickly “pivot their model”, as Ganesh puts it and this convinced him to come on board. Portea Medical recently bagged further funding and 2014 will be a year of “scorching” growth. (pages: 34-36). While state governments do try to plug the gaps, they add to the problem by announcing populist measures. For instance, private and charitable hospitals in Karnataka are protesting that the tariffs under the Yeshasvini and Vajpayee Arogyasri schemes are not viable, especially since the government intends to cover nearly the entire state population under either of the schemes. (pages 38-39) The urban-rural contrast continues. The lead story in the Knowledge section (pages 40-44) analyses cancer care in India and finds that in the rural areas it is almost non-existent. In the urban areas, while state-of-the-art technology is available, unethical practices ranging from unnecessary surgeries and chemotherapy, compounded by dicey histopath reports are literally a lethal combination. Which is why the next issue of Express Healthcare will focus on the tremendous manpower issues threatening to stall future growth in India's healthcare sector. Do tune in for more. VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com
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LETTERS QUOTE UNQUOTE
VERY PERTINENT TOPIC The complex scenario of healthcare in India has been presented very well in the article titled, “BSc Community Health vs MBBS in India's rural healthcare system” published in the EH issue of Januray 2014. As rightly pointed out, "in a running kleptocracy, morbid individualism and crony capitalism" these characteristics are guiding all healthcare policies. The entire Indian population is suffering from micro metastasis of primary cancer of corruption. Redistribution of doctors and specialists is the need of the hour than opening new medical colleges.
Ghulam Nabi Azad
Dr Rakesh Parashar drrakeshparashar81@gmail.com
HEAD OFFICE Express Healthcare Kunal Gaurav The Indian Express Ltd, 1st Floor, Express Towers, Nariman Point, Mumbai-400021. India Tel: 67440519/502 Fax: 022-22885831 Mobile: 09821089213 E-mail: kunal.gaurav@expressindia.com kunalexpressindia@gmail.com Branch Offices NEW DELHI Ambuj Kumar The Indian Express Limited, Basement, Express Building, 9 & 10 Bahadur Shah Zafar Marg, New Delhi, 110 002 Direct Line: 011-2346 5727 Board Line: 011-2370 2100-107 Ext-727 Mobile: 09999070900 E-mail: ambuj.kumar@expressindia.com Our Associate: Dinesh Sharma Mobile: 09810264368 E-mail: 4pdesigno@gmail.com CHENNAI Dr Raghu Pillai
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“In 2009 India accounted for over half of the global polio burden and today (13th Jan 2014) we have completed three years without a single case of wild polio. This monumental milestone was possible due to unwavering political will at the highest level, commitment of adequate financial resources, technological innovation... and the tireless efforts of millions of workers including more than 23 lakh (2.3 million) vaccinators” Union Health Minister
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MARKET NEWS
LVPEI launches 100 primary centre th
It has 100 primary care vision centres and 11 secondary care service centres LV PRASAD Eye Institute (LVPEI) launched its 100th vision centre for primary care as part of its programme providing universal eye health coverage to remote and underserved areas. The institute is expanding its network of permanent primary eye care facilities in rural India with this centre at Araku village, a predominantly tribal area in Visakhapatnam district. To serve the under privileged communities and reach the unreached segment in the eye health value chain, The Gullapalli Pratibha Rao International Centre for Advancement of Rural Eye Care (GPR ICARE), the public health component of LVPEI, has established a network of Vision Centres (primary centres) linked to secondary centres across rural and remote rural locations in
ICARE aims to reach out to the communities to deliver affordable and qualitative eye healthcare services, and conduct systematic research for the improvement and advancement of eye healthcare services. The idea is that any village should be able to walk out the street and get their eyes screened free of cost Andhra Pradesh. The institute’s latest secondary centre was launched in Bellary, in the neighbouring state of Karnataka, and there are projects underway to expand the network into Odisha as well, with three projects underway – Rajgangapur, Berhampur and Rayagada. LVPEI has a ‘pyramidal model of eye care de-
livery’ from the primary to advanced tertiary levels. ICARE aims to reach out to the communities to deliver affordable and qualitative eye healthcare services, and conduct systematic research for the improvement and advancement of eye healthcare services. The idea is that any village should be able to walk
out the street and get their eyes screened free of cost. This is assured at both provisions of care as well as to develop a habit of seeking health care in these communities. Dr Gullapalli N Rao, Founder and Chair – LV Prasad Eye Institute said, “Complemented by dynamic governance, motivated teams
and sophisticated technology, ICARE aspires to evolve into a highly efficient eye health care service delivery component for LVPEI as we step into another year with a success driven manifesto given for the next 25 years. In the seventeen years since its inception, our community eye health and outreach team has gained immense experience in community service delivery by the means of its capable staff who are trained to patiently listen to the community eye health needs before they work to restore sight for many.” With the Araku centre, LVPEI’s network of community eye care services now comprises 100 primary care vision centres and 11 secondary care service centres. . EH News Bureau
Quest Diagnostics India extends access to cancer testing services across India It now offers clinical laboratory testing services broadly to patients and oncologists in all major Indian cities QUEST DIAGNOSTICS, provider of diagnostic information and services, announced that hospitals, physicians and patients across India will now be able to broadly access its cancer diagnostic testing services. Quest Diagnostics India has expanded the ability to access cancer diagnostics services following a successful pilot of the introduction of these services to patients and oncologists in New Delhi. Now, the
company has expanded its marketing, service and logistics operation in order to provide cancer testing services to 25 metros and Tier-I cities across the country, including Delhi, Mumbai, Bangalore, Kolkata, Hyderabad, Ahmedabad, Kochi. Quest Diagnostics, headquartered in the US, provides services in India through its full service laboratory in Gurgaon, India and esoteric testing laboratories based in
the US. Recently introduced services include testing to help detect haematological, or blood, cancers using next-generation sequencing, a technique that identifies mutations and variants in an individual’s DNA or genome. Another service is a test that assesses the ROS1 gene mutation status to help determine a patient’s response to a certain lung cancer therapy. The company also provides testing for breast, cervi-
cal, prostate, soft tissue, bone and several other cancers. “The incidence of cancer cases is on the rise in India. Today, patients and the treating physician need accurate and reliable diagnostic insights in order to make the right treatment decision,” said Mukul Bagga, MD, Quest Diagnostics India.“The most exciting and important advances in cancer diagnostics are occurring in the field of genomics and molecular testing.
Yet, technology and expertise constraints can limit access by clinicians and patients in India. Clinicians and patients in major cities of India can now access the international experience and clinical operations of Quest Diagnostics, the world leader in diagnostic information services, including cancer testing, in India and the US,” he added. EH News Bureau
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MARKET
GE acquires of strategic assets from Thermo Fisher Scientific GE to acquire cell culture media and sera, gene modulation and magnetic beads businesses GE AND Thermo Fisher Scientific have entered into an agreement for GE Healthcare to acquire Thermo Fisher’s HyClone cell culture media and sera, and gene modulation and magnetic beads businesses for approximately $1.06 billion. The acquisition will allow GE to expand its offering of technologies for the discovery and manufacturing of innovative new medicines, vaccines and diagnostics in its life sciences business. The complementary product offerings and strong strategic fit of the acquired businesses will enable GE Healthcare to expand and accelerate the development of innovative ‘end-to-end’ technologies for cell biology research, cell therapy and for the manufacture of innovative biological medicines and vaccines. The acquisition is
consistent with GE’s strategy to invest in high-technology, innovative businesses that deliver strong top-line growth and expanded margins. GE’s acquisition of the businesses, which is subject to regulatory approvals, is anticipated to close in the first part of 2014. John Dineen, President and CEO, GE Healthcare said, “Life Sciences is one of our strongest and fastestgrowing business areas, driven by the world’s demand for improved diagnostics and new, safer medicines. Combining GE’s engineering expertise with our capabilities in life sciences is already bringing great benefits to industry, research and patients. This deal makes a good business even better and will help us realise our vision of bringing better healthcare to more
people at lower cost.” GE Healthcare will also acquire Thermo Fisher’s gene modulation technologies, which will strengthen GE’s technologies for drug discovery research, and the SeraMag magnetic beads product line, which extends GE’s existing technologies in protein analysis and medical diagnostics. Kieran Murphy, President and CEO, GE Healthcare’s Life Sciences division said, “We look forward to the HyClone cell culture and other businesses joining the GE family. They are a great fit with our key areas of focus, and bring exciting new technologies, enhanced manufacturing capabilities as well as a great group of talented people to help grow our business.” “In addition to providing
us with new approaches to drug discovery and biomedical research,” Murphy said, “this acquisition is a significant step forward for our customers in biopharmaceutical manufacturing. They will benefit immediately from an expanded range of ‘start-tofinish’ technologies that will help them improve product yields and reduce time-tomarket. By expanding our production facilities to three continents, we will be able to offer the biopharmaceutical industry greater confidence in the security of supply of cell culture media and sera, a key part of their production process.” The three acquired businesses generated combined annual revenues of approximately $250 million in 2013. EH News Bureau
Merit Medical Systems opens office in Bangalore Plans to invest in distribution, clinical trials, R&D and marketing activities US-BASED, MERIT Medical Systems has started its India operations in Bangalore. Joe Wright, President said, “We are happy to share that the India subsidiary office is being opened in Bangalore. The key reason for our entry into the Indian market now with direct presence is due to the large need that has been generated for our products over the last
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three to five years.” “Over the next five to 10 years we have elaborate plans to invest in sales and marketing initiatives and set up basic infrastructure for product assembly and sterilisation,” Wright added. “Merit Medicals enjoys a great reputation for its world class medical products across countries and we see India as a
strategic place to be present today. Even though we have been selling our products through distributors here last three to four years, we feel our presence is needed more now to be able to reach out to our direct target groups, the doctors and hospitals,” said Ashwin Benegal, President; India & SAARC region. “We would like that more and more Indian doctors know
of our products and thus recommend the same,” he added. “Bangalore is India’s IT hub with multinationals stationed here that have big R&D facilities. We look forward to working with them in the near future for our products, that’s one of the reasons for choosing to base our India office in Bangalore,” added Benegal. EH News Bureau
Narayana Health City launches ‘Senior Citizen’s Privilege Card’ NARAYANA HEALTH City has launched ‘NH Senior Citizen’s Privilege Card’ in association with Dignity Foundation. The privilege card was launched by Dr Devi Shetty, Chairman – Narayana Health and Kannada actor Sundar Raj. The event witnessed presence of over 300 senior citizens from Bangalore. The Privilege card entitles them to avail discounts on treatment, get regular counselling and health check-ups done at Narayana Health City. A two-day interactive patient education programme titled ‘Frontiers in Medicine’ by eminent doctors of NH was also organised. Speaking about the launch, Dr Shetty said, “Economic, social and demographic changes today are affecting the elderly people. They require regular check-ups and proper monitoring of health and diet.” Commenting on the association with Dignity Foundation, he said, “Dignity Foundation has been working for the cause of the elderly and we are happy to be associated with them.” Reportedly, the privilege card will enable senior citizens in managing their healthcare requirements by offering OPD consultation, diagnostic tests and radiology services with regular health check-up. The launch of this card is expected to benefit around 3,000 to 4,000 senior citizens in Bangalore in the first year. The privilege card programme was also launched in Jamshedpur, Jaipur and Kolkata which will cater to over 3000 senior citizens. EH News Bureau
MARKET
Fortis launches multi super-specialityhospital in Ludhiana To bridge need gap for healthcare in the State as 260 bed facility opens for service FORTIS HEALTHCARE launched its 260-bed greenfield hospital in Ludhiana. Sukhbir Singh Badal, Deputy CM, Punjab inaugurated the hospital. Dedicating the facility to the service of patients, Badal, said, “We are happy to see Fortis strengthening its commitment to Punjab by bringing world class infrastructure and medical care to Ludhiana.” At a separate ceremony, he also laid the foundation stone for Fortis La Femme, yet another green-field facility that will come up in the city by 2016. Located on the Mall Road, this will be a 100-bed centre for women, dedicated to meet their medical needs through various stages of their life. Fortis has committed significant investments in creating capacity of over 1,000 beds in Punjab. These include the newly commissioned hospital in Ludhiana; existing facilities in Mohali and Amritsar; the soon to be launched Fortis Cancer Institute in Mohali and the greenfield project, Fortis La Femme in Ludhiana. While the new multispecialty hospital caters to all disease profiles, it has a special focus on those that are endemic to the region and are underserved. Fortis Ludhiana has set up an advanced Centre of Excellence (COE) in oncology (medical, surgical and radiation therapy). A multi-disciplinary Tumour Board of experienced super-specialists, a dedicated Day Care ward for Medical Chemotherapy patients, Ludhiana’s only Time-of-Flight PET/CT scanner and 24x7 Critical Care services for critically ill cancer patients are amongst the unique offerings that set this Centre apart from existing facilities in the region. Other Centres of Excellence (COE’s) at Fortis Ludhiana include orthopaedics, emergency, trauma and critical care and cardiology. Additional COE’s in the near future will include renal sciences and neuro
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February 2014
sciences. The hospital will also offer 24x7 emergency services. Close
to 40 per cent of its beds are dedicated to intensive care units (ICUs) to handle complex
and critical cases. Fortis Ludhiana is among the few facilities in Punjab to offer comprehen-
sive cancer treatment. EH News Bureau
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MARKET
Virtus Health Services forays into Indian healthcare services market Plans to launch oral cancer screening, to address gaps in early stage diagnostic technology VIRTUS HEALTH Services India (VHSI) announced its entry into the Indian healthcare services market. In its first year of operations, VHSI plans to introduce oral cancer screening and digitally supported diagnostic second opinion. Sunil Ikhe, Operations Director & Country Head, VHSI said, “India’s healthcare services demand is grossly underserviced, considering the international standards. They can be matched, given various ad-
vances in technology. These technologies, that are now standard in advance countries globally, have been proven to create higher efficiencies and promptness of delivery across the patient support cycle, right from screening for an early detection to diagnosis, enabling long-term disease or disability management and treatment. VHSI uniquely aims to bridge these gaps by introducing world class cutting edge technology-driven health care products and serv-
ices to India. The healthcare industry in India is estimated to grow to $280 billion by 2020 as per the Equentis Capital Report. The high growth in demand for health care services is being driven by higher disposable income, rapid increase in lifestyle diseases, greater consumer health consciousness and growth in medical tourism and a changing regulatory landscape. As a company, we are committed to empower Indian population
with access to the best healthcare technologies to enhance their ability to make responsible choices for personal health and healthy life.” Ikhe further added, “In our first year of operations in India, cancer screening will be a key focus. Our first initiative in this area focuses on screening for an early oral cancer detection, given that India is the world’s capital for oral cancer. The National Institute of Health and Family Welfare (NIHFW) re-
JSWFoundation signs MoU with Maharashtra government Aims to tackle malnutrition among women and children of Thane district JSW FOUNDATION, the social development division of the JSW Group, signed a memorandum of understanding (MoU) with the Department of Women and Child Development (WCD) under the Government of Maharashtra (GoM) to improve the status of nutrition among mothers (both pregnant and lactating) and children in Thane district of Maharashtra. Sangita Jindal, Chairperson, JSW Foundation and Ujjwal Uke, IAS, Principal Secretary, WCD, GoM have signed the MoU document in the presence of Varsha Gaikwad, Minister, WCD, GoM in Mumbai. The MoU is to address the critical issue of malnutrition in Thane district which has remained as a major challenge in the last few years. The key goal of this project is to track every mother (both pregnant and lactating) and child below the age of six years and ensure both the availability and accessibility of the essential services to them such as immunisation; supplementary nu-
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trition; other basic health services; and key massages on healthy practices at community level. This aims at facilitating the reduction in the cases of low birth weight (LBW) babies which contribute significantly to the cases of severe and moderate malnutrition. The Minister said, “We are optimistic with advanced technology and resources at our disposal. We are working on ensuring efficient health services, clean water supply, sanitation, immunisation, and timely referrals to address the issue. I am happy that Sangita Jindal and her team from JSW Foundation have joined us in this mission against malnutrition in Thane, I am sure this effort will set example for many others to come forward and make an impact.” Commenting on this social initiative, Jindal said, “In partnership with GoM, we are committed towards tackling malnutrition in Thane district. The high rate of infant and child mortality still remains a grave area of
concern in India. I am sure that this project will help each mother and child in Thane district to grow healthy and contribute towards the development of the nation. I wish this project all the success.” Uke said, “We are committed to reduce the rate of malnutrition among women and children in Thane district. Over the last few weeks, we have been working on the processes where the ‘corporates’ also join hands with GoM in addressing the issue of malnourishment.” A six-year phase wise scaling up strategy is planned where two talukas of Thane district will be taken in the first year, six in the second year and the remaining all in third year. In the subsequent years, the focus shall remain on establishing and sustaining the project in all the Talukas of Thane district. Periodic joint reviews shall continue to strengthen the execution of the project. EH News Bureau
ports that India accounts for 86 per cent of all oral cancer cases globally. While this is one of the easier to treated forms of cancer and not fatal if detected early, about 60 pr cent of cases are diagnosed at highly advanced stages due to low awareness and availability of supporting diagnostic technology. At this time over 23 per cent of all recorded cancer deaths in India are from oral cancer.” EH News Bureau
HCG wins Golden PeacockAward for Innovation Management Nikhil Kumar, Governor of Kerala presented the award HEALTHCARE GLOBAL (HCG) Enterprises has received the Golden Peacock Innovation Management Award 2013. It was recently presented by Nikhil Kumar, Governor of Kerala in Bangalore. HCG is the reportedly the first hospital to win the Golden Peacock Award for Innovation Management. The awards were received by Dr BS Ajaikumar, Chairman, HCG Group and Dinesh Madhavan, Director, Healthcare Services, HCG Group. On receiving the award, they said, “We are honoured to receive this award, as this is a symbol of excellence in redefining cancer care in India, through accessibility to technology, expertise and innovation.” Golden Peacock Awards, instituted by the Institute of Directors, India, are now regarded as a benchmark of Corporate Excellence worldwide. The entries to the award are received from over 25 countries. Justice PN Bhagwati, former Chief Justice of India and acting Chairman, UN Human Rights Committee, is the Chairman of the Golden Peacock Awards Committee. EH News Bureau
MARKET POST EVENTS
PD Hinduja Hospital & Medical Research Centre host Redx: MITIndia Health Tech 2014 The event was conducted in association with IIT-Bombay, WeSchool to create a platform for innovation for the youth of India ON JANUARY 26 2014, PD Hinduja Hospital & Medical Research Centre hosted ‘Redx: MIT India Health Tech 2014, Rethinking Diagnostics’ workshop in association with IIT Bombay, WeSchool (Welingkar Institute of Management Development and Research) and Massachusetts Institute of Technology (MIT), US. This event aimed to create a platform for innovation and opportunity for the youth of India. The event is the beginning of a week-long workshop being held at IIT Bombay and at WeSchool with MIT delegates. During this event, doctors from PD Hinduja Hospital presented their innovative ideas and expectations to the young and entrepreneurial students from IIT-B, WeSchool and MIT. Inspired by the doctors wish list, PD Hinduja Hospital’s Executive Trustee Vinoo Hinduja announced an ‘Innovation Lab’ where the youth of India would come together to develop economical medical and diagnostics equipment/facilities for the people of India. This innovation lab will be ‘By India; Of India and For India’ and Indian institutes like IIT-B and WeSchool will join hands Continued on Page 20
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MARKET
BD Diagnostic Systems introduces Meet the Guru Series for its customers Mumbai chapter coincides with the launch of BD BACTEC FX 40 in India
BD DIAGNOSTIC Systems kickstarted its annual Meet the Guru knowledge series with a discussion on New Paradigm in Sepsis Management for customers and key opinion leaders across India. The annual series will be a knowledge-sharing initiative with discussions on path breaking developments in the field of diagnostics. In an attempt towards increasing awareness of new diagnostic solutions, the seminar included a presentation from Dr Patrick R Murray, Worldwide Director, Scientific Affairs, BD Diagnostics. Microbiologists and laboratory heads from well reputed institutions attended the Meet the Guru Knowledge Series. One of the critical concerns and declared medical emergency worldwide is Sepsis. The series had deliberations on the significance of blood cultures that are clinically critical and recommended for faster and superior diagnosis for sepsis. The audience reiterated how important it is now than ever for healthcare professionals to accurately and rapidly detect sepsis as early as possible to effectively treat patients with the appropriate, targeted antibiotics. The highlight of the evening was the launch of BD BACTEC FX 40 Blood Culture System for the detection of bloodstream infections. This new system improves clinical decision-making and laboratory workflow by markedly improving blood culturing practices with realtime, remotely accessible, actionable results that can enhance patient care. The team showcased the journey of BD’s 40 years of blood culturing expertise
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with more than 10,000 blood culture instruments installed worldwide. “This new addition to the FX family of BD Diagnostics will further enhance clinical decision-making and laboratory workflow by its innovative technology & design,” said Punit Kohli, Business Director, BD Diagnostics, India. With a compact and versatile system design, future upgradability and latest technology, the BD BACTEC FX40 Blood Culture system is modular and affordablypriced system that offers customers to expand their workload over time through the modular capability of the instrument. Meet the Guru series will continue to bring experts from around the world in the field of diagnostics to share their experiences with key stakeholders so as to bring these important innovations to the market and help all people live healthy lives.
Continued from Page 19
PD Hinduja... with PD Hinduja Hospital to create this platform with MIT being facilitator in this innovation. PD Hinduja Hospital looks forward to many more collaborations with domestic and international institutes for its innovation lab. Announcing the new innovation lab, Hinduja said, “The deficiencies in healthcare industry are a fertile land waiting for the youth of India to plant it seeds of innovation to reap the fruits of success. I urge you all to embrace transformation so as to be able to address some of patient care issues.” Joy Chakraborty, COO, PD Hinduja Hospital said, “India needs innovation to make healthcare accessible and affordable. Our endeavour is a small step towards the need of the health sector. One of our principles ‘Partnership for Growth’ is followed in different ways in our practices and this Innovation Lab will stand for a partnership with credible and similar minded partners across the globe to achieve our objectives.” Dr Sanjay Agarwala, Director – Professional Services said, “This is a forum where all participating students from IIT, MIT etc could interact with doctors of Hinduja Hospital so that they could innovate and find solutions through ideation, leading to a product that would help the same doctors across the world in diagnosis.” The PD Hinduja Hospital has always been in the forefront of technology. Dr Camilla Rodrigues, Consultant Microbiologist and Chairperson Infection Control Committee said, “One of the thrust areas has been in tuberculosis diagnostics. The hospital is well known as a pioneer in this field. The government of India has recently recognised our lab for second line testing of drug resistant tuberculosis. This innovation lab initiative that will also focus on TB is certainly a step in the right direction to the laudable goal of a TB free India.”
EVENT BRIEF FEBRUARY 1
Green lean six sigma certification training for healthcare
GREEN LEAN SIX SIGMA CERTIFICATION TRAINING FOR HEALTHCARE Date: February 1-9, 2014 Venue: New Delhi Organisers: AUM MEDITEC Participant profile: Hospital CEOs/ COOs, management executives, hospital operations managers, quality in charge, MHA/ PGDHA/ MBA (Hcm) final year students Summary: This programme module shall focus on Six Sigma methodologies, lean concepts in healthcare systems and service delivery. Contact Meeta Ruparel Email:
meeta@meditecindia.com/ meetaruparel@hotmail.com
CLINICAL SKILLS COMPETITION Date: February 8, 2014 Venue: Calcutta National Medical College Organiser: Glocal Healthcare Summary: The event, named Litmus Test, is the first-of-its-kind Open Clinical Skills Challenge for medical students. The contest, designed to test diagnostic skills as well as knowledge of standard treatment protocols, drug indications, contraindications, interactions and adverse reactions, will feature more than 100 participants from leading medical institutions
8
Clinical Skills Competition
in Kolkata and rest of Bengal. The event will provide an avenue for medical students to test their clinical knowledge in a safe and simulated environment. The most innovative part of this event will be the use of a lifeline in the form of LitmusDx. The inaugural event of this quiz series will be held on February 8 at Calcutta National Medical College (CNMC) on the occasion of their 63rd reunion. Glocal Healthcare will also have a booth at the reunion from February 7-9, 2014 at the CNMC campus. Contact Chayan Chatterjee Director, MedTech Glocal Healthcare Systems Private Limited,
17
2nd National Biomedical Engineering Training Program
3B-207, Ecospace Business Park, Action Area-II, New Town, Rajarhat, Kolkata 700156 Cell: (+91) 8697.711.939 www.ghspl.com
2ND NATIONAL BIOMEDICAL ENGINEERING TRAINING PROGRAM Date: February 17-23 , 2014 Venue: NH Healthcity, Bangalore Organisers: TriMedx and Narayana Health Summary: The 2nd National Biomedical Engineering Training Program aims to deliver hands on, practical biomedical engineering training to all healthcare providers, enabling greater
safety, reliability and quality of patient care through skilled healthcare technology management. It also seeks to equip healthcare providers with a proficient biomedical engineering workforce, with special focus on Tier two and three cities in India. Participants profile: Healthcare Technologists – working biomedical/ clinical engineers, technicians/professionals dealing with medical devices Contact Subhashree Rajan, Program Lead, TriMedx India Email: training@trimedx.co.in Online: www.trimedx.com/ india-nbe-training
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February 2014
cover ) PE FUNDING:
FUELLING GROWTH IN HEALTHCARE An analysis of PE funding activity in Indian healthcare and the opportunities for investors in 2014 BY RAELENE KAMBLI
Inside 22
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28 | FINANCIAL 31 | INSURE-ING PERFORMANCE OF UNIVERSAL MAJOR INDIAN HOSPITALS COVER FOR INDIA
32 | MAKING HEALTHCARE HEALTHY
(
FOCUS:FINANCE
$1.2 BILLION PE& VC investments in Indian healthcare in 2013
I N T E R V I E W S
34 | K GANESH, Chairman, Portea Medical
W I T H
37 | DHEERAJ BATRA, Co-Founder and VP Business Development, Arogya Finance
38 | DR PRASHANT KATAKOL, Co-ordinator, Karnataka Private Hospitals Forum EXPRESS HEALTHCARE
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February 2014
cover )
L
ast year, India’s economic turmoil, did not bode well for private equity (PE) investments flowing into various Indian industrial sectors. The depreciating value of rupee, coupled with the dipped growth rate, led to increased uncertainty and negative sentiments about India among global investors. According to an analysis report published by Venture Intelligence, a research service focused on private company financials, transactions and valuations, in 2013 PE investment numbers, were down by 18.5 per cent compared to the $9.2 billion (across 484 deals) invested in 2012. However, the healthcare and pharma sectors were still attractive to investors. “PE funding is giving Indian healthcare the much-needed boost and would help increase the beds-to-people ratio, making healthcare more affordable and accessible. It not only brings in money, but also offers high-quality corporate governance and strategic guidance to a company for further gro0wth,” says Dr E Saneesh, Research Analyst, Business & Financial Services - Healthcare, Frost & Sullivan. Examining the PE activities in healthcare and monitoring investors’ approach, Ashish Bansal, Director, Transaction Services, Healthcare Practice, KPMG opines, “We are seeing a set of very discerning PE players in the sector, who are
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of addressing these contradictions and coming up with a mutually acceptable and beneficial formula.”
Recap 2013
In 2013, Indian healthcare remained an attractive investment destination for global PE and VC investors, with 73 deals totalling about $1.2 billion not passive in their approach and actually spend a lot of time in operations, execute new initiatives and bring in new ideas from their healthcare investments outside India. Most of these funds have industry experts in-house or on their panel and they get them fully involved in their portfolio companies. An area I think PEs add immense value is in evaluating growth opportunities for their healthcare investee companies – greenfield or brownfield, and not just from a financial viability perspective but also from a long term strategy point of view. Plus PEs do inculcate financial discipline, cost efficiency (not reduction) measures and ROI driven decision making. So it’s not just ac-
cess to financial capital which is in store for healthcare players if they partner with the right PE fund – it’s a win-win for the healthcare industry”. Adding to this, Chandra Sekhar, Executive Director (Marketing), Global Hospitals, elaborates, “PE funding is changing the way private healthcare is growing in the country. Both large chains and standalone entities have benefitted from PE funding and this has fuelled expansion and growth. The growth is also now moving into tier II locations. Rural models essentially focussed on primary and secondary care, standalone dialysis centres, day care and urban primary care, speciality care such as cosmetic, eye, dental or
single super speciality such as kidney, heart etc., are also benefiting from this access to PE funding besides large format tertiary care hospitals. However, intrinsically healthcare, especially tertiary care, is a long gestation, capital intensive and manpower intensive industry and the gains are good in the long term, though windfalls may not be expected in terms of returns. Returns are steady and peak in five to seven year timeframe, and in some cases, longer periods. This uniqueness of the industry’s long gestation vs the finite life of PE funds as well as their expectations of high returns in the short term is an area which is evolving. Both sides are trying to find a meaningful way
In the year 2013, while the other sectors were trying to revive PE investments, the healthcare sector in India proved to be a defensive bet for PE investors. Investments in healthcare bucked up PE funding activity in the last financial year despite the overall slowdown in deal making within the country. Growth opportunities for the sector were due to the increasing demand for quality healthcare at affordable rates as well as growing number of tertiary care hospitals and single speciality care centres in metros, tier II and tier III cities. Moreover, the healthcare is a priority service industry which is rarely affected by economy downturn and investors can easily capitalise on the money invested. As reported by research analysts, total foreign investments within the Indian healthcare sector have tripled in the past three years. In 2013 too, Indian healthcare remained an attractive investment destination for global PE and VC investors, with 73 deals totalling about $1.2 billion, up from just over $300 million in 2011, according to data from VCCEdge. This amounts to 10 per cent of all PE/VC money that flowed into India in 2013. According to Bansal, “As with the last five years, PE interest in the healthcare segment continued to be strong in 2013. Except in 2009, the healthcare sector has seen PE investments of more than
(
FOCUS: FINANCE
We should watch out for some interesting PE exits. There have been big ticket investments made by PE players like GIC, Advent, TA Associates, Warburg, Olympus Capital etc and their eventual exits will make for some exciting deal activity in the coming few years Ashish Bansal Director, Transaction Services, Healthcare Practice, KPMG
$300 million annually over the last five years, touching a high of more than $800 million in 2012. In 2013, PE investments crossed $700 million and were across different verticals – tertiary care hospitals, medical devices, diagnostics and single speciality chains. “I believe the $70 billion Indian healthcare industry is at an inflection point. This consumercentric sector is posting double digit growth and offers attractive investment opportunities as well as a decent exit to PE investors without any regulatory bottlenecks. Investors, especially from the US, remain bullish, with prominent hospital chains and super-speciality centres getting significant funding. Healthcare infrastructure is still thinly spread across India, with a very low per capita spend and just about 10 beds for 10,000 people. It thus offers immense scope for future growth and is not prone to a slow-down,” adds Suresh Soni, Chairman and CEO, Nova Medical Centers. Additionally, a large num-
ber of smaller sized deals happened in 2013, especially in alternative formats like primary care, dental care and mother and child among others. Sectors like single speciality care centres, diagnostics and mid-sized hospital chains saw most of the action. Pharma and lifesciences, on the other hand, again saw a different trend with lower number of transactions but of higher value, partly due to the $200 million investment by KKR in drug maker Gland Pharma. While most of the analysts and industry experts felt that the healthcare sector was a promising bet for investors in 2013, Dr Saneesh is of a different opinion. He feels that in 2013 fund flows decreased as investors lost their appetite for risk. He says, “The year 2013 was not a great year for PE investments and VC funding in the Indian healthcare sector. The sector witnessed a decline in both deal volume and deal value compared to 2012. There was a 46 per cent increase in deal volume
between 2011 and 2012; however there was a nine per cent decrease in deal volume between 2012 and 2013. Moreover, the sector witnessed a sharp decrease in deal value to almost 50 per cent between 2012 and 2013. An analysis reveals that most of the deals happened in Q1 and the least number of deals happened in Q4, however in terms of deal value, the deals in Q4 had higher average deal value.” He further states that the average deal value of top ten deals in 2013 was $33.0 million which is significantly low compared to the average value of 2012 which was $75.9 million. Well as the industry battle with difference in opinion, there were some interesting deals that pumped in considerable amount of funds into the healthcare and pharma sectors.
Deal making in 2013 The sector saw a fair amount of investments in unique healthcare service models last year. The year also saw traction in the
medical device and pharma segments. In both these segments the underlying fundamentals remain strong in spite of the regulatory tugof-war faced by the sectors. Some significant PE deals this year were KKR’s investment in Gland Pharma; Carlyle buying out Avenue Capital while also putting some fresh money in Global Health, which runs Medanta; Bain Capital buying Blackstone’s stake in Emcure Pharma and IFC investing in Fortis Healthcare.
PE exits in 2013 2013 also saw some good PE exits that boosted the investors’ confidence. “Though there was no great increase in the overall PE exit climate for 2013 in India, the PE backed exits increased in healthcare sector. The increase in exits implies that the investor was able to realise the value created over the period of their ownership. This will attract the investors to invest in healthcare sector,” explains Dr Saneesh speaking about the PE exits scenario for last
Though there was no great increase in the overall PE exit climate for 2013 in India, the PE backed exits increased in healthcare sector. The increase in exits implies that the investor was able to realise the value created over the period of their ownership Dr E Saneesh Research Analyst, Business & Financial Services Healthcare, Frost & Sullivan
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cover ) MAJOR DEALS ABOVE $15 MILLION
The average deal size in the sector is expected to increase going forward as funds with larger ticket size are looking at the healthcare space. Going forward we may see buyouts of companies in the healthcare space by large funds. Rana Mehta Executive Director- Leader Healthcare, PwC
year. He goes on to say, “The sector witnessed an increase in exits during 2013 as compared to 2012. In 2012, there were only three exits but 2013 witnessed around nine exits, of which two transactions are yet to be closed. The two transactions include IPO filing of draft prospectus by Emcure Pharmaceuticals and Intas Pharmaceuticals. Emcure Pharmaceuticals planned to raise $98.8 million in the IPO when it filed the draft prospectus in June 2013. In December 2013, The Blackstone Group, PE investor in Emcure sold its stake to Bain Capital, LLC for $112.63 million.” Some of the other major PE exits in 2013 were Apax Partners exiting Apollo with 3x returns after an investment period of six years for ~ $360 million, Avenue Capital which exited its stake in Medanta after a period of seven years for ~ $155 million with more than 4x returns. ICICI Venture exited its stakes in Quadria Capital for ~$26 million and Vikram hospitals for ~$15 million.
What’s in store for 2014?
The $70 billion Indian healthcare industry is at an inflection point. It is posting double digit growth and offers attractive investment opportunities as well as a decent exit to PE investors without any regulatory bottlenecks. Suresh Soni Chairman and CEO, Nova Medical Centers
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Healthcare seems to be a safe bet for investors as the sector offers reasonable valuations. PE funds will surely continue to flow in, especially in unique healthcare models. Experts sharing their forecast for 2014 are of the opinion that the areas of healthcare which will attract PE funding in 2014 could be mid-sized hospitals aspiring to expand, diagnostic centres, hospitals in the single speciality segment that focus on the ophthalmology, orthopaedic as well as the mother and child space, pharmacy chains and day care clinical services (eye care and dental). Giving an update on the deals and deal values, Rana Mehta, Executive DirectorLeader Healthcare, PwC, opines, “The average deal size in the sector is expected to increase going forward as funds with larger ticket size are
Investee company
Investor name
Amount $ million
Global Health Private Limited (Medanta)
Carlyle
156
Medica Synergie
Quadria Capital, DEG, Swedfund
65
Fortis Healthcare
IFC
100
Stanchart PE
50 (est)
HCG
Temasek holdings
26
Rainbow Hospitals
CDC Group,Abraaj Capital
17.5
Vikram Hospital
Multiples Asset Management
30
Source: PwC report
THE TOP DEALS OF 2013 Target
Deal Value Investor ($ Million)
Fortis Healthcare Limited (BSE:532843)
55.0
International Finance Corporation
Symbiotec Pharmalab Limited
47.85
Actis Capital, LLP
Dr. LalPathLabs Pvt. Ltd.
44.0
TAAssociates Management, L.P.; KPCB China; WestBridge Capital
Global Hospitals Private Ltd.
41.4
International Finance Corporation; Sabre Partners
HealthCare Global Enterprises Limited
25.73
Temasek Holdings (Private) Limited
Trivitron Healthcare Private Limited
24.57
India Value Fund Advisors Private Ltd
Lotus Surgicals Private Limited
24.0
Samara Capital
BPL Medical Technologies Private Limited
20.1
Goldman Sachs (Asia) L.L.C.
Rainbow Hospitals Limited
17.52
CDC Group plc; Abraaj Capita
Source: Frost & Sullivan
looking at the healthcare space. Companies which have been funded five or six years ago will see exits happening and also other companies which have been funded in the last two or three years could go in for an additional round of funding. Going forward we may see buyouts of companies in the healthcare space by large funds.” Bansal chips in saying, “We expect the momentum in historical growth rates to sustain in 2014. Consensus growth rates amongst various research reports peg growth at 12- 15 per cent CAGR, which should play out in 2014. From a value perspective, high ticket investments (upwards of $50 million) will continue to be in tertiary care hospitals and diagnostics and to some extent in eyecare chains, as these are scaled up and mature models and can absorb a higher investment. But single speciality chains (like dialysis, diabetes clinics, orthopaedics, paediatrics, eyecare, etc) and medical device players (with manufacturing capabilities and IP) should see higher volume of investments albeit at a lower ticket size. In addition to this, we should watch out for some interesting PE exits – the timing is always uncertain, but there have been big ticket investments made by PE players like GIC, Advent, TA Associates, Warburg, Olympus capital and many more and their eventual exits will make for some exciting deal activity in the coming few years.”
Going forward Well, the forecast for 2014 looks quite promising, but it’s important to note that the Indian economy is yet to revive from the economic slowdown. Currently, India’s economy condition depends a lot on the political stability within the country. However, India’s political arena at present seems to be in an upheaval. With the Lok Sabha elections on the anvil, India’s political and economic position is set for a big change. So,
( will the forthcoming elections make or break PE inflow into healthcare? Will investors still play their safe bet on healthcare? Or will they wait and watch? Answering some of these questions, Dr Saneesh replies, “The elections expected in April 2014 will definitively impact the PE investors, as it has created a sense of uncertainty. The uncertainty is primarily because of the new regulatory reforms expected to be introduced by the new government. Healthcare being a sector prone to regulations, the investor confidence is not very easy to boost up. Moreover, if the election results are not very favourable for a stable government, more policies to cut the prices of drugs and healthcare services can be expected, resulting in a slowdown in healthcare sector”. Analysing this scenario, Sekhar answers, “2014 would be a two-track or a two-half
story, with the first half in a pre-election environment witnessing optimism on the back of a much-awaited wave of economic reforms implemented in the latter half of 2013 with foreign direct investment (FDI) in multi-brand retail, civil aviation, broadcasting, insurance and pension sectors. The fate of the second half would be determined by the outcome of the general election, undoubtedly the single most defining event of 2014. A decisive mandate will lift the veil of uncertainty and encourage investments from both domestic and international investors, who have been conspicious by their absence. The euphoria among market participants would precede the real action on ground, driven largely by the expectations from a new government to kick start stalled projects, de-bottleneck investments and let go of a policy paralysis, setting the stage for putting India on a multi-year growth
Post general elections, a decisive mandate will lift the veil of uncertainty and encourage investments from both domestic and international investors, who have been conspicious by their absence Chandra Sekhar Executive Director (Marketing), Global Hospitals
FOCUS: FINANCE
trajectory. Instead, if we were to be confronted with a fractured electoral mandate, the overriding positive sentiment prevailing currently would turn bearish, in a short to medium term, thereby temporarily impacting the overall growth prospects.” While Dr Saneesh and Sekhar are of the opinion that the coming elections will certainly have some impact on the PE scenario in healthcare. Bansal and Soni have a different view. Bansal feels that the investors may not get affected by the political scenario in the country. He feels, “The demand for healthcare is somewhat inelastic and with the current dearth of supply, we should continue to see an interest in the sector. It’s one of the few sectors which doesn’t have a FDI limit, there are tax exemptions available for new hospitals in certain classes of towns and service tax is exempt on healthcare services – so those are posi-
tives from the government side. Any new measures to augment growth and investment in the sector post elections will always be welcome.” Soni adds, “I think the Indian healthcare sector has got delinked from the vagaries of the country’s political system as it offers a tremendous value proposition to investors in terms of growth prospects, easy exit and afavourable investment climate. If a stable government following pro-market policies is formed after the Lok Sabha elections, it will improve the overall sentiment about the Indian economy and the PE funding inflow may actually increase. An improving economy will increase the risk appetite of investors.” Finally, India’s political fate is yet to be decided. Till then, we can only hope that investors continue to bet on India’s healthcare sector bringing in the much needed funds to grow. raelene.kambli@expressindia.com
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EXPRESS HEALTHCARE
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February 2014
cover ) INSIGHT
Financial performance of major Indian hospitals Dr E Saneesh, Research Analyst, Business & Financial Services – Healthcare, Frost & Sullivan gives an insight on the the kind of financial growth registered by major healthcare players in the country
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APOLLO HOSPITALS REVENUE TREND ANALYSIS, INDIA, 2009-2015F Total Revenue
1,500.0
Revenue (US $ Million)
THE INDIAN healthcare industry has achieved considerable success in addressing the healthcare needs of the population since independence. The Indian hospital sector is a key component of Indian healthcare industry with contribution of nearly 70 per cent of total revenues of the industry. Until 1980s healthcare was delivered mainly by government-run and non-profit based institutions. From 1980 the Indian hospital sector started receiving private capital from corporate investors. From that point on, increase in population, incidence of non-communicable diseases, rising middle class incomes, technological intervention for better quality delivery etc have driven the growth for private sector hospitals in India. Various incentives at the policy level along with legal clearance for FDI have played a great role in driving private sector participation. In 2012, the size of the private hospital industry in India was about $ 25 billion; it contributes more than 50 per cent of the total beds in India. Most private hospitals are located in urban India with very low penetration in the semi-urban and rural parts. To reach the goals of 12th
1,000.0 2 GR A C
00
20 9-
1
2 3:
3.6
%
934.0 770.0 632.0 527.8
500.0
436.9 270.7
0
2009
339.8
2010
2011
2012
2013
2014F
2015F
Source: Capital IQ and Frost & Sullivan analysis
Five Year Plan, India has to increase bed capacity by adding at least 650,000 beds by 2017. Demand for services and requirement for increasing beds has created huge opportunities for investment in this sector. Increasing investments in this sector from private investors have increased financial risks and returns the investor expects from his portfolio of investments. Thus, financial performance of hospitals is the key factor that motivates and encourages investments into Indian hospital sector. The key players of the Indian hospital sector analysed in this article are Apollo Hospitals Enterprise, Fortis Healthcare and Kovai Medical Center & Hospital.
(
FOCUS: FINANCE
FORTIS HEALTHCARE LTD REVENUE TREND ANALYSIS, INDIA, 2009-2015F 2,000 1,800
Revenue (US $ Million)
1,600 1,400
Revenue growth
1,200 1,000 800
GR CA
9 200
13 –20
1004.6
.6% : 75
974.3 856.3
600
500.4
400 250.8
200
105.7
0
2009
157.3
2010
2011
2012
2013
2014F
2015F
KOVAI MEDICAL CENTER, REVENUE ANALYSIS, INDIA, 2008-2013 70
Revenue (US $ Million)
60
33.9% 20.7%
33.6%
18.2%
40 CAG
30
29.3%
25.4%
50
20
Based on our analysis, the Indian hospital sector is expected to pose a steady growth in 2014, which will attract investors to this segment and also in the secondary market
17.6
008 R2
-20
% 26.6 13 :
47.5 35.6
27.9 20.9
Profitability
14.1
10 0 2008
2009
2010
Apollo Hospitals Enterprise (Apollo) witnessed a steady growth at a compound annual growth rate (CAGR) of 23.6 per cent from FY09 to FY13. The growth in revenue is primarily attributed to rapid expansion, which led to addition of beds; bed capacity increased by 46 per cent between 2009 and 2013. The company is projected to grow by 21.6 percent between 2013 and 2015 primarily by expansion into other cities and also into tier 2 and tier 3 cities. Fortis witnessed strong growth between 2009 and 2013 at a CAGR of 75.6 percent. This robust growth was primarily because of inorganic expansion, unlike Apollo, which grew organically. The latest activity was acquisition of 86 per cent stake of Super Religare Laboratories in May 2011 and 85.0 per cent stake in Radlink Asia of Singapore in January 2012. The payout of debts in future is expected to reduce revenue growth in 2014 and 2015. Kovai Medical Center & Hospital (KMC) is smaller in size compared to both Apollo and Fortis; however, it maintained a steady growth at a CAGR of 27.6 per cent between 2008 and 2013. Unlike Apollo and Fortis, KMC’s expansion plans are not that aggressive.
2011
2012
2013
Source: Capital IQ and Frost & Sullivan analysis
On analysis of profitability margins, Apollo witnessed a gradual increase in gross profit margin and net income margin primarily because of the expansion of beds bringing in economies of scales. Fortis
witnessed a reduction in profitability in 2012 primarily because of its inorganic expansion activities. KMC posed a strong EBITDA and EBIT margins between 2012 and 2013 compared to Apollo and Fortis. The increase in financial cost in the same period was attributed primarily to increase in interest rates.
Capital structure The debt equity ratio of Apollo across the years 2009 and 2013 has not varied; this is because the company has expanded without mergers and acquisitions. However, the debt equity ratio of Fortis is quite volatile, primarily because of acquisition activities in the concerned period. Moreover, Fortis witnessed a low Altman Z score of 0.44 in 2012, which implies a high debt burden of the company. KMC has been increasing its debt level between 2009 and 2011, with highest debt equity ratio recorded as 79.2 per cent in 2011. Among the three, KMC always had a higher debt equity ratio; however, it had started debt payments post 2011, which is quite evident from the decreasing debt equity ratio in the subsequent years. The repayment of debt is also witnessed in the changes of the interest coverage ratios, which decreased from 3.4x to 2.6x between 2011 and 2013.
Viewpoint Based on our analysis the Indian hospital sector is expected to pose a steady growth in 2014, which will
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cover ) APOLLO HOSPITALS PROFITABILITY ANALYSIS, INDIA, 2009-2013 Gross Profit Margin (%) EBIT Margin (%)
The hospital sector occupied around 70 per cent and 62 per cent of the total volume and total value of PE deals in 2013, respectively
EBITDA Margin (%) Net Income Margin (%)
40.0% 30.0% 20.0% 10.0% 0.0% 2009
2010
2011
2012
2013
FORTIS HEALTHCARE PROFITABILITY ANALYSIS, INDIA, 2009-2013 Gross Profit Margin (%)
EBITDA Margin (%)
Net Income Margin (%)
60.0%
48.9%
50.0%
40.0% 30.0%
24.8%
20.0%
14.5%
27.3%
26.7%
15.4%
27.3% 13.7%
11.8%
6.0%
10.0% 0.0%
7.4%
3.3%
2009
2010
8.3%
8.3%
2011
2012
2.4%
2013
KOVAI MEDICAL CENTER, PROFITABILITY ANALYSIS, INDIA, 2009-2013 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0%
Gross Profit Margin (%)
EBITDA Margin (%)
EBIT Margin (%)
Net Income Margin (%)
21.9%
6.5%
2009
23.1%
8.9%
2010
24.3%
6.9%
2011
attract investors to this segment and also in the secondary market. Moreover, the hospital sector is expected to attract higher PE investments compared to other sectors in healthcare. The hospital sector occupied around 70 per cent and 62 per cent of the total volume and total value of PE deals in 2013, respectively. The largest deal was the investment by International Finance Corporation in Fortis. Apollo is expected to focus more on tapping the unmet gaps in tier 2 and tier 3 cities in the Indian market through its brand “REACH� hospitals. Apollo is also posing strong growth in its pharmacy chain, revenues from its pharmacy
business as a part of total revenue increased from 34 per cent to 43 per cent between 2011 and 2013. Fortis is expected to tap both national and international demand with a mixed strategy of investment in both brownfield and greenfield projects to increase its bed capacity in the next three to five years. KMC is planning to focus more in the southern region by increasing its bed capacity in the existing hospital. The future strategy of KMC is to tap market needs in specialty care; with the success of oncology care, KMC views specialties such as hepatic and cardiac care for future growth opportunities.
DEBT EQUITY RATIO, 2009-2013 Hospital
2009 (%)
2010 (%)
2011 (%)
2012 (%)
2013 (%)
Apollo Hospital Enterpri se Ltd.
31.0
35.3
33.3
24.5
29.1
Fortis Healthc are Ltd.
26.4
26.4
72.3
24.7
48.9
Kovai Medical Center
70.1
73.0
79.2
78.9
72.5
27.0% 23.7%
5.4%
2012
6.9%
2013
*End of FY on the 31st of March
Source: Capital IQ and Frost & Sullivan analysis
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Source: Capital IQ and Frost & Sullivan analysis
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INSIGHT
Insure-ing universal cover for India Shobha Mishra Ghosh, Sr Director and Sidharth Sonawat, Sr Assistant Director, FICCI stress on the need to improve the health insurance scenario to ensure universal health coverage in the country
UNIVERSAL HEALTH coverage (UHC) has now been widely adopted as a developmental imperative across the mid and low income world. India too has articulated its intention to move towards universal health coverage in the 12th Five Year plan. The road to UHC, however, is being intensely debated in policy circles. Considering the inadequate public spending (1.1 per cent of GDP), huge deficit in healthcare infrastructure and high out of pocket expenditure (61 per cent), health insurance has emerged as one of the mechanism for moving towards UHC. It is increasingly been seen as the ideal mechanism to complement the public health system available at the primary care level. Secondary and tertiary care is sought to be made affordable through insurance pooling. FICCI recently came up with a futuristic paper –‘Health Insurance Vision 2020’ which envisages ~80 per cent coverage by 2020 through the health insurance mode. It emphasises that UHC, attained through a balanced and integrated approach that combines supply and demand side financing, building upon the existing health system in the country shall ensure continuity of care at optimum cost and efficiency in a sustainable and feasible manner. It also laid out a draft roadmap for progressively moving towards this objective. Clearly India is at an inflexion point wherein the healthcare scenario could see a dramatic and unthinkable change. The advent of government-sponsored health insurance schemes has
changed the way and pace of change in the healthcare security scenario in the country. From less than 10 per cent in 2007, insurance now covers 30 per cent of the total population. It has clearly the potential to grow faster and deeper if an enabling environment is developed and political will is forthcoming. However, to fill this gap from 30 per cent today to 80 per cent in 2020 (less than seven years), numerous structural changes including regulatory, legal, product-related, new operating entities, partnership with providers, universal health coverage have to move in tandem. To understand this, let’s look at the fundamental premise of health insurance business product, distribution and service/settlement of claims. Product: Health insurance product development has traditionally focused on covering inpatient events and even today a significant part of the market comprises such products. This has to change significantly to enable participation of larger pool
of beneficiaries and increase the breadth and depth of coverage. Already much exclusion prevalent in the system (coverage to HIV/AIDS patients, senior citizens, pre-existing diseases etc.) have been addressed by the regulator and the industry. This has to further improve to make health insurance products more inclusive. Eventually, health insurance product should be focused on management of health of the policy holders as a long term solution as well as management of demand for health services and health costs. Distribution: Most of the trust deficit and miscommunication in the health insurance sector can be addressed through ushering in transparency in the distribution and selling of insurance. Ease and simplicity of the process from point of sale up to claim settlement would draw more people to insurance and help creating a larger pool of beneficiaries. Product features have to be communicated clearly by the various existing and new distribution channels to
reduce avoidable complexity. Greater awareness, new distribution channels including the internet and transparent processes will lead to demand pull leading to higher growth of the sector. Settlement of claims: The regulator and industry bodies have undertaken a lot of ground work in streamlining issues related to settlement of claims by a major push to standardization. The new health insurance regulations (October 2013) is a milestone in this regard. When implemented, this would mean that there is no ambiguity regarding commonly used insurance terms, policy exclusions and meaning of critical illnesses. Standard common pre authorisation form and uniform billing and discharge summary formats would mean a lot of transparency and reduced friction between the provider and the payer. Standardisation would continue to play an important role in further improving payerprovider relationship and reduce the hassle to the consumer.
Healthcare regulators have also realised the other critical elements of data availability; interoperability and standard costs for completing a conducive healthcare ecosystem. While a system of coding is already prescribed by the insurance regulator, this would be increasingly applicable and acceptable with the introduction of recently notified national electronic health record standards. Seamless data availability would not only help clinicians and patients but also policymakers by development of a national health profile of the population. It would also open the scope for large scale clinical analytics and resultant positive impact in the form of newer insights into individual and societal health. While it may not appear so to an outsider, healthcare sector have seen major positive and transformative reforms in the last three years. We now have a clinical establishments act in place, initiation of development and adoption of standard treatment guidelines and national standards for data capture and sharing. Simultaneously, the government is also working on developing a scientific reimbursement methodology through national costing guidelines. However, the real impact of these reforms would be felt when they are implemented over the next two to three years. We will have to deal with a lot of bottlenecks to usher in change. In the midst, insurance has presented itself as a major tool for enhancing affordability of healthcare in the near future.
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cover ) OPINION
Making healthcare healthy Dr BK Modi, Chairman, Spice Global and Chairman, Saket City Hospital, Delhi opines on the need to devise realistic plans to increase the outreach of India’s public health system ALMOST 70 PER CENT of 1.2 billion Indians live in communities away from doctors, clinics and pharmacies. It is ironical that even 66 years after Independence, India invests only 1.2 per cent of gross domestic product (GDP) in healthcare sector against four per cent in developed countries like the US, Britain, Australia, Norway and Brazil. At the same time, India has an average of 0.6 doctors per 1,000 people against the global average of 1.23. As a result, most residents are left without access to treatment, medicine and health insurance cover. The annual income loss due to diabetes, stroke and heart diseases is estimated at $ 54 billion by 2015, according to the World Health Organisation (WHO). The total economic cost of three tobacco related diseases – cardiovascular, cancer and chronic obstructive pulmonary – is over $ six billion.
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Healthcare is a social goal which is becoming more plausible, feasible and accessible globally. The spread of mobile phones opens new possibilities for delivering healthcare services cheaply and effectively to millions of people. There is a growing body of evidence that technology can be brought to bear on challenges of rising population, scarce resources and financial limitations for providing care to remotely-located or underserved people. The combination of electronic health records, mobile health devices, virtual teamwork and electronically-enabled disease and knowledge management has emerged as a platform for catalysing the transformation of healthcare in developed world. Indian parliamentarians should thus provide a supportive policy environment as eHealth and tele-health require significant investments in tech-
( nology and infrastructure. The participation of private sector is critical – particularly in building the basic infrastructure to support these emerging technologies. I believe access to modern healthcare system should be made a fundamental right if the country aspires to become an economic superpower. It is interesting to note that 75 to 80 per cent of incremental investments in recent years have been by the private sector. The Indian healthcare industry, currently estimated at $75 billion, is expected to grow to $280 billion by 2020. India thus needs to augment its healthcare capacity to meet the booming demand as over 2.4 million doctors and two million hospital beds will be required in the next decade. Various experts say the time has also come for convergence of pharma and biotech,
of academia and industry, of healthcare and information technology, of government and pharma industry to ensure good quality medicines at affordable prices for most people. The catalyst here again is new emerging technologies.
Official figures show that India has 12,760 hospitals having 576,000 beds. Of these, 6,795 hospitals with 149,000 beds are in rural areas and 3,748 hospitals with 400,000 beds are in urban areas. The average distance travelled by urban and rural population to
FOCUS:FINANCE
access health services is 6 and 19 km which significantly increases the total cost of treatment. And 20 million Indians are pushed below poverty line every year due to out-ofpocket spending on health. About 6.6 million children aged under five years die
every year – or 18 000 every day – mostly due to infectious diseases. The problem can be tackled through a threepronged strategy of crisis management, timely care and cure through early diagnosis. India needs to look beyond grandiose populist schemes and instead devise realistic plans to increase the outreach of public health system. The government should increase GDP share of healthcare system and aggressively forge public-private partnership model to reach the last mile. Emphasis should be on building lasting blocks of healthcare infrastructure that reach out to the bottom of pyramid instead of short-term populism. The health of a country's population defines the state of development. A healthy population holds greater capacity to access opportunities for education, knowledge and employment.
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cover ) S T A R T
U P
M A N T R A
The target is to be in every city with a population of more than 10 lakhs Serial entrepreneur K Ganesh acquired Portea Medical in July 2013 from the founders who started it in 2012 and recently bagged Rs 48 crores in Series A funding, the largest ever Series A funding by any company in the sector. Viveka Roychowdhury gets him to dissect his philosophy as an investor, the long term vision for Portea Medical and share some tips for both budding healthcare entrepreneurs and prospective investors
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Portea Medical was acquired in July 2013 from founders Karan Aneja and Zachary Jones, who started it in 2012, based on the US model of home healthcare. But given that there are major differences between the US and India's healthcare practice, what were the initial teething problems and how was the model tweaked? What differentiated them from the other start-ups in this area? At the very early stages, Aneja and Jones tried to create a replica of the US model. While the needs were similar, they realised that the skill set of clinicians in India vs. the US was different – this drove them to think critically about the types of services that could be offered and in turn, analyse and understand their needs and wants. Through meetings with various doctors/ hospitals/patients, they were able to address the core needs such as general physicians’ visits, nursing care and physiotherapy services for primary and post-hospitalisation care. But the two chose to dive deeper – they looked into various other aspects of the healthcare ecosystem in India and chose to offer counselling and nutritionist services in the privacy of patients’ homes. This really let individuals address their various health problems, but without the pressure of thinking about what was culturally appropriate. Being two Americans starting something up in India, this was a totally different ballgame for them; the two faced quite a few issues, but were quick to pivot their model and had a deeper understanding of the space to help resolve them as soon as they could. What really differentiated these two was their understanding of the space and their ability to figure out what the market needed and
what was lacking – they were fearless and were able to confidently convince decision makers to make bold decisions, to change what they had known for so many years. They started various pilots with hospitals/ insurance companies to address many of their issues and help them to be run more efficiently. This forward thinking vision is what really attracted us to the team. Why do you feel this is the right time for this idea to click? There are a few things that come to mind: ◗ Healthcare is a need, but can be looked at as a direct to consumer product. You can carve out a niche – people are ready to pay for convenience as well as top quality healthcare services, it doesn’t matter if we’re providing it in someone’s home or if they have to go to the hospital ◗ Family dynamics – India is moving away from the joint family, we are all independent and want to remain that way. But at the fundamental level, we are Indian and want to take care of our families – Portea allows individuals living away from their families to take care of them and be connected at all times ◗ Technology – this is the time to disrupt the market, everybody has a smartphone and we can use this technology to really improve the quality of care that is delivered as well as ensure better health outcomes by tracking individuals. Today power in the hands of the consumer with a smartphone is like having a supercomputer in your palm – be it for imaging, video conferencing, analysis , communication, is mind blowing. ◗ Personalised medical devices – the advances in this field have been
( phenomenal in the last two years. The latest Consumer Electronics Show (CES) show at Vegas was all about wearable devices and mobile health. This makes “personalised” and “proactive” medicine a real possibility in the coming years as against traditional “population-based” and “reactive” medicine. How does the model work from the patient point of view? What kind of services/packages are on offer? From the patient’s point of view, it is quite simple. ◗ They give us a call (they’ve either been referred to us by their senior clinician or they find out from other sources). ◗ They schedule an appointment (we are able to book appointments based on the clinician’s availability in the field – they carry GPS-enabled smartphones and we can estimate the time it will take them to reach a patient’s home) ◗ Clinician reaches out to the patient to understand their illness - we then get in touch with their senior clinician to inform them that we are going to see their patient and ask if there is anything that we should be wary of when treating their patient since they understand all nuances of the patient ◗ Clinician visits patient – we do general procedure/ protocol and carry out senior clinician’s orders. (clinicians’ have a checklist on their smartphone of things they are to do/input into the system, this ensures holistic treatment + update of EMR). The senior clinician is updated on the patient’s progress ◗ EMR is updated fully (using smartphone) + synopsis of patient’s visit is emailed to senior clinician. Right now, we are focusing on general primary health care, posthospitalisation care, and
chronic disease management. We have packages addressing various aspects in all of these areas.
PROMOTERS’PROFILE Zachary Jones, SVP
The Rs 48 crore in Series A funding from venture capital firms, Accel Partners and Ventureast will fund the scaling up of Portea Medical for 2014 so could you spell out the expansion plans? And beyond 2014? We are currently in seven cities across India – we intend to address three more large cities by the end of June. There are currently ~50 cities that we are looking at, based on the disease prevalence/size of population/education levels and ability to pay. The target is to eventually be in every city which has a population of more than 10 lakhs.
Graduated magna cum laude from Columbia University, New York. Previously with Sanford Bernstein Equity Research, New York and Copal Partners, Gurgaon. Co-founded home healthcare business in 2012 and was CEO prior to roll up
Karan Aneja, SVP A serial entrepreneur and molecular and cell biologist by training. Graduated from the University of California, co-founded SidKar Green Technologies and Filtered Helmets before venturing into the home healthcare business in 2012. Was head of business development prior to roll up
Given that this is a relatively asset light model of healthcare, when do you expect it to break even? What are the revenue targets for 2014? And revenue growth targets for the consecutive years? Given that we are in the early stage, we are growing at a scorching pace. In the last three months we have gone from two cities to seven cities, from 50 people to 350 people. We expect each city to break even in two years and as a company we expect to break even in three to four years as we will be expanding to new cities constantly. What is the target revenue mix from the different segments you are targeting: direct patients/consumers, hospitals and insurance? The target mix is 70/30 – that’s 70 per cent direct to consumer and 30 per cent (B2B) focusing on post-hospitalisation care, plus some of the initiatives that we have begun piloting with various hospitals. Portea Medical has the first/early mover
FOCUS: FINANCE
Meena Ganesh, Co-founder & CEO Previously promoter and Board member of TutorVista and CEO and MD of Pearson Education Services. Prior to this, was the CEO of Tesco's operations in India, the Tesco Hindustan Service Center
advantage but going forward, what's your USP from competitors, existing or future? There are several: ◗ Proven ability to execute: This is a very hard, execution-led business and not something that two geeks or computer science guys can create with an app or cool software. Hiring, training thousands of healthcare workers, across the length and breadth of
India - most of them in remote locations, is a major challenge. Hiring, deploying, monitoring and motivating a distributed workforce remotely is a major task. The founders have a successful track record of doing so in multiple ventures. TutorVista, was India’s largest employer of teachers and India’s largest employer of remote workers across all
industries, employing over 6000 teachers across India. TutorVista has trained over 10,000 teachers, remotely. This execution capability is a major USP. ◗ Technology: Developing a technology platform that is integrated, proprietary and open enough to meet all the requirements of the patient, hospital, insurance company, employees and the healthcare worker is a huge and complex task needing substantial investment and technology DNA. The tech background of the founders and past experience in developing such technology platforms is a major asset. The entire service is possible only with very strong technology using smart phones, geo fencing, GIS applications, integrating personal medical devices, high end analytics of patient data, predictive modelling and remote management. This takes time and money to create. We have at least a year’s head start in terms of anyone else entering the space. With the current investment in technology and the funding, this will become a three year head start very soon for anyone else to catch up. ◗ Capital: This is a low margin business but high growth and scale business. It needs a lot of capital to roll out in multiple cities, and investments in training and technology. With Rs 48 crores in funding - the largest ever Series A funding by any company in the sector, we have raised the bar for others. Unless you invest this quantum of money, you cannot provide high quality service at reasonable cost. Unless you operate pan-India, you will not be able to break even. So capital is an important consideration to kick off such a venture. ◗ Stellar team: Our core team of technology entrepreneurs possess a good track record of execution. Aneja and Jones
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cover ) come with strong exposure to US quality home healthcare, Dr. Manjusha Anumolu our cofounder, has worked in the US and India in general medicine. All of these are important ingredients to the success of this business model. The founders of the company have been pioneers in identifying a big business need, using technologydriven execution models to create lasting, valuable businesses that address major pain points in India.
What factors could be potential road blocks? ◗ Successful execution: This is a very hard business. The speed with which we are able to hire, train, deploy and motivate large healthcare workforce, and scale our operations will be key. ◗ Technology innovation in personal medical devices: While there are a lot of breakthroughs, will the good work that is being done, be commercially viable soon? How reliable and quality certified will such innovations be for commercial use? Of course, this does not affect the whole business model; just that part where we intend to use the devices for monitoring on a continuous basis.
What are the pain factors? The services we provide are very personal in nature – it’s not like selling a book or providing another credit card facility. There is a great deal of emotion involved; people come to us when they are in pain or distress and look to us to solve their problem and give them solace. This is a huge responsibility. We take that very seriously. This keeps us awake at night, so to speak, and all our plans, systems and processes reflect the enormous trust and responsibility that our customers are placing in us.
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We have at least a year’s head start in terms of anyone else entering the space. With the current investment in technology and the funding, this will become a three year head start very soon for anyone else to catch up So investment in technology, systems, hiring people and training is to ensure that we are able to discharge this responsibility day after day. Each and every transaction is very important – it throws up challenges in terms of three parameters consistency, reliability and quality of medical care. If you look at the market, we believe that this is an accessto-services play. It will take time to build awareness, but we are confident that people will need our services. We have been scaling quite rapidly, but it would always be great to move a little faster! We are firm believers in providing the best – we’ve been exceptionally picky about the people that we have hired, but we believe that it differentiates us – we provide patients with the best possible experience in their time of need. We’re creating an all-star team, not one that just comes out to play – finding that talent takes a bit of time, but we’ve been quite fortunate in finding it. How do you as an investor, choose the sectors, and business ideas to invest in? ◗ We look at sectors that are large and unaddressed – where we can create a large impact and thereby large, valuable businesses. We don’t like niche businesses. For example, we will not fund a website that sells online jewellery for pets in India or provides vocational skills to people in New Zealand, and so on. ◗ We look for simple, day to day pain points that are not
addressed and explore if we can build businesses that can use technology or new models to disrupt the status quo. TutorVista was built to address the need for a tutor, Portea Medical is built on the need for healthcare which is affordable, convenient and accessible from home ◗ We look for nascent sectors where we can create a category leader. We want to be among the first three players to enter a category and want to become the largest or second largest player in the sector. That gives us the ability to create disproportionate valuation and benefits for all the stakeholders. All my ventures were the first in the sector or industry and became category leaders: TutorVista – world largest online tutoring company, CustomerAsset/First Source – top 3 call centres in India, Marketics – first data analytics company from India with a $ 63 million exit, IT&T – India’s largest third party maintenance company in the 1990s. ◗ We like Internet and technology-based models where there is an offline and online combination as we believe this suits the Indian market very well. Bigbasket, India’s largest eGrocery company focusses on online for booking and sales, but the last mile delivery is through our own warehouse and vans, with drivers delivering groceries at home. Portea Medical is online in terms of sales and marketing, but
delivery of medical services is offline at homes. ◗ We like strong execution plays which are tough to pull off – where most people will fear to tread. This creates a big barrier to entry. How long do you stay invested? We are not angel investors. We are promoters of the businesses, so like any founder we stay till the end. We exit only when there is a monetisation event. Unlike angel investors we don’t look to exit in series A or series B. We expect companies will typically take 5 to 10 years to monetise and give us an exit. In terms of past track record, IT&T was eight years, CustomerAsset was two years, Marketics was five years, TutorVista was six years. What is your role? We are promoters. We come up with the idea, develop the business plan, formulate the strategy, bring in cofounders and the core team, fund the business till institutional investors come in, stay actively involved in running the business, raise series A money from VCs and continue on the board. For instance, at Bigbasket, we put together the idea and got the cofounders – ex Fabmart/Fabmall founders to come together and create BigBasket and raised $ 10 million from Ascent Capital. Another example is Bluestone.com, which is focused on online sales of fine jewellery. We wrote the business plan, got the
founding team together, launched the business and raised $ 5 million from Accel partners and Sama Capital. In all cases, we are promoters and will be with the company till full monetisation and take active part in running of the company. What is your advice to entrepreneurs in the healthcare space looking for investments? ◗ It is a large, exciting space which is evolving rapidly. There are innumerable opportunities. But pick and choose where you want to enter after a lot of thought. ◗ Choose a big area where there is a large opportunity and space. Preferably new disruptive model rather than, say, open another super speciality hospital or open a pharma chain. There are too many players and unless you have very special skills and have lot of capital, this is difficult to pull off. ◗ Play to your strengths rather than copy the US model or someone else’s model. What is right for them or right in another geography are not the same here in India. and for you. For instance, healthcare is mostly covered by insurance and Medicare in the US and Europe, while in India it is mostly privatepay. So the factors are very different. Any advice to funders who are looking to invest in this space? ◗ Healthcare is long-term play and one needs to be patient. It is difficult to scale and even more difficult to exit. So, please be aware of the time-frame. ◗ While there are lot of cool apps and cool technology, building real revenues and real scale is tough – this is a very emotional, involved and personalised decision – so bet on strong, real business models that address real pain points. viveka.r@expressindia.com
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I N T E R V I E W
‘Arogya is targeting lower and lower-middle income groups who are covered neither by government schemes nor by corporate insurance plans’ The patient financing model, introduced just a couple of years ago, has been slowly picking up momentum. Raelene Kambli talks to Dheeraj Batra, Co-Founder and VP Business Development, Arogya Finance about how the concept works for India and how Arogya Finance reaches out to a million Indians to make healthcare affordable
How can patient financing can improve healthcare access in India? Given that only about 15 per cent of the Indian population is covered by health insurance, the vast majority of people have to pay for healthcare out-of-pocket. We all realise that only a small percentage of this 85 per cent can afford to do so easily from their savings. Of the remaining, the lucky ones are able to lean on family, but most of these people end up selling personal assets like their jewellery or their residence, borrow at criminally high rates of interest (often exceeding five per cent a month) from money lenders or simply go without care. In fact, the problem is so bad that unplanned healthcare expenses are the number one cause of poverty in India. With Arogya, the patient starts paying after the care has been administered and that too for a definite period of time which it takes to repay the loan.
patient pays a premium indefinitely and is benefitted only if he/she needs care. In addition, using health insurance in India is anything but straightforward.
How different or similar is patient financing from health insurance? It’s very different from health insurance. With health insurance, the potential
What are the advantages and disadvantages of patient financing in the Indian context? Advantage is that the patient gets access to funds
Do you think that patient financing is a better option than insurance? Both options have their own strengths. From a macro perspective, insurance is great. If everyone pays for coverage and gets it, then the burden on any one person during a time of need is not that great. From an individual perspective and that too for someone who is in the lowerincome segment and doesn’t have access to a lot of excess funds, a loan may be more suitable. A person is likely to think that instead of paying a monthly premium for something he or she may never need, the person is better off spending that money on food or on children’s education or clothing.
Arogya is active in a limited way in nine states. We have a tie-up with 50 hospitals when the person needs it and is thus able to avoid selling personal assets or taking a loan from unscrupulous moneylenders. How does Arogya Finance help a patient to access healthcare? Who is your target group? Arogya Finance helps patients to access care by lending money to them. Arogya’s goal is to provide a safety net for these people. Arogya’s loans can help people
get back to work quicker, retain their assets and avoid the downward spiral that pushes them into poverty. Through its proprietary approach, Arogya is able to lend to those who don’t have the funds to pay for their healthcare expenses and those who are outside the formal system and lack things like collateral or formal proof of income. From an income perspective, Arogya is targeting the lower and lower-middle income groups who are covered neither by government schemes nor by corporate insurance plans. How does the model work in India? Arogya has partnered with multiple hospitals throughout the country. When one of the partner hospitals encounters a patient who is unable to pay for his/her medical expenses, the patient is referred to Arogya Finance. At that point, an Arogya Finance Counsellor meets with the patient’s family and puts the borrower through our process. Within 24-48 hours the patient’s family is given an answer on eligibility and the quantum of loan approved, but in emergency cases Arogya
Finance can make and communicate a decision in as little as four hours Our approach doesn’t require any collateral or formal proof of income. We have designed an approach from the ground up keeping the constraints of the borrowers in mind. Tell us about your reach in India? Arogya is active in a limited way in nine states. We have a tie-up with 50 hospitals. But going forward in 2014 and early 2015, Arogya will focus primarily on two geographies – Mumbai and Kolkata – before expanding its focus on include other states and metros. Who are the other players in the patient financing space? According to me, no one in India is financing the segment of the population we are targeting. What developments do you foresee in this new year for the patient financing space in India? We are hopeful that healthcare financing will qualify for priority sector loans. raelene.kambli@expressindia.com
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cover ) I N T E R V I E W
‘Government schemes have non-viable package rates for almost all surgeries under their list’ Recently, private and charitable hospitals in Karnataka appealed to the government to revise tariff of Yeshasvini and Vajpayee Arogyasri schemes. All the private hospitals of Karnataka along with their medical associations namely- IMA, PHANA, KPMEA, came together on a common platform - Karnataka Private Hospitals Forum (KPHF) to address the current crisis situation arising out of non-viability of existing health schemes and government’s move to cover nearly entire population of Karnataka under one or the other health schemes. M Neelam Kachhap spoke to Dr Prashant B Katakol, Co-ordinator, KPHF to understand their concerns
How many hospitals come under KPHF and on average how many scheme patients do they cater to in a month? All the hospitals and several medical college hospitals are on KPHF platform to put united efforts to resolve the current crisis. They amount to more than 90 per cent of the surgeries performed in the state on a day-to-day basis under the schemes, today. Please explain the dilemma faced by KPHF in dealing with the scheme patients? This can be explained by a short story. There were 10 tailors (hospitals) in a city. The government donated a hanky (BPL, Yeshasvini, RSBY cards) to a poor man and the poor man came to a tailor requesting him to stitch a pair of trousers (perform surgery) for him. The tailor realised that this poor man has only the hanky and no more cloth with him, but he needs trousers to wear (needs surgery for survival). The tailor thought that he has nine people coming to
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him with enough cloth (cash paying patients) to stitch trousers for them and he saves 15 per cent of the cloths from them and so he can stitch trousers for this poor man with the saved cloth from others, though, this poor man has come with an impractical demand. The tailor did stitch the trousers for the poor man from the cloth he saved from his rich clients. The government witnesses this and concluded that a hanky is sufficient for stitching full trousers. It then starts doling out hankies to the entire population directing them to get trousers stitched out of the hankies issued to them. Over a period of time all the tailors in the city started having more than 80 per cent of their clients coming with the hanky, demanding trousers to be stitched for them. The tailors are now in a situation in which they are not able to stitch trousers for anyone because the government has decided to give hankies to 100 per cent population, and directing them to get trousers stitched.
There is no control over the beneficiary population, the number of BPL and Yeshasvini card holders has spiralled out of control
Problems with the schemes: ◗ All three schemes have non-viable package rates for almost all surgeries under their list. ◗ The package rates are same for patients with co-morbid conditions such as an elderly person with associated heart or renal disease and a patient with no co-morbid conditions such as a youth. ◗ The entire responsibility of the patient is that of the hospital once it accepts the patient for treatment and no payment is sanctioned for any kind of complications arising subsequently, even when they are one arising from the nature of the disease itself and not doctor or treatment induced .Which doctor or hospital can handle any patient if such a condition is put-forth to him, prior to taking up the treatment? ◗ How can any hospital offer all OPD evaluation, OPD medicines and OPD investigations free, from his side, without being compensated for the same?
The trust wants us to pay only package rates, if and when we undertake surgeries. For example, if a hospital performs 100 free MRI s on OPD basis, more than 85 per cent to 90 per cent will have medical diseases and hospital has to spend for it from its coffers and the Trust does not compensate. From their side, hospital would have spent Rs 3500 per MRI amounting to Rs 3.5 lakhs. If it has 10-15 patients who need surgery, ultimately only fraction of them agree to subject themselves for surgery. The entire package amount of all the surgeries performed among these patients will be grossly less than what has been spent by the hospital on OPD investigations alone! ◗ There is no control over the beneficiary population, the number of BPL and Yeshasvini card holders has spiralled out of control and the government, is very much aware of how many bogus BPL cards are issued to population of Karnataka. ◗ Over the last 11 years in Yeshasvini scheme and over
( the last three years in Arogyasri scheme, the package rates have either remained the same or have been further reduced with time.(CABG package rates have been reduced, spinal fusion surgery package rates have been reduced unilaterally by the government). RSBY scheme releases only Rs 10000 per person per surgery with a maximum of Rs 30000 for the entire family. The scheme expects all complicated heart, brain, spine, urological surgeries to be performed within Rs 10000! ◗ The cost of running private healthcare establishment has gone up several times in the last 10 years with consumer price index also increasing from Rs 100 to Rs 241 according to governments own publications. ◗ Though this scheme is a voluntary one, in which, hospitals can decide whether to join the scheme or not, with more than 90 per cent of their clientèle insured under the schemes, do we really have a choice? It is suicidal both ways. ◗ There is no control over the list of beneficiaries which has spiralled out of control and there is rampant misuse of the schemes with the rich and even government servants aremisusing it. ◗ The non-viability of the package rates combined with uncontrolled number of beneficiaries is posing serious threat to the survival of private healthcare industry. ◗ This problem is now going to be multi-fold with the Governments plan to extend the schemes to cover 100 per cent population, to include APL population, without proper thought process or planning. Could you give examples of tariff costs that are
FOCUS: FINANCE
If the entire population is to be included into the healthcare model proposed for the poor minimum population of the state, then the private healthcare industry will degenerate into what the state government health set ups have become unreasonable for hospitals to comply? There are numerous glaring examples: ◗ Cardiothoracic surgeryEg. Aortic Valve Replacement costs Rs 1,33,000 and Yeshasvini offers Rs 75,000 only. ◗ Neurosurgery - Aneurysm coiling procedure- Package rate is Rs 50,000 irrespective of number of coils used for the patient. This includes entire pre op investigations such as angiogram, CT scan, surgery, medicines, entire hospital stay, medicines at discharge, travel charge of the patient, and continued care for one year. Angiogram costs Rs 9000 in a government hospital such as Jayadeva Hospital for general ward, CT scan cost a minimum of Rs 3000 for plain and contrast CT consumables for the procedure which needs to be purchased by the hospitals are as follows ◆ Microcatheter - Rs 36800 ◆ Microwire - Rs 18500 ◆ Detachable coils (Rs 32000+ per coil) three coils on average, sometimes more. Rs 96000 ◆ Guiding catheter Rs 8500 ◆ Total cost of purchase for the hospital - Rs 1,59,800 ◆ Cost of pre operative investigations - Rs 12000 ◆ Plus other consumables and this is excluding professional fees or establishment/ running cost in the calculation. How is Rs 50,000 sufficient for the procedure? ◗ Urology Case 1: (Under Vajpayee
Arogyasri Scheme) Procedure code: 901 Procedure name: Open Pyelolithotomy Package amount: Rs 10,000 Total calculated expenses - Rs 31,500 ◆ Investigation charges Rs 5,000 (Including both pre-op and post-op) ◆ Drugs: approximately Rs 7,000 The package amount is crossed at getting pre op investigations and purchasing drugs for the patient! What about expenses below? ◆ OT charges (Minimum) ◆ Anesthesia ◆ Surgeon charges ◆ Assistant charges ◆ Hospital stay for one week @ Rs 500 per day ◆ Food and transport charge Case 2: (Under Yeshasvini scheme) Procedure code: URO-14 Procedure name: Adrenelectomy (Open) Package amount: Rs 15,000 It is a supra major operation ◗ Cost of drugs: Rs 8,000 ◗ Anaesthesia charges: Rs 3000 Within the remaining Rs 4000, all the below charges are to be covered! ◗ Surgeon charges ◗ Assistant charges ◗ Operative room/equipment utility ◗ Hospital stay for one week Total incurred expenses: Rs 34,000 In this case hospital will incur a loss of Rs 19,000 What demands will KPHF put forward to the government? ◗ Population below poverty line- 20-23 per cent of
population- Hospitals need viable package rates. ◗ Mid income but vulnerable segment of population- 55 per cent- let the government fix maximum cap on the rates, but pay only part of it, allowing the rest of the amount to be collected from the beneficiaries to add up to the capped limit. ◗ Well to do population- 25-27 per cent- Not to govern the pricing, or, fix a base price and allow any amount to be collected above the base price from the beneficiaries. Critical assessment of existing health insurance models in India , report released by Planning Commission of India, states, “The recent growth of insurance schemes in India, in many ways, marks a new phase in India’s quest to provide healthcare to all. The key design features of health insurance scheme, revenue collection, pooling of funds and purchasing care need government intervention in order for the schemes to be equitable, efficient and effective. In terms of revenue collection, general taxation is the main source of funds for both health insurance schemes and direct public provision of care. Government must revisit the decision to bear dual financial burden of funding the network of public hospitals and national insurance. The risk pool for most schemes comprises the BPL population with least ability to pay leading to segmentation of the society. If the same schemes
are extended to other populations of the society, the pools will become bigger and more financially unsustainable unless the beneficiary contribution is increased as in the case of rich subsidising the poor in typical health insurance. The benefit package and package rates are the tools of purchasing care that government can use not only to control costs but also to monitor public expenditure on health, but these two need coordinated effort by different schemes to optimise benefit for the beneficiaries.” What will happen if the tariffs are not revised? The economy of a hospital includes provisions for the establishment costs, the running cost, cost of replenishment of equipment which have a finite life span, continued investment on Human training towards advances in medical science and on latest technology to be inducted into their healthcare units to be relevant in the context of current standards existing across the globe. If the entire population is to be included into the healthcare model which was proposed for the poor minimum population of the state, then the private healthcare industry will degenerate into what the state government health set ups have become. What are your suggestions for the government to benefit both the patients and the hospital? Sustainable quality healthcare for all should be the theme. What is good for politics is not good as a policy. What is good for policy is not good for politics. The government can certainly strike a balance between the two if it puts honest efforts. We as a forum are ready to play any constructive role in partnering the government to resolve the issue. mneelam.kachhap@expressindia.com
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KNOWLEDGE
Changing paradigm in
cancer With World Cancer Day approaching, an analysis of the cancer care in India, the challenges to be conquered in this arena and the way forward to make cancer treatment more affordable BY M NEELAM KACHHAP
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care
T
here are 2 to 2.5 million cancer patients in India at any given point of time. Additionally, about 0.7 million new cancer cases are detected every year and nearly half die every year. Cancer is a huge burden, both on the people and the government. Yet the means to fight cancer are not easily available. From detection technology to chemotherapy drugs everything is expensive. Cost is one of the detrimental factors pushing patients to die in oblivion.
Current status India is at par when compared to any country in the world in terms of advanced technology and experienced surgeons for cancer treatment. The problem is that these facilities are concentrated in some areas, mainly the metropolitan cities. Cancer detection and treatment facilities vary widely in rural India where 70 per cent of the population resides. “Yes, we do have all the facilities available. Unfortunately, concentrated in cities and not in remote areas or villages in the country,” explains Dr Anthony Pais, Head of Oncoplastic Breast Surgery Unit, Narayana Health City, Bangalore. Concurring Dr Ganesha D Vashishta, Chief Medical Oncologist, BGS Global Hospitals, Bangalore says, “Cancer care is centralised in the cities, and not easily accessible to the rural population. Though state-of-the-art facilities are available, only few patients can afford that.”
India is at par with the world in terms of advanced technology and experienced surgeons for cancer treatment. The problem is that these facilities are concentrated in some areas Public vs private Taking into account the huge difference between private and public healthcare in India, one would assume that cancer care is better in the private healthcare setting. In reality, cancer centres in India, despite and state-of-the-
art-technology, leave much to be desired. “In private settings, situation should have been ideal but unfortunately it is the opposite,” laments Dr Pais.” The high costs and competition have driven centres to do a lot of unethical work,” he reveals. “Hospitals who are only
after financial returns have no quality control or audit on surgeries, type of chemotherapy and indications for radiotherapy etc.,” he adds. Talking about positives of cancer care in private settings, Dr Vashishta says, “The private setting is well equipped
with the latest machines and better infrastructure where patients get individual care and have shorter waiting time, but is expensive.” Agreeing Prof Dr Anita Ramesh, Professor Medical Oncology, Department of General Medicine, Sri Ramachandra Medical College and Research Institute, Porur says, “Private care hospitals provide comprehensive cancer treatment which is costly. Expensive chemo therapeutic drugs are used and unnecessary surgeries take place due to corporate pressure to increase the revenue. Even high end radio therapeutic techniques are used for palliative cases and patients are made to pay. If the doctor cannot satisfy the goals and target of the private hospital he is asked to leave.” Cancer care in the public sector is delivered by 17 regional cancer research and treatment centres spread across India. Efforts are ongoing to develop oncology wings in government medical college hospitals to fill up the geographical gaps in the availability of cancer treatment facilities in the country. “In the public setting, cancer care is mainly given by regional cancer centres and major medical colleges where the facilities are okay and comparable to the facilities available in private sector,” says Dr Jayaprakash Madhavan, Chief of Radiation Oncology, KIMS Pinnacle Cancer Centre, Thiruvananthapuram. However, the public sector has its own challenges. They are dependent on the government for funds and since cancer treatment technologies are expensive they have to wait till the funds are mobilised. Besides, they have huge patient
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0.7
KNOWLEDGE
MILLION New cancer cases detected every year in India
NEAR
50%
OF CANCER PATI DIE EVERY YEA
2-2.5 MILLION
CANCER PATIENTS IN INDIA
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11, 48, 692
TOTAL NUMBER OF NEW CASES DIAGNOSED/PER YEAR/2015
CANCER BURDEN BY ANATOMICAL SITES
Y
%
28%
19%
Tobacco related cancers
Gastro Breast intestinal tract
9%
8%
5%
10%
3%
2%
Cervix
Corpus uteri and ovary
Lymphoid and haemopoietic malignancies
Prostate
Central nervous system
S
PROJECTED NUMBER OF CASES BY 2015 Males – All Sites – 5, 48, 844/ New cases diagnosed per year Females – All Sites – 5, 99, 847/ New cases diagnosed per year Brain 22,025
Liver Colon Rectum 19,697 17,376 17,188
Breast 1,00,611
Cervix 94,857
Oesophagus 22,161
Ovary 39, 080
Stomach 22,893
Lung 24,164
Larynx 24,169
Corpus uteri 23, 925
Tongue 36, 457
Gall bladder 22, 686
Prostate 39,200
Mouth 51,362
Thyroid 17, 852 Lung 55,834
NHL 14, 032 Myeloid leukaemia 14, 068
Mouth 18866
Oesophagus 15, 183 Colon 14, 440
Stomach 13, 944 Source: Population based cancer registry - ICMR Study
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KNOWLEDGE
Tumour Board helps in multidisciplinary approach to cancer care
load and fewer oncology specialists which makes cancer care very challenging for public sector centres. “Public settings are lacking in infrastructure, there is longer waiting period for patients and doctor to patient ratio is huge,” laments Dr Vashishta. “In public hospitals, the patient load is too much and individual care or even standard of care cannot be given,” says Dr Ramesh. Explaining further, Dr Pais says, “In a public set up the problem of finance, out-dated machines, lack of availability of chemotherapeutic drugs and a lack of dedicated and motivated staff makes cancer treatment ineffective.”
Mismatched care Much is said about multidisciplinary approach to cancer care. Medical collaboration is of utmost importance in cancer treatment. Many hospitals emphasise on Tumour Boards which consist of surgeons, medical oncologists, radiation oncologists, and other specialists who work together to provide the best treatment plan for cancer patients. How far is this approach applied in the Indian settings? Not often. There is a huge mismatch of therapy recommendation, burdening the patient with long bills. Tumour Boards are not common sites although their assessment can enhance treatment. Dr Ramesh explains that if a patient consults the surgeon first he opts for surgery while if he approaches a radiation oncologist then he is
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given radiation first. “Most of the hospitals do not have Tumour Boards and cases are not discussed in multidisciplinary meetings. Individual decision taken may not be good for the patient,” he adds. “The type of therapy to be used should be decided by the Tumour Board and not by one radiation oncologist, especially in private setups,” emphasises Dr Pais.
India. Unless we change, many new molecules for treatments are not going to be marketed in India in early phase,” insists Dr Madhavan.
Drastic measures required
Skyrocketing costs Cancer care is dynamic and a continuous process. It is needless to say that cancer care is expensive. “Cancer treatment facilities require large capital investment and hence treatment is more expensive,” explains Dr Madhavan. Elaborating on costs, Dr Vashishta says, “Cancer care is expensive because of expensive infrastructure; costly machines including radiotherapy machines; expensive anticancer drugs; longer hospitals stays; advanced cancers need longer duration of therapies increasing the treatment costs.” In fact, cancer drugs are the single largest cost factor that the patient has to deal with. A single dose of most cancer drugs are in the vicinity of Rs 50,000 – Rs 75,000. Even the generic versions of the branded drug are not within easy reach of the patients. “Price of the chemo drugs are also high because pharma companies have to spend so much for drug development clinical trials and till the
Cancer drugs are the largest cost factor that the patient has to deal with.A single dose of most cancer drugs cost around Rs 50,000 – Rs 75,000 approval of the drug in the open market. If they test thousands of molecules, one or two drugs may be successful to recover the expense and get profit. Companies are forced to fix the price and
insist on exclusive market rights by patent rates. So many newer drugs are uniformly priced all over the world. So many cases are pending in courts regarding exclusive market rights and patency in
Price control of cancer drugs is not only necessary but imminent. It is the need of the hour. India has taken drastic measures to check drug pricing in the last few years. In 2012, India deferred patents and exclusive sales of cancer drugs; Novartis’s Gleevec, Pfizer’s Sutent and Roche’s Tarceva. In addition, Bayer AG lost a legal battle to protect the Indian patent on its Nexavar kidney cancer medicine. On the other hand, Roche gave up the patent for Herceptin, a breast cancer drug. However, this has not made a drastic impact on the drug pricing. Cancer patient support groups and healthcare activists are demanding an even bigger discount, hoping to emulate the ripple effect caused by domestic competition that drove down prices for HIV medicines in the past. There is universal consensus across board on making cancer care affordable and this needs a multi-sectoral effort. “No curable cancers should be left untreated,” insists Dr Madhavan. “Cancer prevention, early detection and appropriate treatment can reduce cancer related mortality considerably. There should be close co-operation between public and private centres to make cancer care affordable,” he adds. mneelam.kachhap@expressindia.com
KNOWLEDGE INSIGHT
AMATTER OF INHERITANCE Dr JB Sharma, Senior Consultant, Medical Oncology, Action Cancer Hospital (Delhi) gives an insight into cancers that can be passed on due to heredity and the factors that
THE INCIDENCE of cancer has increased to such an extent that every second family now has at least a few members diagnosed with it. The causes of cancer largely include heavy smoking and drinking, sedentary lifestyle, improper diet, obesity, environmental factors etc. Besides these, cancer can also be hereditary in nature. However, hereditary cancer genes account for a very small percentage of all cancers. Often referred to as inherited cancer, what is inherited is the abnormal gene that can lead to cancer, not the cancer itself. Only about five per cent of all cancers are inherited, resulting directly from gene de-
fects inherited from a parent. At times, when there are numerous cases of cancer occurring in a family, it is most often by chance or maybe because of the family members’ exposure to a common toxin, such as cigarette smoking. There are very less chances of acquiring cancers by an inherited gene mutation. However, there are certain things like cases of an uncommon or rare type of cancer, cancers occurring at younger ages than usual and more than one type of cancer in a single person, more than one childhood cancer in a set of siblings that are more likely to cause cancer in a family through an abnormal gene.
Cancer in a close relative, like a parent or sibling, is much more a cause for concern than cancer in a more distant relative. Even if the cancer develops from a gene mutation, the chance of it passing on to a person gets lower with more distant relatives. Above all, what also matters is the type of cancer. More than one case of the same rare cancer is more worrisome than cases of a more common cancer. And having the same type of cancer in many relatives is more concerning than if it is several different kinds of cancer. Still, in some family cancer syndromes, a few types of cancer seem to go together. For e.g., breast cancer and ovarian
cancer run together in families with hereditary breast and ovarian cancer syndrome (HBOC). Colon and endometrial cancers tend to go together in a syndrome called hereditary non-polyposis colorectal cancer (HNPCC), also known as Lynch syndrome. Age is again an important factor when a person is diagnosed with cancer. For e.g., colon cancer is rare in people under the age of 30. Having two or more cases in close relatives of similar age group could be a sign of an inherited cancer syndrome. On the other hand, prostate cancer is very common in elderly men, so if both a father and his brother were found to have prostate
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KNOWLEDGE
cancer when they were in their 80s, it is less likely to be due to an inherited gene change. However, when many relatives share a similar type of cancer it is important to notice if the cancer could be related to smoking. For e.g., lung cancer is commonly caused by smoking, so many cases of lung cancer in a family of heavy smokers are more likely to be due to smoking than to an inherited gene change. Hereditary cancers are majorly of four types. ◗ Breast cancer There are concerns over breast cancer running in the family since a woman having a first-degree relative with breast cancer is about twice as likely to develop breast cancer compared to a woman without a family history of this cancer. Still, most cases of breast cancer, even those in close relatives, are not part of a family cancer syndrome caused by an inherited gene mutation. Chances of inheriting a form of breast cancer are higher when younger or when they have more relatives with the disease. Inherited breast cancer can be caused by several different genes, but the most common are BRCA1 and BRCA2 in which inherited mutations cause hereditary breast and ovarian cancer syndrome (HBOC). For women with a strong family history of breast cancer, we must prescribe them to undergo genetic counselling to estimate their risk for inherited breast cancer. If a mutation is present after the tests, the woman has a high risk of developing breast cancer. In such cases mammography must be conducted at an age younger than 40 along with special breast cancer screening tests. ◗ Colon Cancer It is caused by a disease called familial adenomatous polyposis (FAP). People with this disease start getting colon polyps by their teen years, and over time may have hundreds of polyps in their colon. If left alone, at least one of these
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ing cancers of the bone, brain, nasal cavities, and a type of skin cancer (melanoma).
Breast cancer
Childhood cancers
Colon Cancer
Li-Fraumeni syndrome
Even if the cancer develops from a gene mutation, the chance of it passing on to a person gets lower with more distant relatives polyps becomes cancer. The gene for this syndrome is called APC, and testing for mutations in this gene is available. If FAP is diagnosed early in life, a surgery to remove this colon helps stop the cancer from developing. Meanwhile, the hereditary non-polyposis colorectal cancer (HNPCC), or Lynch syndrome, which is the most common inherited syndrome of increasing a person's risk for colon cancer, carries a high risk of colorectal cancer. Most of these cancers occur before the age of 50. HNPCC also leads to a high risk of endometrial cancer in women, besides cancer of the ovary, stomach, small intestine, pancreas, kidney, brain, urethra and bile duct.
HNPCC is caused by mutations in one of the DNA repair enzyme genes MLH1, MSH2, MSH6, PMS1, or PMS2. Mutations in these genes can be found through genetic testing. For someone who is carrying an HNPCC gene mutation, they should start colonoscopy screening at an early stage. Some people even have surgery to remove most of the colon to try and prevent cancer from starting. A screening can also be done for endometrial cancer whereas in some cases, uterus needs to be removed after a woman is done with bearing children. ◗ Childhood cancers Like adult cancers, most childhood cancers are not inherited. But there are a few
types of childhood cancers that occur more often in some families. They occur due to hereditary cancer syndromes like Retinoblastoma, a childhood cancer that starts in the eye, can be caused by an inherited mutation in the tumour suppressor gene-Rb. One out of every four children with retinoblastoma carries this abnormal gene in every cell of their body. In most of these cases, this is due to a new mutation (gene change) in the sperm or egg, whereas in others, the abnormal copy of Rb is inherited from a parent. Children with the hereditary form of retinoblastoma are more likely to get tumours in both eyes. They also have an increased risk of developing other types of cancer, includ-
◗ Li-Fraumeni syndrome This syndrome occurs when a person inherits a mutation in the gene for p53 (TP53, a tumour suppressor gene). People with a TP53 gene abnormality have a higher risk of childhood sarcoma, leukaemia, and brain (central nervous system) cancers. Li-Fraumeni syndrome also raises risk of cancers of the breast and adrenal glands. Since inherited mutations affect all the cells of a person's body, genetic testing helps in identifying the mutations. We need to recommend genetic counselling and testing to people with a strong family history of cancer. Genetic testing can be suggested to those people who have several firstdegree relatives with cancer, cancers in their family that are sometimes linked to a single gene mutation, family members who had cancer at a younger age, close relatives with rare cancers that are linked to inherited cancer syndrome or a known genetic mutation in one or more family members. However, if a genetic test result turns positive, managing the risk should become a priority for us as well, besides the patient. Some of the ways to lower the risk includes prescribing chemoprevention, preventive or prophylactic surgery, and suggesting lifestyle changes. The increasing evidence of genetic or hereditary linkage to cancer onset and development can no longer be overlooked. While genetic testing facilities are available, they should be made more accessible to individuals. Although researches are being conducted to find newer and better ways of detecting, treating, and preventing cancer in people who carry genetic mutations, but an awareness of genetic predispositions coupled with a healthy lifestyle among the individuals, will result in significant reduction in the risk of developing cancer.
KNOWLEDGE INSIGHT
Drug resistance testing: Making anti retroviral therapy more efficacious Dr BR Das, President-Research & Innovation, MentorMolecular Pathology and Clinical Research Services, SRL expounds on drug resistance testing in HIV and its importance for improving the efficacy of ART India’s national anti retroviral therapy programme: A successful feat The Joint United Nations Programme on HIV/AIDS called “UNAIDS” has praised India’s efforts in reducing the spread of HIV/AIDS in the country in the last decade and has considered India’s efforts in making anti retroviral therapy (ART) available to more and more people as exemplary for other nations. The number of Indian HIV patients receiving anti-retroviral therapy approximately doubled from 2007 to 2009 and then again from 2009 to 2012. On a global scale, India ranks second with respect to the number of HIV patients having access to life saving ART. It is commendable that 650 000 HIV positive Indians are receiving treatment in the country. India continues to strive to reach the target of ART coverage for one million seropositive Indians in near future with the help of its national treatment programme.
Drug resistance testing: A crucial step to fortify the efficacy of ART However, the biggest challenge faced while planning ART for a patient is drug resistance. Though several anti retrovirals
have been developed; drug resistance minimises the therapeutic options available to HIV/AIDS patients. In this way drug resistance poses a major challenge for successful management of HIV/AIDS cases. Though HIV Viral Load values are indicative of non-responsiveness of the ART, it becomes extremely important for a clinician to understand the drug sensitivity profile of a seropositive patient towards a wide
spectrum of anti retrovirals. Total 19 antiretroviral drugs have been approved for the treatment of HIV-1 infection: one nucleotide and seven nucleoside reverse transcriptase inhibitors (NRTIs), seven protease inhibitors (PIs), three nonnucleoside RT inhibitors (NNRTIs), and one fusion inhibitor. Extraordinary patient effort is required to adhere to drug regimens that are expensive, inconvenient, and often associ-
ated with dose-limiting side effects. Incomplete virus suppression due to these factors predisposes to the development of drug resistance, which threatens the success of future treatment regimens. HIV has remarkable genetic diversity during course of infection therefore it behaves differently in different patients. Due to these variations in viral population the anti retroviral sensitivity and resistance profiles of
different patients or even same patient may differ widely at various stages of the disease. A significant proportion of new HIV infections results from the transmission of strains which are already resistant to one or more antiretroviral drugs. Detection of drug-resistant virus before starting a new drug regimen is an independent predictor of virologic response to that regimen. Several prospective controlled studies have also shown that patients whose physicians have access to drug resistance data, particularly genotypic resistance data, respond better to therapy than control patients whose physicians do not have access to these assays. Therefore, in order to ensure that ART works effectively for every patient at every stage of the disease, it is imperative and highly recommended to perform anti retroviral drug resistance testing. Drug resistance testing in HIV/AIDS improves therapeutic efficacy, the risk benefit ratio of the therapy being provided to the patient and the survival and prognosis.
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KNOWLEDGE
Anti-retroviral drug resistance testing: The nittigritties Genotypic and phenotypic resistance assays aid in predicting or confirming the drug response of HIV in a particular patient. Phenotypic resistance assays measure the extent to which an antiretroviral drug inhibits virus replication in vitro, whereas Genotypic assays detect mutations that are responsible for drug resistance.It is used more commonly than phenotypic testing because of its lower cost, wider availability, and shorter turnaround time. Genotypic testing provides early evidence of drug resistance within a virus population. Genotypic assays detect mutations present as mixtures even if the mutation is present at a level too low to affect susceptibility in a phenotypic assay, and detect transitional mutations that do not cause drug resistance by themselves but indicate the presence of selective drug pressure. Genotypic assays detect mutations even if the phenotypic effect of the mutation is suppressed by other mutations in the sequence. The clinical usefulness of genotypic testing has been demonstrated in four of five prospective randomized studies in contrast, phenotypic testing has been shown to be clinically useful in just one of four prospective randomized studies. Co-tropism assay is also available as research based assay which can be performed prior to CCR5 antagonist therapy. In the subsequent sections, let us have a closer look at the genotypic assay.
Genotypic drug resistance testing in HIV/AIDS The half-life of HIV-1 in plasma is approximately 6 hours, which enables isolation of actively replicating virus from this specimen. Sanger sequencing is the standard approach to HIV genotyping; it involves specific amplification of Reverse Transcriptase (RT) and Protease genes of HIV-1 genome followed by sequencing of these target genes using sensitive capillary automated Sequencers.
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RECOMMENDED TIMEPOINTS FOR HIVVIRAL LOAD TESTING AS PER INTERNATIONAL GUIDELINES CD4 Count
HIV Viral Load
Follow-up Baseline before ART initiation
At ART initiation or switch
After ART initiation or switch
Follow-up on Treatment failure effective or clinical ART indications
✓
✓
1-3 months
Every 3-6 months*
✓
✓
2-8 weeks, then every 4-8 weeks until HIV RNA is undetectable
Every 3-4 months**
✓
✓
Every 3-6 months
Every 3-4 months
* Patients on a stable ART regimen with sustained viral suppression for >2-3 years may be monitored every 6-12 months. ** Adherent patients on stable ART with sustained viral suppression and stable clinical and immunologic status for >2-3 years: some experts may monitor every 6 months.
Obtained mutations are then compared with comprehensive and exhaustive mutation database available with the International AIDS Society US and the Stanford University HIV Drug Resistance Database. "Drug Resistance Interpretation," is conducted by submitting generated protease and RT sequences, the online program returns inferred levels of resistance to the 16 FDA-approved anti-HIV drugs. Each drug resistance mutation is assigned a drug penalty score for inferring the level of drug resistance as: susceptible, potential low-level resistance, low-level resistance, intermediate resistance, and high-level resistance. Since many mutations in both the protease and RT are known to be associated with drug resistance, it has become customary to label some drug resistance mutations as either "primary" or "major" and other mutations as "secondary" or "minor". Primary mutations are those that reduce drug susceptibility by themselves whereas secondary mutations reduce drug susceptibility in combination with primary mutations or improve the replicative fitness of virus isolates with a primary mutation. Interpreting the results of HIV genotyping vis-à-vis drug resistance requires in depth of knowledge of known mutations and their impact on the efficacy of ART. Just to cite an example, HIV positive patients with an M184V mutation would not benefit from therapy with antiretrovirals like Epivir or Emtriva, as
this mutation confers resistance to these drugs. Such information helps clinicians to decide and make an informed choice while therapy planning.
CD4 count, HIV viral load testing and drug resistance profiles: In conjunction with each other CD4 counts and plasma HIV RNA load (viral load) have been the cornerstones of the monitoring work up for HIV/AIDS. CD4 counts and HIV viral load should be performed at baseline before initiation of ART. This provides an idea about the urgency of starting ART or whether treatment can be deferred. CD4+viral load testing can be repeated every 3-6 months; however timepoints for viral load testing may vary based upon patient status, baseline viral load levels and changing clinical situations. The duo of CD4 count and viral load testing yields the following clinically pertinent information: ◗ Current status of the patient’s HIV (severity, disease progression, survival prediction ◗ Risk of opportunistic infections/Need for prophylactic therapy ◗ Urgency of initiating ART/ Determining the efficacy of ongoing ART ◗ Monitoring adherence and compliance to ongoing ART and overall prognostication Optimal virologic response in HIV is generally considered to be plasma HIV load below the lower limit of detection of different assays which could range from <20 to 75 copies/ mL; de-
pending upon the assay being used. Occasional peaks in viral load may be seen in successfully treated patients (<400 copies/mL), however, such peaks cannot be regarded as virologic failure. The snapshot of recommended timepoints for HIV viral load testing as per international guidelines is given above. One of the most common reasons for a suboptimal virologic response as seen by viral load results and a low CD4 count is poor efficacy of the ongoing ART due to antiretroviral drug resistance. Therefore, in any given clinical setting, antiretroviral drug resistance testing cannot be viewed in isolation. It has to be considered and performed in conjunction with CD4 counts and HIV viral load. A consistently depleting CD4 count and perpetually high viremia are pointers towards the fact that ART might not be working due to HIV mutations and resultant drug resistance. Therefore, this needs to be tested and confirmed and if need be, therapy needs to be changed as per the results of drug resistance testing.
When to perform drug resistance testing for HIV patients? The US-FDA’s Department of Health and Human Services (DHHS) and the National Institute of Health (NIH) set up a panel of experts to frame guidelines for the use of antiretrovirals in adults and adolescents. Under this initiative, a detailed set of guidelines have been promulgated. These guidelines
present a comprehensive and elaborate set of recommendations regarding the use of drug resistance testing before and during HIV/AIDS therapy. Given below are the strongly recommended situations for considering genotypic drug resistance testing in HIV-1 patients: ◗ HIV drug-resistance testing is recommended in persons with HIV infection at entry into care regardless of whether ART will be initiated immediately or deferred. ◗ Genotypic testing is recommended as the preferred resistance testing to guide therapy in antiretroviral-naïve patients. ◗ HIV drug-resistance testing should be performed to assist in the selection of active drugs when changing antiretroviral regimens in persons with virologic failure and high HIV RNA levels. ◗ Drug-resistance testing in the setting of virologic failure should be performed while the person is taking prescribed antiretroviral drugs or, if not possible, within four weeks after discontinuing therapy. ◗ Genotypic resistance testing is recommended for all pregnant women before initiation of ART and for those entering pregnancy with detectable HIV RNA levels while on therapy.
References 1.http://www.unaids.org/en/resources/presscentre/featurestories/2013/august/20130830india/ 2.http://www.aidsmeds.com/cn/p rintView.php?page=/articles/Resistance_10312.shtml&domain=w ww.aidsmeds.com 3.Panel on Antiretroviral Guidelines for Adults and Adolescents: Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents: Department of Health and Human Services. Available at: http://aidsinfo.nih.gov/ContentFiles/Adultand 4.HIV drug resistance, CD4 and viral load fact sheet accessible at: http://www.mtnstopshiv.org/sites /default/files/attachments/HIV%2 0Resistance%20Fact%20Sheet_13 AUG10.pdf
STRATEGY
mHEALTH: THE NEXTGAME CHANGER With potential applications which could enhance the value proposition for all players in the ecosystem i.e. from improving productivity in hospitals, creating opportunities for pharmaceutical companies to differentiate and adding functionality to medical technology offerings, mHealth could be a potential game changer. It is time to take action urge Bart Janssens, Partner and Director, BCG and Rahul Guha, Principal, BCG
PROFESSOR JACQUES Marescaux and his team of surgeons in New York created history when they performed a laparoscopic gall bladder removal. Routine in every way except for one fact - the patient was 7,000 kilometres away in France. Operation Lindbergh, as this feat came to be known was the worldâ&#x20AC;&#x2122;s first transatlantic tele-surgery, and represented a technological leap for mobile networks and a paradigm shift for medicine. With patient location no longer hindering access to healthcare this opened up a wide gamut of opportunities to change how healthcare gets delivered today. Tele-surgery fits under the broad gamut of what is called mHealth today. mHealth is a platform which leverages information and communication technology to deliver a range of healthcare services to end users (patients, physicians, healthcare administrators). mHealth at the basic level leverages technology platforms to provide information and learning to the patient. As you integrate technology deeper into the care segment, mHealth could provide a platform of communication between healthcare provider and patient, support decision making through an analytics platform and support remote diagnostics and even treatment as we saw in Operation Lindbergh. With potential applications which could enhance the value proposition for all players in the ecosystem i.e. from
improving productivity in hospitals, creating opportunities for pharma companies to differentiate and adding functionality to medical technology offerings, mHealth could be a potential game changer. By 2020, even by the most conservative estimates, we believe the Indian mHealth market will be worth over a billion dollars (see EXHIBIT 1). The next decade will witness the development of ideal conditions for this massive rollout of mHealth. Smart phone and Internet penetration will expand rapidly (Internet penetration will increase from the current level of 13 per cent to over 50 per cent), and so will consumer and institutional spend-
ing on healthcare. Additionally, mHealth addresses several fundamental supply side constraints placed on healthcare access and quality faced by the traditional delivery model. As we know, with a doctor to population ratio of less than 1:1500 healthcare delivery is severely resource constrained across both urban and rural segments. The current delivery model is also burdened by transaction costs i.e. travel time, significant waiting time which impacts both the cost of access to healthcare but also the opportunity cost of the
visit. e.g. a full day and the income for that day could be lost in travel to and from the nearest doctor and waiting time. Add to that the complexity that the doctor might not be available and you can see that for even minor ailments, transaction costs (transportation costs, time spent) could be as high as multiples of the consultation fees. mHealth tackles these resource constraints by boosting the productivity of healthcare personnel, and by, giving patients direct access to healthcare information (see EXHIBIT 2). mHealthâ&#x20AC;&#x2122;s role in shifting this supply curve comes from three areas i.e. improved access, enhanced productivity and better healthcare out-
comes through increased engagement of the patient. Access improves as mHealth disaggregates elements of the healthcare supply chain, allowing healthcare personnel to extend their reach beyond the physical catchment area of their facilities. Services such as virtual doctor (patients diagnosed by doctors over video conferencing facilities) and eICU (remote monitoring of ICUs in resource constrained hospitals) demonstrate these advantages. This implies greater capacity utilisation translating to lower costs, lower transaction costs for the patient greatly improving the supply curve. Enhanced productivity through mHealth could be achieved by leveraging decision support systems to help doctors diagnose and treat better. At present, despite a growing body of clinical trial data and patient records, medical science remains as much an art as a science. Existing applications such as Clinical Decision Support (CDS) distils the contents of medical databases and patient records to present relevant information to physicians at the point of care and have tremendous value in enhancing the efficiency of providers. Finally, by empowering patients, mHealth reduces demand on the traditional healthcare setup through applications such as self-monitoring, particularly for conditions requiring chronic care. By engaging the patient in the management of the disease
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STRATEGY
mHealth strives to achieve greater compliance and therefore greater outcomes and efficiency in the care process.
Radical change across the ecosystem The emergence of mHealth will alter market dynamics in the healthcare space. Participants should invest the time in thinking through how mHelath could add value to their business model. Using mHealth to better the value proposition of improved access, enhanced productivity and better outcomes could convert this into a significant opportunity. Pharmaceutical companies in India compete in a highly crowded market dominated by generics. and relatively undifferentiated space. By offering disease specific value added services along with their basic drug products, pharmaceutical companies can alter the choice spectrum for prescribers. This will help providers deliver better services and drive enhanced outcomes for their patients. For the companies, this is an opportunity to build differentiation and get closer to the endcustomer. Several categories of services such as diet and lifestyle advice for patients of chronic diseases, information
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Healthcare systems around the world are in dire need for structural reform, and mHealth has the potential to deliver portals and reminder services (ex: ovulation reminders) offered through mobile applications and call centres hold the potential to improve patient outcomes. While these services could be offered as free add-ons, Indian customers have even shown a willingness to pay. For example, a study conducted by the Institute of Reproductive Health in Delhi and Lucknow revealed that women were willing to spend Rs 25 and 50 per month for ovulation reminder SMSâ&#x20AC;&#x2122;s. Medical technology companies will experience a shift in market dynamics due to mHealth. Software platforms added to devices such as Clinical Decision Support can significantly enhance a doctorâ&#x20AC;&#x2122;s productivity. These applications add significant functionality to various devices and medical technology run the risk that value could shift away from their products and towards these services. This situation has parallels with the evolution of the computer in-
dustry, where market power shifted from the hardware makers to software companies as customers gained familiarity with the interface abstracting themselves away from the hardware. On the bright side, there is much to be gained if medical technology players extend their offerings into the mHealth space. Besides the cross selling synergies of bundling products and services, companies can build significant switching costs for doctors and hospitals by training personnel on their integrated mHealth systems. Hospitals have been a space with high capital expenditure and long gestation periods. mHealth offers attractive alternatives for new entrants. It allows for the centralization of physical infrastructure with scale benefits on capital expenditure and utilization of both equipment and personnel. As a result, new entrants could leverage better capital efficiency and productivity to expand faster than traditional
chains. Traditional chains might face competition not just in their catchment area, but from players who are in other cities. The onus then lies on established players to bolster their mHealth capabilities as a flanking defense to ward off these potential competitors. Utilising their established network, these hospitals could use a hub and spoke model to expand their network using mHealth as a platform. This also has the added benefit of expanding the primary care network for the hospital.
Time to take action Healthcare systems around the world are in dire need for structural reform, and mHealth has the potential to deliver. India in particular, with strong demand drivers and fundamental supply constraints is primed to leverage this opportunity. Additionally, the nascent nature of the healthcare ecosystem is the ideal market to test new mHealth models.
To tap into this opportunity, companies should ask themselves which of their segments are currently underserved in their business and how a disruptive offering leveraging technology could change the game. A caution, underserved need not be low income segments e.g. non compliant diabetic and hypertensive patients are as equally underserved today as rural farmers. Further, to incumbents mHealth could substantially disrupt the current business model. Its important players closely examine their core value proposition and the barriers to entry in their business. Asking ask how mHealth could change these dynamics should help companies turn this trend to their advantage. mHealth today is a small part of the healthcare landscape, but its future is bright. It remains to be seen in the next few years which companies recognise the tremendous potential technology and connectivity has to offer in the healthcare delivery space. Acting on this agenda not only makes business sense, but also moves the needle significantly in improving and scaling up our nationâ&#x20AC;&#x2122;s healthcare infrastructure.
STRATEGY REPORT
Maharashtra’s elderly show higher levels of abuse: UNFPAreport 35 per cent of the elderly in Maharashtra reported abuse, as opposed to 11 per cent in the other six states UNFPA AND its collaborating institutions – Institute for Social and Economic Change (Bangalore), Institute of Economic Growth (New Delhi) and Tata Institute of Social Sciences (Mumbai) – have successfully conducted an in-depth survey on ‘Building a Knowledge Base on Population Ageing in India (BKPAI)’ in 2011. The survey was conducted in seven major states in India, having relatively higher proportions of the elderly in the population. It was strongly felt by the Technical Advisory Committee (TAC) of the project and many other experts that a separate state level report be brought out for each of the seven states. The preparation of state wise reports was undertaken and the Punjab and Kerala State reports were released in December 2013. On January 16, 2014 the Maharashtra State Report entitled ‘The Status of Elderly in Maharashtra, 2011’ was released during the Inaugural session of the Indo-UK two-day workshop on ‘Ageing’ held at the Library Conference Hall, TISS, Mumbai. This was followed by a presentation of highlights of the Maharashtra Report by Dr D K Mangal. The Indo-UK workshop included discussions to explore and strengthen Indo-UK collaborative partnerships between academia, experts, governmental and non-governmental departments in the area of ‘ageing’ and was therefore seen as a relevant context for release of the state report. The dignitaries on the dias were Prof S Parasuraman, Director, TISS, Mumbai, Prof F Ram, IIPS, Mumbai, Dr Sujaya Krishnan, Joint Secretary, MoHFW, GoI, New Delhi and Frederika Meijer, UNFPA.
After the screening of a UNFPA film on ageing at the workshop, Meijer commented on the need to see the people behind the data because each one has different needs and we need to think of them as individuals. Speaking about the larger issues and the context of the two-day workshop, and the reason for UNFPA’s engagement, she said, “Population ageing is a major trend of the 21st century. And India's population is ageing fast. According to latest UN projections, India's elderly population is growing at 314 per cent per cent while the overall population is growing at 55 per cent. There is a higher proportion of the elderly in rural areas, and even here, we see a higher percentage of women.
Rationale for ageing research UNFPA’s programme for ageing in India started in 2007 and Meijer indicated that they were are looking at ways to bring forward the ageing agenda in India. Ageing research is at a very nascent stage in India, and we have to also keep in mind that each state of the country is at a different stage of the demographic transition and therefore has different needs. To illustrate her point, she drew attention to some of the results of the Survey Report, The Status of the Elderly in Maharashtra, 2011. The results could be termed as a study in contrasts. While there was good news that compared to the other six states whose Survey reports have been already made public, Maharashtra had the highest number of active elderly, 35 per cent, of the elderly reported abuse, as opposed to 11 per cent in other states. Such re-
search is important because data /evidence can strengthen advocacy for policy change as well as intervention and implementation at the grass roots level. This research will also help modification of appliances and services for rural area for instance, walkers with wheels might not work in (will not work in) India’s sometimes muddy rural areas, pointed out Meijer. She cited a study done in Gujarat which showed how many hurdles the elderly came up against to access their pension and how the process could be simplified by getting ASHAs to play a facilitating role. Similarly she said it was important to strengthen the healthcare professionals at all levels but especially in the rural areas, to recognise signs of ageing and associated medical problems like Alzheimer’s, dementia, hearing loss since most of these signs are difficult to recognise. Meijer stated, “It is important to create a bridge of inter generational dialogue. The young complain that the elderly do not understand them while the elderly complain that they do not get the respect. Both are right, both have something to say, have their needs which both sides need to understand.” The 89-page report has
seven sections analysing various data points ranging from work, income and assets, living arrangements and family relations, health and subjective wellbeing, social security a swell as suggestions on the way forward.
Recomendations Importantly, the survey findings help in drawing some conclusions and suggestions for framing policy and programmes. The first suggestion was the need for covering all the needy elderly (irrespective of BPL status of household) under economic and other security programmes. It was also suggested that fertility reduction policies should go hand in hand with provision of social security in old age, as the elderly with no income and children to support them need the state to provide a safety net. The third suggestion was that livelihood programmes should be designed to provide work opportunities for the elderly as per their abilities and interest to keep them engaged and maintain their self-worth. The Report also pointed out that as across the world, among the elderly population of Maharashtra too there are more women than men. The scheme providing pensions to widows needs to
cover all the needy widows, even those from APL families and the amount provided has to be revised in accordance with the rising cost of living. Harking back to Meijer’s comments, the Report also touched on the need for sensitisation of the families and persons from other age groups (in schools/colleges) in order to prevent discrimination and abuse of the elderly. There is also need to encourage the identification of the elderly found to be facing abuse and plan interventions to handle such situations. At the family level, stronger inter-generational bonding needs to be encouraged and at community level, greater participation of the elderly has to be ensured by having agefriendly environments which will ensure harmony. Since the Report showed that arthritis and cataract are the major health problems among the elderly in Maharashtra and since surgery is the only remedy for cataract, the Report recommended that health care schemes that provide concessions are warranted in government hospitals for the elderly who require this surgery Touching on the need for proper financial planning, the Report pointed out that the financial resources of the elderly get depleted as they do not plan for their old age, particularly since most chronic diseases start in the late 40-50’s. Government programmes or NGO initiatives to educate and set good practices about financial planning for old age and elderly health care for persons in their fifties can prepare them better to have a peaceful later life.
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Dose management: An urgent need With more evidence mounting against ionising radiation, hospitals need to put comprehensive dose management programmes in place to balance patient safety, radiation dose and image quality BY M NEELAM KACHHAP
PATIENT SAFETY is of utmost importance in medicine. Having realised that patient safety may be compromised while engaging new technology, radiologists world over are now trying to reduce radiation dose given to patients and eliminate unnecessary radiation exposure. The concern is that new technologies are being used increasingly today. Technologies like fluoroscopy, nuclear medicine and computed tomography are being used more often than they were used 10 years ago. In addition, growing obesity has mandated the use of larger radiation doses as effective dose received by the patient is greatly affected by the size of the patient. One of the most discussed and debated concerns with radiation exposure is the risk of cancer associated with it. Although, there is wide disagreement about the extent of cancer risk; experts agree that there has to be a balance between benefits of imaging scans and risks posed by them. Calculating the risk to patients is a complex process that often does not generate any clear answers. Yet, radiation dose management is gaining popularity among Indian hospitals. “There is reasonable, though not definitive, epidemiological evidence that organ doses in the range from 5 to 125 mSv result in a very small but statistically significant increase in cancer risk,” says Dr Sharad Maheshwari, Diagnostic Radiologist, Kokilaben Dhirubhai Ambani Hospital, Mumbai. “These results come primarily from studies of
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approximately 30,000 atomicbomb survivors who were several kilometres away from the explosions and were thus exposed to low doses,” Dr Maheshwari explains. In a study, Berrington de gonzalez et al estimated that approximately 29,000 future cancer cases could be related to CT scans performed in the US in 2007 alone. In India, there is considerable buzz regarding radiation dose reduction and management, but this somehow fizzles out at the operational level.
“At the operational level, there is scope for improvement in the radiation safety processes followed by many institutions,” says Raveendran Gandhi, Senior Director, Radiology, Philips India. “At the operational level, technologists and doctors who operate CT scanner machines should be well qualified and adequately trained on the radiation aspects and should be aware about radiation dose delivered to patients for every investigation conducted on the equipment. Optimum quantity of
dose should be delivered for CT tests adhering to as low as reasonably achievable (ALARA) principle for obtaining diagnostic quality images,” he explains. Apart from this, on-site monitoring and site inspection during installation of the facilities and accessories, proper equipment installation, optimised use of radiation protection devices, radiation checks by integrating with equipment vendors should be mandatory to minimise dose to operators and public from CT
scanners. Presence of site radiation safety officers, training of the operators, planning and implementing QA processes and SOPs as well as conducting periodic radiation safety checks are essential requirements in the process of efficient radiation safety management. These multiple tasks will require on-going expert interactions and engagements from members of radiation facilities with regulators who will guide and be empowered to conduct regular monitoring for ensuring safety compliance.
“Ionising radiation is a double edged sword and has harmful effects such as causing infertility, radiation burns and cancer on prolonged exposure or on exposure beyond a permitted threshold,” opines Dr R Chandrasekar, COO and Chief Radiologist, Yashoda Hospital, Hyderabad. “Careful handling, dose optimisation and strict adherence to the safety guidelines are of utmost importance in ensuring that its harmful effects on patients and hospital staff are minimised,” he adds.
There is reasonable, though not definitive, epidemiological evidence that organ doses in the range from 5 to 125 mSv result in a very small but statistically significant increase in cancer risk’
Radiation dose management programme at hospitals The most systematic way to track, report and monitor radiation dose and eliminate unnecessary exposure is to develop a comprehensive, radiation dose management programme. “Radiation dose management starts with a conscious choice by institute /hospital to educate, monitor and maintain optimal radiation dose. Besides acquiring the right technologies, the focus should be on education and sensitising the staff on the benefits of radiation management and radiation safety,” says Sanjay David, Business HeadCT Scanners, Siemens Healthcare, India. “CT dose management relies on the ability of institutes/hospitals/organisations to adequately educate, monitor and maintain CT radiation. This forms the core of right dose management and radiation safety,” he adds. “The primary focus of such a programme is to optimise radiation procedures and associated processes in order to ensure minimum use of radiation to patient,” says Gandhi. “Operators should adhere to established safety measures during radiation procedures. Hospitals should focus on training operators and employees regarding radiation effects, safety features, and safety devices, as well as encourage them to use radiation monitoring devices such as TLD badges. Hospitals need to have an established radiation monitoring system in place, including documented standard operating protocols
Dr Sharad Maheshwari Diagnostic Radiologist, Kokilaben Dhirubhai Ambani Hospital, Mumbai
(SOPs) for the entire radiation testing procedures,” Gandhi further adds. In India, Atomic Energy Regulatory Board (AERB) has the mandate of ensuring radiation safety. “As per AERB regulation, it is essential for hospitals offering CT scans to have documented procedures and programmes for radiation safety,” explains Gandhi. “The programme should be managed by a certified Radiation Safety Officer (RSO). Periodical safety assessment reports should be recorded and reports should be submitted to AERB. Operational licenses are required for the facility, equipment installation and continuous operations of CT scanners in hospitals. These regulations are essentially
compelling in nature to implement effective radiation safety programmes,” he further adds. Talking about the guidelines followed to minimise radiation at Mumbai's Kohinoor Hospital, Dr Priya Darshan Chudgar, Consultant Radiologist, Kohinoor Hospital says that CT exams must be appropriately justified for clinical need. All technical aspects of each CT examination must be optimised. The most dose-efficient technique should be used to achieve the target image quality. For instance, these are the techniques followed at Kohinoor Hospital: ◗ Justification of the CT examination from referring physicians ◗ Not using unnecessary CT examinations (e.g., whole-
body screening) ◗ Optimising the dose performance of detector, collimator and beam-shaping filter ◗ Using manual technique charts or automatic exposure control systems to adapt the dose to patient size, and select the appropriate tube potential ◗ Improving data processing and image reconstruction to gain more information from each study and avoid repeat examinations Expressing his views, Dr RK Gupta, Director & HOD – Department of Radiology & Imaging, Fortis Memorial Research Institute, Gurgaon, says, “It is very important to use protocols with reduced radiation to ensure optimal image quality with minimal radiation. All children below
Hospitals need to have an established radiation monitoring system in place, including documented SOPs for the entire radiation testing procedures Raveendran Gandhi Senior Director- Radiology, Philips India
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Careful handling, dose optimisation and strict adherence to the safety guidelines are of utmost importance to minimise harmful effects of radiation on patients and hospital staff Dr Chandra sekar COO and Chief Radiologist, Yashoda Hospital, Hyderabad
Radiation dose management starts with a conscious choice by nstitute/hospital to educate, monitor and maintain optimal radiation dose Sanjay David Business Head-CT Scanners, Siemens Healthcare, India,
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16 years of age should not undergo diagnostic procedures which use radiation including CT unless it is absolutely justified and indicated and we do not have options like USG, IR imaging, optical and MR imaging for those investigations.”
Goals of dose management programmes Dose management programmes involve collaborative efforts of the entire radiology department. Elaborating on the topic Dr Maheshwari says, “The radiology department has certain guidelines which have been posted on the intranet and are available for radiology staff, including radiologists, resident radiologists (assistants/ associates), DNB students and technologists. The technologist and residents radiologists have been trained and sensitised to radiation protection and urged to follow the guidelines wherever possible without compromising diagnostic quality.” He further points out five primal goals for these programmes:
Gathering radiation dose data: It is the first step in the optimisation process. Typically, dose data is collected when a cause for concern is raised for some reason or as a recurring quality control measure. A more systematic approach and a permanent solution is required for automated collection of dose data from all modalities. Monitoring, analysing and finding best practice: A dose monitoring solution is required to implement ALARA principles. In-depth analysis, benchmarking between different modalities, different hospitals, or even different technologists and doctors leads to developing best practices. Visualising radiation dose data (multidisciplinary team approach): Showing the dose level will create a curiosity about dose. That is an important first step in raising the discussion and finding the optimal balance between dose and diagnostic quality. The interest in dose monitoring needs to spread from the physicists to radiologists, technologists and clinicians.
With the dose information at hand, better decisions can be made, answering questions such as: Which type of follow-up examination is optimal? Given the higher dose level, is the CT exam really necessary or is a regular X-ray sufficient? Appropriate use of radiation: It is an important patient safety and quality issue. Radiation dose-management programmes should focus on determining the right test at the right dose in a timely fashion. Ensure that the test is clinically indicated; avoid duplicate tests; and make sure alternative tests, such as an ultrasound or magnetic resonance imaging, are not viable options. Keeping pace with technology: Another challenge is the fast pace of technological development. In many instances, the technology is not being used to its fullest extent to help reduce radiation exposure. Forming strong vendor relationships and participation in training for technologists can help overcomethis challenge.
Most important for dose management programme Most dose management programmes look at appropriate justification for ordering and performing each procedure, and careful optimisation of the radiation dose used during each procedure. Explaining the process further Dr Maheshwari lays down the following points: Justification and optimisation: Setting a goals to use imaging only when the potential clinical benefit outweighs the potential risk and to strive for an imaging examination that delivers the lowest dose necessary to obtain the desired information: In short, we must aim for justification and optimisation of each imaging procedure Standardisation is crucial: Professional organisations, including American College of Radiology (ACR) and the American College of Cardiology (ACC), have developed and are working to disseminate imaging referral criteria, called “appropriateness criteria” or “appropriate use criteria,” associated with a number of
RADIOLOGY
medical conditions. However, criteria for appropriate ordering of medical imaging exams have not yet been broadly adopted by the practising medical community. Ensure the right test: Enhance communication between ordering physicians and radiologists to ensure that the right test is ordered based on an individual patient's needs and diagnostic requirements. Ensure the right dose: Conduct a periodic check of imaging equipment to ensure proper functionality. Adopt "ALARA” guidelines set forth by the US Nuclear Regulatory Commission. Develop low dose protocols. Develop a process to review dose protocols on an annual or biannual basis to ensure that protocols are followed. Examine cases in which protocols were not followed and provide education to prevent future occurrence. Increase patient awareness: Empower patients with information and tools to help them and their physicians manage their exposure to radiation from medical imaging in the short term, even before longer-term changes take effect. Developing comprehensive radiation dose-management programmes to track, report and monitor patients' exposure. Patients can be provided with a medical imaging record card that tracks the type of test performed, the date and location of the test and the radiation dose.
Technology of dose management There are numerous tools for dose management. In fact, various vendors have inbuilt software and mechanisms to manage and reduce radiation dosage like: ◗ X-ray beam filtration ◗ X-ray beam collimation ◗ X-ray tube current modulation and adaptation ◗ Patient body habitus (automatic exposure control) ◗ Peak kilovoltage optimisation ◗ Improved detection system efficiency ◗ Noise reduction algorithms ◗ Iterative reconstruction
Sharing responsibility
Most equipment manufacturers today are torchbearers of dose management and have focused services for dose reduction and management for the doctors Most equipment manufacturers today are torchbearers of dose management and have focused services for dose reduction and management for the doctors. “CT dose management relies on the availability of dose data and adequately educated personnel. These two aspects are at the core of right dose management, which further optimises dose reduction,” says David. “We have applied the ALARA principle to its true spirit while designing our low dose diagnostic machines. We strive to excel in this field by extensive research and regularly come up with latest technologies in reducing radiation dose in our new and existing diagnostic devices,” says Gandhi. Some of the initiatives by leading equipment manufacturers are:
Siemens Healthcare DoseMAP - Siemens CT Dose Management Programme: Provides functionalities like CARE Analytics to report, document and analyse dose. It lets the user access dose values per case, per examination type or per patient. Additionally, access to scan protocols can be restricted to protect the set dose levels and to prevent unauthorised changes to the scan parameters. EduCARE: It bundles dedicated trainings from Siemens that focus on key technologies and their application in clinical practice. Exclusive tutorials, webinars, etrainings and brochures cover a wide range of topics related to achieving the right dose. Optimize CARE CT: It is a cross-modality consultancy programme offered by Siemens Customer Service. Over the course of the pro-
gramme, Siemens professionals guide users towards optimising the use of radiation in order to reduce dose. Through onsite and offsite support and trainings, users learn how to use the right dose technology to deliver the right dose levels for every patient.
Philips Healthcare iDose4 is an iterative based reconstruction technology recently introduced with Philips CT scanners through which the machine is enabled to reduce radiation dose up to 80 per cent without compromising on the quality of images it delivered. iDose4 is also capable of improving the image quality at low radiation dose! The company claims to has shipped more than a thousand iDose4 Scanner upgrades within a short span of its inception into the market. This technology is among the most successful low dose imaging technology in the CT industry which got widely appreciated by the entire radiology community. Philips CT received excellence in radiology award from AuntMinnie.com (the "Minnies" awards recognise excellence in radiology) which picked out the iDose4 Premium Package as the Best New Radiology Software during RSNA 2012. “Dose-Aware” is a radiation exposure monitoring device which Philips developed for cath lab operators. This device will provide live feed about total exposure the operator received during a cath lab procedure to avoid unnecessary exposure to radiation.
GE Healthcare GE Blueprint: Launched in June 2012, GE Blueprint offers a comprehensive approach based on an assessment of a healthcare provider’s
technology, people and processes and helps identify breakthrough imaging technologies, system-specific solutions and processes, and comprehensive imaging “blueprints” to help providers achieve low-dose, high-definition diagnostic capabilities. GE Blueprint’s goal is to work with healthcare providers to reduce their average patient exposure by up to 50 per cent, based on longitudinal tracking of average dose. DoseWatch, enables radiologists to measure, track and optimise patient radiation dose over time. It is a web-based dose monitoring software used to capture, track and report radiation dose statistics directly from the imaging device, multi-modality and vendor agnostic. Doctors can produce sharp, focused diagnostic images, all while keeping dose levels as low as reasonably achievable (ALARA). DoseWatch monitors cumulative dose over time, and prevents excessive medical radiation exposure.
CT exams must be appropriately justified for clinical need. All technical aspects of each CT examination must be optimised and the most dose-efficient technique should be used Dr Priya Darshan Chudgar Consultant Radiologist. Kohinoor Hospital, Mumbai
More to come The healthcare industry in India is undergoing rapid changes. Radiology is also evolving. It has many important clinical uses and can provide significant benefits. But the concerns related to CT, fluoroscopy, and nuclear medicine imaging procedures are also real. In future, better software systems are expected that will help radiologists analyse images much better and avoid unnecessary radiation exposure to patients. “The future will bring newer machines with advanced automatic exposure control techniques that select the appropriate tube potential and then modulate the tube current to reduce radiation dose. With ever-increasing computational power, iterative reconstruction will be implemented in daily clinical practice, which may lead to substantial image quality improvements and radiation dose reduction,” Dr Chudgar predicts.
It is very important to use protocols with reduced radiation to ensure optimal image quality with minimal radiation RK Gupta Director & HOD – Department of Radiology & Imaging, Fortis Memorial Research Institute, Gurgaon
mneelam.kachhap@expressindia.com
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IT@HEALTHCARE CASE STUDY
Cloud Power for Healthcare HCL presents a case study on cloud solution for efficently managing IT infrastructure Client brief The client is a healthcare IT service company in India. They are pioneers in enabling efficiency in the healthcare ecosystem by providing innovative web-enabled services and technology solutions to the healthcare industry. The Government of Tamil Nadu launched a flagship scheme for mass health insurance that covered 40 million people in the state, giving them cashless access to more than 500 life-saving treatments and surgeries. The scheme was aimed at providing affordable and quality health services to the people. The client was chosen as one of the healthcare solutions partner in this initiative for providing solutions to automate the IT infrastructure and create a web-based information exchange platform.
Client requirements The client was looking for an IT partner who could assist them in creating an agile and scalable IT infrastructure to ensure successful implementation of the Chief Minister's Comprehensive Health Insurance Scheme. The project included automating the claims processing and management cycle and make it available online so that 600+ healthcare providers distributed across Tamil Nadu could access it. The system would also have to be robust enough to process large volumes of applications quickly. The
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client was very particular about enabling the applications to run at peak performance, simultaneously reducing the CAPEX and OPEX.
Solutions offered Keeping in mind the varied business needs of the client, HCL offered the following solutions ◗ blu IaaS (Infrastructure as a Service): HCL provided IaaS with customer's choice of configuration and operating environment for the enter-
prise setup. This included high storage capacity and multiple layers of security to secure huge volume of data large data Troubleshooting virtual hardware as and when required ◗ Smarter and faster backup retention and restoration ◗ High uptime of services ◗ Pay-as-you-go pricing models, nearinstant scalability, provisioning of servers on the fly and ready availability of bandwidth and infrastructure.
Business benefits The implementation of the blu Enterprise Cloud Solutions at the client's premises enabled the IT team to manage its IT infrastructure in an efficient and ondemand manner. The business benefits, which emerged as a result of the deployment included ◗ Reduced Capex and Opex by 40 per cent ◗ Improved operational efficiency with 99.5 per cent
uptime ◗ Coverage of more than 50 per cent of the state population under the scheme ◗ Treatment outreach to more than 1.6 lakh beneficiaries within nine months of launch of the scheme ◗ Single window view of the entire IT Infrastructure performance ◗ Greater business agility ◗ Scalable IT infrastructure available at the touch of the button
HOSPITAL INFRA FAQs ON HOSPITAL PLANNING AND DESIGN | MEDICAL EQUIPMENT PLANNING | MARKETING | HR | FINANCE | QUALITY CONTROL | BEST PRACTICE
ASK A QUESTION How can I dispose prescription drugs?
destruction of pharma products.
DR ANIL JAIN, Nashik
Never flush prescription drugs down the toilet or drain unless the label or accompanying patient information specifically instructs you to do so. For drugs not labelled to be flushed, you may be able to take advantage of community pharmaceutical return programmes or other programmes, such as household hazardous waste collection events that collect drugs at a central location for proper disposal. Call your city or county government’s household trash and recycling service and ask if a safe drug disposal programme is available in your community Q If a drug return or disposal programme is not available in your community. Q Take your prescription drugs out of their original containers. Q Mix drugs with an undesirable substance such as cat litter or used coffee grounds. Q Put this mixture into a disposal container with a lid, such as an empty margarine tub or into a sealable bag. Q Conceal or remove any personal information, including Rx number, on the empty containers by covering it with a black permanent marker or duct tape, or by scratching it off. Q Place the sealed container with the mixture, and the empty drug containers, into the trash. Waste management is preparing to launch environmentally-protective and safe solutions for the return and
What is hospital indemnity insurance and how is the hospital indemnity insurance benefit paid? MANISH MALHOTRA, Bhopal
Hospital indemnity insurance is a type of plan that pays a set amount – per day, per week, per month, or per visit – if you are confined to a hospital. The hospital cash plan is a hospital indemnity insurance plan. When you experience a hospital confinement, outpatient surgery, or emergency accident or sickness, you submit a claim form along with the receipts for services received. You or your designer will receive a lumpsum payment as described in the policy. You or your designer can use the cash for whatever you choose.
DR DEEPAK MEHTA, Surat
The objectives of manpower planning are very wide and varied. The most important ones are: Q Ensuring maximum utilisation of personnel. Q Assessing future requirements of the organisation. Q Anticipating from past records: ●Resignation ●Discharge simplicities ●Dismissals ●Retirement Q Determining recruitment sources. Q Determining training requirement for management development and organisation development. What are the objective of catering and vending services of hospital? VISHAL GOYAL,Dehradun
What is the objective of manpower planning in hospitals? DR KAILASH, Jodhpur
I think that is all to do with efficiency and saving money.In this context that means having an appropriate level of staff on duty at all times. So less doctors/nurses at quiet times in the middle of the night, but enough to handle an emergency if it happens. It should also take into consideration the maximum number of hours doctors can work, so they are not pushed too hard and should have arranged backups so people can be called in if someone is sick or cannot work. What is the objective of man power planning in a hospital?
Objectives of in-house catering services: Q Provide a high quality catering service, responsive to your needs Q Aid your recovery with nutritionally healthy meals, cooked in the traditional way Q Provide a service that caters for all appetite and dietary requirements Q Provide an appetising and varied menu Q Deliver your exact meal requirements within the specified delivery time at the appropriate temperature Objectives of Vending Services Q Vending hot drinks Q Cold can/bottle Q Mars confectionery Q All day vending snacks
TARUN KATIYAR Principal Consultant, Hospaccx India Systems
Express Healthcare's interactive FAQ section titled – ‘Ask A Question’ addresses reader queries related to hospital planning and management. Industry expert Tarun Katiyar, Principal Consultant, Hospaccx India Systems, through his sound knowledge and experience, shares his insights and provide practical solutions to questions directed by Express Healthcare readers
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LIFE
MY TRYST IN
Rural India I
N 1968 WHEN I joined medical school, 80 per cent of MBBS students aspired to settle down as practitioners in their native villages. But I had different plans. I wanted to be medical officer (MO), a gazetted officer of the government and a very glamorous post. It is a prestigious position in the society. I gave Andhra Pradesh Public Service Commission (APPSC) in 1977 with eight senior batches while I was a PG student in paediatrics. I completed my PG in January 1978, got APPSC selection in April 1978 and a posting order in September 1978. After eight months' stint as a MO of ESI dispensary at Hindupur, Anantapur district, I was transferred as MO, PHC Kallur in Kadapa district due to the separation of ESI wing from the main Directorate of Medical and Health Services. I was told that Kullur is a remote place and many refuse to go there. May 24, 1979 was a red letter day in my life. I was 29 years old, full of energy and enthusiasm. A day when I started my work in the country side of my nation. I was quite euphoric. From that day, I was the custodian of health of 70,000 and odd people and the team leader of 60 plus nursing and paramedical personnel. I had to work with several formal and informal leaders across 50 and odd villages. I still remember the day I took a crowded private bus from Proddutur, a town near by Kallur to start my stint as MO PHC. Many people
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Dr Araveeti Ramayogaiah, FounderOrganization for Promotion of Social Dimensions of Health (OPSDH) and Former Additional Director of Health, Andhra Pradesh shares his experiences as a MO in rural India and recommends it as a great way of personality building for MBBS doctors
in the bus looked at me curiously as I was a stranger. After knowing that I was their next MO, they vacated a front seat for me immediately. The bus conductor refused to take the bus fare as I was their MO. By the time the bus reached Kallur, two elders of the village invited me for lunch. Through I declined their offer politely they did not budge. I reported at the PHC and started my work. The news about the new MO spread like wildfire in the village and a crowd thronged the PHC to see me! As I was born and brought up in a rural agricultural family, it was not embarrassing for me and I could easily mingle with them. At 1.00 pm exactly, a person came to take me for lunch to one of those two hosts. I had my lunch, relaxed, conversed with some inmates of the house, had a cup of tea and returned to the PHC by 4.00 pm. That is the kind of love and affection that a medical officer of a PHC receives! After two years' stint there, and four years of working at a 30-bed urban hospital, I went to the PHC at Rajupalem as a MO. Rajupalem covers 1,20,000 population with hundred and odd staff. Several people used to take me to their houses for lunch. They are all very good to me! I worked there for four years before starting a PHC at Mylavaram as Additional Incharge MO. My entire PHC service was in the Kadapa district. I visited villages regularly, visited schools and hostels, conducted several village leaders
training programmes and implemented National Health programmes etc as part of my work. Rajupalem PHC stood first in the district twice during my stint there. During my visits to villages, I never returned to headquarters without dining in these villages. I covered these places on cycle, tractors, bullock carts, PHC vehicles and public transport. I was part of the village games, festivals, cultural activities, folklore and customs. In 1990, I went to Guntur district from Kadapa to work in cyclone ravaged villages. PHC Visweswaram was my area of operation. I was ‘dropped along with food and milk pockets’ in a marooned village by an army helicopter! The protocols of the day didn’t allow even legislators to board the helicopter. I lived in the Visweswaram PHC without power supply, in the midst of water snakes, lying and sleeping on benches. There was no regular MO at that time. It used to be a Herculean task to secure food and drinking water! I can’t forget covering Lankavanidibba on the tractor provided by the neighbouring village people as my vehicle could not navigate in the slush lands there. Even a Sarpanch (Pradhan) could not take care of us! Such was the calamity. It was a great learning experience and I will never not forget the resilience of the people in the midst of calamity. What more can a MBBS doctor expect from this country than opportunities like this? To my great luck, I became the dis-
PEOPLE trict officer of Guntur in 2003. I took the earliest opportunity to visit Visweswaram and I shared my experience of the days there with the staff and people present. Some senior paramedical staff could recognise me. As Additional District Medical and Health Officer (DM & HO), I visited 70 and odd PHCs several times. It was a great opportunity to lead a team of 3500 and odd people. I implemented celebrations of all health days, promoted donation of mosquito nets, visited many government schools along with PHC staff without the directions from the state headquarters and without any additional budget! I had the opportunity of organising the launch of state level ‘Vande Mataram’ programme as DM & HO, a great responsibility was thrust on me by my state administration. Guntur is a big district in Andhra Pradesh and a district officer is a crucial person in the rural healthcare system. What more does an MBBS doctor expect than opportunities to provide healthcare services to a district from this nation? In 2005-06, I visited hundreds of PHCs across the state of Andhra Pradesh as a Joint Director of Commissionerate of Family Welfare. I played a major role in designing the NRHM interventions. The The then Chief Minister of Andhra Pradesh, Late Dr YS Rajasekhara Reddy launched two subjects handled by me. None of the other officers had this privilege where the CM launched their subjects. For launch of free RTC bus passes to pregnant women, I went to PHC Kanthi in Medak District to look after the arrangements. I used to sleep on benches of the PHC at Kanthi. My MBBS and DCH belong to this nation. If anybody asks me which is the best part of my service, my reply would be - my PHC service. PHCs make a leader out of a MBBS doctor. These days many are voicing the view that there is a need to include personality
Working in a PHC for three years is enough to mould your personlity and enhance it. The people and experiences at the PHCs in rural villages would mould the doctors' attitudes and personalities for the better
development in the MBBS curriculum! Working in a PHC for three years is enough to mould your personlity and enhance it. The people and experiences at the PHCs in rural villages would mould the doctors' attitudes and personalities for the better. Villagers are the best teachers and personality developers!
PHCs and MBBS now The public sector rural medical care is ailing from vacancies of MO posts, absenteeism of health functionaries, disfunctionality and physical non-availability of staff. How can we implement any programme when functionaries are not physically staying at the place of posting? A MBBS is the best leader to lead a PHC however they do not want to go the rural areas. In India, a MBBS doctor is privileged, across all castes, religions and regions. He gets sympathy from all quarters of society. Whenever we talk about posting of an MBBS at a PHC,
everybody talks about the facilities there! However, these considerations are not given to revenue staff, panchayat raj staff, power supply staff, teachers, women and child development officers and even the nursing and paramedical staff. MBBS doctors are the only ones getting incentive money for working in rural and tribal areas. In India, MBBS doctors expect all the facilities at a PHC like those in the tertiary hospital where he/she received his/her training. MBBS is the only cadre to get preference in PG if they work in rural areas. MBBS doctors are mightier than state in India. State prostrates before a MBBS. Indian State is MBBS centric, but not people centric. An Indian MBBS is a very discontented person and always broods that he is the subject of lot of injustice. He always seeks sympathy from every quarter - rightists, leftists and centrists and all stands by them in every genuine or perceived crisis. He compares his life with all haves in the world. Every MBBS aspiring plus two student’s goal is super specialisation. Towns, cities and foreign countries are their dream destinations when there is dire need for doctors in rural areas. However, this situation has not been created by MBBS graduates, they are not the culprit. He/she is a victim of circumstances. The economic model is the real culprit. If my daughter or a grandson would be a MBBS doctor, they would be no different from others. I predicted this in 1970 itself. Indeed, a paradigm shift happened. A set of professionals earlier to 1980 have been completely replaced by post 1980 professionals who possess a diagonally opposite value system. History alone will decide which is the best. (The author was also Former Medical Consultant - Indian Institute of Health and Family Welfare- Hyderabad and Former State Coordinator, Breastfeeding-Promotion Network of India, Andhra Pradesh)
Dr Mohan Thomas elected to the board of trustees of AACS The leading cosmetic surgeon is the first Indian to be elected to this prestigious post
LEADING COSMETIC surgeon, Dr Mohan Thomas has become the first Indian to be elected to the board of trustees of the prestigious American Academy of Cosmetic Surgery (AACS). Speaking about the development Dr Thomas said, “I am thrilled and honoured to be associated with an institution such as AACS which is known for its commitment towards the development of the field of cosmetic surgery as a continuously advancing multispeciality discipline that delivers the safest patient outcomes through evidence-based information.” AACS provides educational opportunities that deliver procedural knowledge, hands-on training and mentorship to cosmetic surgery professionals. It has more than 2000 members and is growing all
over the world. Dr Thomas is an American trained surgeon, at present attached to Breach Candy Hospital and Hinduja Healthcare as a senior consultant. He was the first one to introduce minimal access cosmetic surgery in India and a ver reputed facial and rhinoplastic surgeon in the world. He has made significant contributions to the plastic surgery literature including Plastic and Reconstructive Surgery Journal, Aesthetic Surgery Journal, Journal of Plastic Reconstructive and Aesthetic Surgery, Journal of the American Academy of Cosmetic Surgery and The Clinics of North America to name a few. He is the Chairman and Managing Director of The Cosmetic Surgery Institute, Mumbai.
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TRADE & TRENDS
Dexact-f: Simplifying diarrhoea diagnosis Dexact-f, a product of world’s most innovative research from Sweden
THE INCIDENCES of diarrhoea are growing every day. Today the diarrhoea has become a major concern worldwide and especially in India. The biggest challenge of today is to diagnose diarrhoea if they are ‘infectious or not’ at earliest stage by simple and easy technique. When a patient visits a hospital with complains of diarrhoea, then, in order to provide a secure and efficient treatment management, the medical team should answer the following questions. 1. Is it a transmittable disease? 2. Should the patient be isolated? 3. Is treatment with antibiotic indicated? 4. Are there any other serious diseases presenting diarrhoea as a primary symptom? 5. Which diagnostic tests and procedures should be followed in this situation? Yes, Dexact-f gives the answer. Dexact-f can answer the above questions with a simple equipment-free stool examination immediately. Our previous studies on 1200 stool samples collected from patients in Sweden have shown that; 1-A positive Dexact-f indicates acute inflammation/ infection in the bowel with sensitivity >90 per cent; the patient should be isolated. Feaces pH is always > 6-7 in positive tests. 2-In positive Dexact-f results where feaces pH is 6-9, there is low risk for translocation of bacteria and septicaemia. No antibiotic treatment is indicated in clinically stable patients. 3-In highly positive cases and high feaces pH> 9-10 broad spectrum antibiotics is indicated due to risk for perforation and septicaemia.
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choose with meeting a patient with diarrhoea.
Benefits for the patients from Dexact-f
4-If the test is negative in spite of loose feaces other causes such as chronic inflammatory bowel disease, other infectious foci in lungs, kidneys, abdomen or colon cancer should be ruled out (specificity > 90 per cent). Now it is possible to detect if diarrhoea is transmissible or not within one minute with the help of Dexact-f. PEAS Research Institue Sweden is a research oriented organisation and involved in doing extensive research in lifescience. PEAS Research Institute is the first company in the world who introduced most scientific solution and easy to use technology - rapid faecal strip test to distinguish transmittable diarrhoea by pioneering, developing and producing of Dexact-f device.
Dexact-f: The problem solver Acute gastroenteritis is a very common disease. Large numbers of patients seeking to
the hospitals/doctors are mainly troubled by symptoms such as nausea, vomiting, diarrhoea and pain in the stomach. Diarrhoea, the most dominating symptom is caused by various infectious agents or by other reasons. In spite of the routine tests it is nearly impossible to distinguish between different causes of diarrhoea at admittance or within one minute. Therefore the patients are either isolated at The Department of Infectious Diseases until the culture results are available or they have to be at risk to others health. With the help of Dexact-f strip, one can distinguish infectious (bacterial, viral, parasite) gastroenteritis from non-infectious (IBD, functional) at admittance within one minute.
Dexact-f is important because….. There are no other tests yet available in the world that
can distinguish between infectious and non-infectious diarrhea (gastroenteritis) at admittance or almost immediately. This is a new concept in the world of lifescience. It is very useful and.... 1. Decreases isolation costs 2. Decreased stool examination costs in non-relevant cases. 3. Decreased antibiotic consumption and risk for multi-resistant bacteria (ESBL) 4. Rapid diagnosis of septicaemia in need of immediate antibiotic treatment 5. Using appropriate diagnostic procedures (colposcopy) on time in serious diseases such as IBD and colon cancer. 6. The test by Dexact-f strip is not sensitive to previous antibiotic treatment or low bio-burden. 7. The information obtained using the test might be complemented with other tests. In principle Dexact-f strip should be the first test to
A significant amount of patients seeking medical treatment are consisted of patients suffering from bowel disturbances. Several diseases show diarrhoea as the primary symptom, such as pneumonia, septicaemia, acute bowel obstruction, abscess or perforation, cholecyctitis, transmittable gastroenteritis, antibiotic caused diarrhoea, inflammatory bowel disease, urinary tract infection in children and elderly, toxins and over consumption of laxantia. Because of risks for transmission such patients are required to be isolated in at least for three days before culture results are available. Approximately 10-15 per cent of such patient’s population needs isolation and the rest of patients might suffer from therapy delays. This period is much longer and expensive in hospitals and many times it is impossible to isolate mass population. In concept the patients might receive a proper treatment after couple of days only. In this situation damage could be done by a patient who suffers from infectious gastroenteritis to many other people by infecting them. The test by Dexact-f can distinguish infectious gastroenteritis at admittance and within a minute.
Brief description of the product: Dexact-f Hepatocyte growth factor is an acute phase cytokine which is produced at the site of injury and shows high affinity to sulphated glycans such as heparan sulphate proteoglycan and dextran sulphate; this
binding affinity is lost during chronic inflammation. Faeces pH strongly impacts the prognosis of outcome for severe diseases. Based on these premises, a strip test was developed to determine binding affinity of HGF to dextran sulphate in faecal samples. An included pH-meter in the strip assessed the severity of illness. Based on the previous studies it has been seen that the production of a growth factor is increased during acute inflammation locally in bowel. This growth factor (HGF) has high affinity to the receptor (HSPG). We have developed a rapid semi-quantitative test strip with double surfaces. The first surface evaluates binding of HGF to the receptor HSPG and the second surface is simply a pH indicator for faeces. Combination of these two tests at the same time gives information about 1-Presence or absence of HGF in faeces 2-Faeces pH
With the help of Dexact-f strip, one can distinguish infectious (bacterial, viral, parasite) gastroenteritis from non-infectious (IBD, functional) at admittance within one minute. There are no other tests yet available in the world that can distinguish between infectious and non-infectious diarrhea (gastroenteritis) at admittance or almost immediately
titive. Possible at the equipped centers only. Concentration is increased during both infection and IBD. Negative result is valuable to rule out IBD. 7.Faecal haemoglobin: Shows presence of blood in faeces and it is unspecific. 8.It is important to know that in spite of routine examinations not more than 50-55 per centof all infectious gastroenteritis (diarrhea ) might be verified by available methods being applied currently.
The key point Unique advantages of Dexact-f 1.By seeking the hospital with diarrhoea a panel of different blood and faecal tests are taken. 2. Blood tests are intended to check if the patient is dehydrated, liver and kidney functions and WBC that are not specific and gives general information about the diseases. Serum C-reactive protein and
procalcitonin are used to identify bacterial or viral nature of infection. The faecal tests available are taken at the same time. In cases of faeces cultures the results not available at admittance. 3. Viral diagnosis by PCR for Calicivirus, Rota virus and Adenovirus: are expensive and performed in few centres. The results not available at admittance.
The Index test by Dexact-f recognises infectious gastroenteritis at admittance before culture, toxin, PCR, or microscopy results are available and at much lower cost. No other test can function in this way in whole world today.
4. Toxin test for Chlostridium deficile: the results available within 24-36 hrs. at centers (not holidays). It diagnoses presence of antibiotic diarrhoea. 5. Direct microscopy: Expensive. Needs trained technician. Diagnoses parasites and cysts. Results not available at admittance. 6. Calprotectin: New test. Both semi-quantitive and quan-
Contact PEAS Institut AB Söderleden 1, Linköping, Östergötland 58723 Sweden Tel: +46 13 15 40 30 Website:www.peasinstitut.se
covers….all in one place…under one roof. The company looks forward
to serving their Delhi clients with their complete product range.
Bluestream@HBII 2013 Bluestream’s products like Purell Instant Hand Sanitizer and Bluestream Personal Wash cloths and Touch Free Dispensers were appreciated and received good response at HBII 2013
BLUESTREAM MANUFACTURING Services has been participating in HBII since the inception of the exhibition. They saw much better responses in Mumbai than they received in Delhi. Their products were very well received by the visitors in Delhi. The concept of sanitary sealed refills in a sanitizer is a new introduction to the North and was highly appreci-
ated by the medical fraternity for its fragrance free and skin friendly properties. Purell instant hand sanitizer and Bluestream personal wash clothes received the highest response out of their complete product range. The touch free dispensers were the best appreciated amongst the lot. Another highlight of the show was the total solutions
that Bluestream’s customers got to see – right from the hand sanitiser to the show
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Medisystems OPD patient-call and queue management systems They assist the busy OPD departments of hospitals and clinics in handling the daily chaos of managing large numbers of OPD patients
Overview
Central display panels
Medisystems OPD patientcall and queue management systems are designed to assist the busy OPD departments of hospitals and clinics in handling the daily chaos of managing large numbers of OPD patients. These electronic systems help alert waiting patients about when they have to enter the examination room and to which particular room number they have been called to. They also help to streamline patient flows.
The central display panel is placed in the patient waiting hall. It displays the patient/case number along with the examination room number to which the patient has been called. This part of the display is in bold characters and it scrolls vertically to display the list of patient numbers called. An audible chime accompanies the call for each new/next patient called in for examination.
Features
Medisystems OPD patient-call and queue management systems are designed to assist the busy OPD departments of hospitals and clinics and help to streamline patient flows
These systems comprise one or more central display panels placed in the main and subsidiary waiting areas, and as many room and door display combinations as are required, based on the number of consulting/examination rooms for the OPD.
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The lower display is in smaller characters. It scrolls horizontally from right to left. It alternates the day/date/ time display with the name of the hospital as also any messages or advisories of public importance. Bilingual displays are also available. Typically, an admissions clerk fills in a fresh case paper, with a case number for each new patient. This number, along with the case/file numbers of repeat visit patients,
has only to be conveyed to the assigned doctor or consultant. The call is initiated directly from the examination room by the examining doctor, or assistant. As many as 32 such rooms can be simultaneously accommodated on a single system.
Room calling unit The room calling unit module is located in the examination room on the doctor's desk. Its numerical keypad feeds
the command to enter the patient/case number onto the central display panel in the waiting hall, while simultaneously triggering the audio chime to alert the waiting patient. It displays this number on its own display which is updated each time the next/new patient is called into the room. After the patient has entered the room, the doctor may also press another key to change the door display message from
TRADE & TRENDS
Medisystems queue management systems have been specially designed for modern OPDs that are now a routine necessity in hospitals all over India 'Call' to 'Busy'. The doctor can also enter the patient number with remind key ‘R’ to repeat unattended calls.
Door display modules The door display module is located next to the door frame at the entrance to the examination room. Its display alternates the called patient/case number with a message saying 'Call'. After the patient is in the room, the examining doctor may operate the room unit keypad to change this message to 'Busy' to forestall inadvertent entry by others while the patient is undergoing examination. In addition to the examination rooms, such desktop calling units and door display units can also be placed at the counters and windows of the main registrations/ admissions/payments counter located in the OPD lobby. Patients can approach the admissions or payment counters after their case number has been called up on the main display. This helps keep the place
orderly by reducing the queues at the admissions counters. The Medisystems 8020 OPD Patient-Call System is a fully decentralised system. It requires no central operator. A single power unit, located conveniently near the receptionist's desk, carries the master switch for the whole system. Peons, reception staff or nursing assistants need not be employed merely for the task of calling in patients. This is a modern queue management system based on very rugged and reliable digital technologies. Medisystems configures OPD patient call systems based upon the OPD area requirements. This includes the number of consultation rooms, the number of waiting areas and whether or not the OPD receptionist or the cashier would like to be connected. We undertake turnkey installations once the wiring is completed as per specifications.
OPD queue management systems Medisystems queue man-
agement systems have been specially designed for modern OPDs that are now a routine necessity in hospitals all over India. These have been specially configured to manage the registration of advance and current patient appointments, along with orderly collection of payments, calls to the assigned consulting rooms by the concerned doctors, and finally, provision for immediate logging of doctor’s examination reports – if so required. On option, connectivity to the hospital’s HIS can also be provided. These systems comprise an OPDMS server, LCD panel call display drivers, door display units and all associated software modules to manage and control the OPD appointment, registration, payments and patient-call activity. Wherever opted for, high visibility LED matrix displays can also be included within the scope of supply. The patient after approaching one or more OPD registration counters is asked to log in patient name, gender, age,
reported symptoms and desired doctor’s name. If no desired doctor is named, the counter clerk may assign a doctor’s name from an available list of physicians. A print out with patient’s assigned token number or a patient ID is generated. The number is automatically system generated in chronological sequence regardless of the counter from which the print out is obtained. The system updates an appointments chart which is made available on the PC terminal of every examining doctor’s desk. All the doctor has to do is click on the line indicating the next appointment. The correct ID or token no. will flash on the relevant display in the waiting area indicating the room the patient has to visit. The same number will also be displayed at the entrance door of the calling doctor where it will flash along with the 'Call' invite. The doctor can remind for any unattended call or press 'Busy' when examining patients. After completion
of the examination/consultation the doctor may proceed to click on the next in line patient showing up on the appointment chart on his screen, before calling in the next patient, the doctor may also call for the report screen and quickly type in a brief report of the patient just examined. The system can also be, optionally, linked to a wider hospital HIS. Report data from the OPDMS can be made available to the HIS for permanent record keeping like daily/ monthly/weekly patients examined, attendance by doctor, volume of patient traffic, wait time summary, etc. Contact Vinay Thadani, Marketing CR Medisystems, 335 Pragati Estate, N. M. Joshi Marg, Mumbai - 400011. Tel : 91-022-23094416, 23004930 Fax : 91-022-23061903 E-Mail: medisystems @ gmail . com Website: www.medisystems. in
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RxOffice HMS: An ideal ITsolution from Indisoft It is designed to resolve most of the challenges faced by small and medium-sized hospitals IN THE current medical scenario of India mediumsized hospitals face tremendous challenges in optimising their operations for competing with the quality of larger hospitals. Providing similar facilities with the same infrastructure and without increasing cost is one of the major challenges. Smaller budgets have typically made it difficult for them to afford certain technologies and some areas have limited technology resources too. Common challenges faced by the smaller hospitals are: maintaining medical records; maintaining MLC and TPA records for future references (not-to-do); experiences and learnings of the hospital gets lost if not introduced into the system; non-uniform discharge summary causing crucial data to go missing; track patient outstanding; insurance claims and payment; missing automated discharge summary; incorrect/less/high billing to patient; malpractices in concessions; correct payments to the visiting doctors for hospital image management; creating a one page review of hospital health and duplication of work due to entry in Tally etc. Solutions provided by RxOffice HMS to these problems are: RxOffice HMS is well-equipped to keep track of old patients and avoids repetition of work. It also maintains error free OPD/IPD billing process within a reduced amount of time and fewer manual interventions.
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RxOffice HMS generates a report,‘Day Summary’, where the user is able to view the hospital activities of the day in a single window Discharge summary is ready at the time of patient discharge, which in turn saves the time of the staff and patients. RxOffice HMS also generates a report termed ‘Day Summary’, where the user is able to view the hospital activities of the day in a single window. This has proved to be a time saver for the administrators. It also helps to create a one page review of hospital health. The tally integration utility manages the accounts department’s work by transferring the daily entries or date wise activities directly into Tally thereby avoiding duplication of work. RxOffice HMS also generates the patient outstanding report on a daily basis. Thus, RxOffice HMS can resolve most of the challenges faced by small and medium-sized hospitals. Contact Kishore Shinde Tel: 9892869870
BELOW ARE THE EXPERIENCES OF TWO HOSPITAL ADMINISTRATORS S uyash Hospital-Seawoods is an advanced tertiary care, multispeciality hospital, in terms of affordability, accessibility and availability of healthcare services. A 50 bedded hospital, with focus on super specialities-cardiology, neurology, oncology, orthopaedic and joint replacements, minimally invasive surgeries, renal and gastroenterology (medical and surgical), besides the complete range of allied medical services which include internal medicine, general surgery, pulmonology, paediatrics, obstetrics and gynaecology etc. The hospital is planned with quality specifications and equipped with state-ofthe-art equipment for all specialities. Three modular
S
ampada Hospital and Intensive Care Unit- Thane is a 15 bed hospital with six bed critical care unit, along with operation theatre, special rooms and general ward. 24x7 pathology, pharmacy, ambulance services, X-ray, USG and neuro-imaging services are available. Sampada hospital provides services in critical care to people from all stratas as money is of lesser importance and ‘Hope, Health and Humanity’ is what the hospital believes in. Sampada Hospital-Thane has an experienced and talented team of senior medical
DR DHAVAL DERASHRI Suyash Hospitals - Seawoods
modern and state-of-art operation theatres equipped with LED lights, operating microscopes, and image intensifiers, laparoscopic equipment, C-arm etc. Stateof-the-art neonatal/paediatrics/medical/surgical and
consultants and doctors and a full team of paramedical staff that ensures availability and access of the best medical talent round-the-clock. Dr Umesh Alegaonkar, Sampada Hospital and Intensive Care Unit says, “Rx Office Software has helped in proper record keeping.. The software is time saving and user friendly. All our requirements are properly handled in the software. It has streamlined our hospital’s working. We are thankful for the fast and prompt service given by their support department.”
cardiac intensive care units. Connected with the imaging department with state-ofthe-art of facility mammography, two ECHO, ultrasound and digital X-Ray. Suyash HospitalSeawoods brings in highly experienced and talented team of senior consultants and Doctors and a full team of Paramedical staff and excellent working environment that ensures the availability and access to the best medical team round-the-clock. “Rx office HMS software is very simple to use. Provides end to end solution. Rx office also helps you in getting statistical data of your hospital at your finger tip in a simplified way which is important for any organisation,” says Dr Dhaval Derashri from Suyash Hospital.
DR UMESH ALEGAONKAR Sampada Hospital and Intensive Care Unit - Thane
TRADE & TRENDS
Is accreditation a journey or a destination? Dr J Sivakumaran, Sr VP, SPS Apollo Hospitals talks on the importance of accreditation and explains how it is an ongoing, dynamic quality improvement programme
CUSTOMER SATISFACTION is the cornerstone of success in any industry. Business cannot function in an ivory tower and needs to constantly stay attuned to the pulse of the customer. The same analogy is true for every industry including healthcare. A satisfied patient will act as an ambassador for the hospital, propagating its goodwill in social circles and choose to visit the same hospital for future healthcare needs. A disgruntled patient on the other hand can mar the reputation of the hospital. Patients being customers in the healthcare space have become very conscious, selective and particular about their rights as a patient and are demanding quality healthcare. Due to technological advancements and heavy competition among the service providers, the patients have a wider choice to select from. Patients have become spoilt for choice given the plethora of options at their disposal. Dissatisfied patients find it easier and convenient to switch loyalties. Quality of service could often be the sole differentiating factor between good and bad hospitals as far as patients are concerned. Presently, comparable facilities and infrastructure are available with competing hospitals but with a difference in service delivery, which discerning patients will never fail to notice. For providing better quality care many hospitals go for accreditation programmes. It is believed that hospitals with accreditation offer better quality services to patients. Accreditation brings standardisation of procedures,
protocols, correct and timely documentation of events apart from safety of patients and improved medical outcomes. If hospitals follow the processes and pathways, clinical outcomes are bound to be better. The intent of accreditation is to set a minimum standard so that it could be assessed and evaluated. It will set the framework under which the organisational clinical and other processes are formulated. One important point to be noted here is that accreditation will not guarantee quality service delivery but only will enable the hospitals to follow protocols and systems to deliver service quality. The hospitals need to make sure that execution of laid down protocols are carried out. Accreditation leads to improved quality protocols which can stop adverse events like morbidity, patient falls or hospital acquired infections. Only if the processes and protocols are understood and implemented with true spirit, corrective actions and preventive measures could be initiated to thwart adverse events.
Accreditation is a voluntary exercise in India, in which trained external peer reviewers assess and evaluate the level of compliance of a hospital with pre-established performance standards. These standards are important elements in an accreditation system. These standards are for comparison and for measuring the degree of excellence. There are several accrediting agencies available for healthcare organisations. National Accreditation Board for Hospitals & Healthcare Providers (NABH) based in India, Joint Commission International (JCI) based in US, Trend accreditation scheme and The United Kingdom Accreditation Forum (UKAF) based in the UK, Australian Council for Healthcare Standards International (ACHSI) based in Australia, Canadian Council on Health Services Regulation (CCHSA) based in Canada are few of the renowned and reputed accrediting agencies. In India 191 hospitals have been accredited by NABH and 544 hospitals are in the pipe line
for getting accreditation. While around 700 healthcare organisations were accredited by JCI worldwide covering 90 countries, in India there are 22 hospitals accredited by JCI. It is encouraging that more and more Indian hospitals are opting for accreditation for improving their processes and protocols. These accrediting organisations focus on optimal care with patient safety ranking among the foremost parameter. Accreditation sets certain standards to be followed by hospitals at all times and hospitals need to maintain those standards to remain accredited. These accrediting firms formulate systems driven processes which are independent of individuals or designations, so that every time an activity is carried out, uniformity could be maintained, irrespective of the service provider. There are few opportunities and challenges in opting for an accreditation in any hospital. Opportunities: While preparing for accreditation, a lot of internal process over-
hauls take place. Hospital employees who have gone through the paces of an accreditation process often report a paradigm shift in their perception regarding certain quality control processes earlier viewed by them as redundant or frivolous. An accreditation exercise exposes the chinks in the existing processes and helps strengthen processes for better patient safety and outcomes. In a normal course, the fire fighting equipment in a non-accredited hospital would not be checked for its pressure level or functioning at frequent intervals, unless itâ&#x20AC;&#x2122;s usage is warranted. However, if it does not work at the time of need due to long storage, it may lead to disaster. An accreditation guide line stresses the need for such checking at frequent intervals with proper documentation. Blood spillage in a hospital ward is common. But if it is not properly neutralised, chances of nosocomial infections are high. Accreditation guide line insists on neutralisation, in case of blood spillage. These small protocols could save patients, service providers and the hospital. Similar guidelines for needle stick injury, hand washing practices, physician order system, medication error etc. are available in the guidelines and strict adherence to such compliances can thwart disastrous consequences. The awareness measures and prevention protocols followed for these sentinel events will be high in accredited hospitals than others. This is primarily because of the long hours of training spent on obtaining accreditation and re-
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taining the same. The tracer methodology followed by accrediting agencies ensures that the patient files are documented and completed in all aspects. In the process of accreditation, all the bio-medical equipment right from weighing scale is re-calibrated and hence the patients get accurate readings. A complete credentialing of all medical and paramedical professionals involved in patient care is carried out revalidating aspects like their qualification and experience, to ensure that nothing is left to chance as far as patient safety is concerned. Accreditation ensures that patients’ rights are respected and protected. Accreditation fosters confidence within the patient-community and also provides a boost to marketing efforts as far as the medical tourism market is concerned. It prepares hospitals for any disaster or epidemic
like events. An accreditation exercise warrants hospital staff to work in close co-ordination with one another where everyone works for a common purpose transcending individual and department level differences. Apart from fostering the spirit of team work, collective efforts result in overall synergy. Challenges: While accreditation brings in a lot of accolades apart from pride and prestige, it cannot be denied that the work load of the staff including doctors increases. This is due to the stringent documentation requirements. On the flip side compliance is often at the cost of patient care. At times there is a trade off as regards the ideal time to be spent on patient care with the time spent in completing the file. Further, due to overemphasis on training, an upsurge in attrition rate is quite common. Many healthcare profes-
sionals view this exercise as bureaucratic, cumbersome and uneconomical. Substantial resources are expended on accreditation, making it unviable for many hospitals. Perhaps the time has come to analyse the cost of accreditation vis-a-vis its benefits as many healthcare professionals are voicing their concerns on this. In India, healthcare is already becoming unaffordable due to high costs at every stage of the value proposition and service delivery chain. If cost of accreditation is also added to the cost, the affordability is further reduced. Valuable time and resources are spent, whenever any standards are changed. Accreditation is only a tool and not a solution in itself. Recently a study conducted in overseas on 36777 patients at 73 hospitals concluded that there is no significant association between accreditation and patient satis-
faction. As per this study, accreditation is not linked with better quality care (C.Sake and others, 2011). While it is prestigious to get accreditation, there is always a risk of a marred reputation, if accreditation is not renewed, or withdrawn due to issues. Withdrawal of accreditation can dent the reputation of a hospital significantly with a direct impact on its fortunes and sustainability. The expectation level of patients goes up in accredited hospitals as they start evaluating the standards of service vis-a-vis the service levels in a non-accredited hospital. Hence, healthcare professionals in accredited hospitals are always under pressure to ensure that the expectations of patients are met. Accreditation is an on-going, dynamic quality improvement programme. The activities don't stop, once certification is
received. Accreditation brings along a responsibility of always maintaining the standards and safety which lead to the accreditation in the first place. Every survey is a litmus test for accredited hospitals and the pressure to maintain and improve the quality of service never ceases. Paradoxically, successful accreditation can mean reaching the destination as well as commencement of a new journey for the next round of accreditation.
Reference “Is there an association between hospital accreditation and patient satisfaction with hospital care?” A survey by C.SACK,A.SCHERAG, P.LU¨TKES,W.GU¨NTHER , K.-H. JO¨CKEL AND G. HOLTMANN.International Journal for Quality in Health Care 2011; Volume 23, Number 3: pp. 278–2.
PAXMAN-ORBIS hair loss prevention system No longer will patients on chemotherapy suffer the trauma of hair-loss!
ALOPECIA (HAIR-LOSS) remains a traumatic side-effect many cancer patients experience. A constant reminder of their disease, alopecia also alters patients’ facial features, thus leading them to reduced social interactions and even refusal of treatment. The Paxman Scalp Cooling System, which effectively mitigates alopecia, is a product from Paxman Coolers Ltd (UK) with more than 1800 installations in Europe. The system consists of a mobile refrigeration unit connected to lightweight silicon caps. It has a special coolant circulating through o the cap at – 4 C, which lowers
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o
scalp temperature to 8-10 C before, during, and following chemotherapy. Due to low scalp temperature blood flow to hair follicles is reduced, keeping hair-loss to the minimum.
How it works? Scalp cooling works by lowering the temperature of the head and scalp immediately before, during, and after the administration of chemotherapy. This in turn reduces the blood flow to the hair follicles, thus preventing or minimising hair loss. Scalp cooling has found to be effective across a wide range of chemotherapy drugs such as Epirubicin, Doxorubicin, Taxol
and Docetaxol. Highlights: Effective across a wide range of drugs; double model available (with each patient treated independently); easy touch-screen display; five cap sizes for various head size shape and contour, effective insulation using Neoprene maintaining constant temperature, no cap changes during treatment; minimal nursing supervision; patient mobility. Paxman-Orbis is now in India through: Access Devices, Bangalore Email:accessdevices@ gmail.com www.accessdevices.in
TRADE & TRENDS
Sonosite's POC solutions SonoSite offers point-of-care ultrasound education when and how you want it, says Pavan Behl, Director and General Manager, India & Middle East, FUJIFILM SonoSite India
ULTRASOUND DEVICE signifies an important pointof-care (POC) diagnostic modality which is increasingly being used in several specialties, like musculoskeletal, rheumatology, anaesthesia, pain management, surgery, interventional, and emergency care amongst others. Especially, its use during the critical situations when the physician is able to carry the portable ultrasound system to the point of diagnosis has enabled further expansion of ultrasound use. Despite its widespread utility into clinical practice, point-of-care ultrasound is relatively a new field and many older clinicians had completed their training before ultrasound use was introduced into their respective specialities. Hence for their and others’ training, hospitals and medical institutions are encouraging ultrasound training among the practitioners. Says Pavan Behl, Director and General Manager - India & Middle East, FUJIFILM SonoSite India, “As this advanced and improving technology continues to become popular in diverse medical specialities, FUJIFILM SonoSite strongly believes that imparting training on effective use of point-
FUJIFILM SonoSite has integrated education and learning in its newest generation of point-of-care ultrasound: the X-Porte Ultrasound Kiosk
of-care ultrasound is vital and that education and training combined with technical talent makes point-of-care ultrasound a lifesaving tool. It improves care delivery along with patient satisfaction. Therefore, since its inception SonoSite India has partnered with leading Indian institutions, associations and medical centres to provide point-of-care ultrasound training to physicians, nurses and other clinicians
and helping deliver the best possible care to the society. Going forward, we plan to hold many more similar workshops in various cities to provide education and training to physicians wanting to integrate point-of-care ultrasound in their daily practice.” FUJIFILM SonoSite considers physician education and training so critical in the use of POC ultrasound, that it has integrated education and learning in its newest generation of point-of-care ultrasound: the X-Porte Ultrasound Kiosk. The kiosk integrates highresolution ultrasound imaging synchronously with 3D animations that enable 'any user, any time of day' to use POC ultrasound in patient management. Realtime learning on the product enables any and all members of a healthcare team—nurses, mid-level providers, and even a physician-hospital administrator—to be empowered to take advantage of X-Porte's high-performance visualisation.
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Akhand Enterprises: Offering quality medical equipment Jatinder Pal Singh, CEO, Akhand Enterprises talks about his companyâ&#x20AC;&#x2122;s eclectic product range AKHAND ENTERPRISES is a well-known service provider for a comprehensive range of medical equipment. The basket of services provided are sale, after sales service, maintenance and repair solutions in the critical sphere of cardiology, anesthesiology, emergency, operation theatre (OT) equipment and critical care. We are trusted as one of the most reliable service providers in this realm. High quality of service defines our organisation. We are motivated by an altruistic sense that goes far beyond our business objective. Our entire range is is critically valued for accuracy, high performance and multi-functionality. We offer our services in almost entire North India. Our area of operation is New Delhi NCR, Haryana, Punjab, Jammu, Rajasthan, Gujarat, Lucknow, Uttar Pradesh and many other cities. Our service embraces an extended area such as various major installations for medical equipment in the goverment, private and public sector, providing on line services for all 24 hours and
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365 days, undertaking AMCs and CMCs of life saving medical equipment, regular training for awareness of new technologies. These are just a few of the services provided by us. We consider ourselves fortunate to be associated with the most trusted manufacturers of medical equipment in the country. The range offered by us is appreciated for sterling qualities such as excellent performance, accuracy, negligible malfunction, in-built voice activated guide lines and many other significant features. We are supported by our team of highly experienced professionals with great expertise in the healthcare sector.
Accessories We offer a versatile range of medical equipment and accessories that we offer as dealers. We associate ourselves with the most reputed service providers. Quality is a passion shared by the vendor and the procurer. Our entire range comprises: CT Scan, C-Arm, Patient Monitors, Ultrasound, Color
at healthcare centres and hospitals in the local areas.
Our quality assurance
Doppler, Ultrasound Probe, CTG, Ventilator, Defibrillator, AED, TMT, Syringe Pump, Humidifier, Ventilator Compressor, Oxygen Concentrator, BiPap, C-Pap, Pulse Oxi-meter, Transport Ventilators and other equipment
Refurbished equipment We do inspections, calibrations services and depot repair on most CT Scan, CArm, Patient Monitors, Ultrasound, Color Doppler,
Ultrasound Probe, CTG, Ventilator, Defibrillator, AED, TMT, Syringe Pump, Humidifier, Ventilator Compressor, Oxygen Concentrator, Bi-Pap, C-Pap, Pulse OxiMeter, Transport Ventilators, and other equipment. We assure instant turnaround time. We also provide a free estimate before any repairs are made. Our services also takes in to account emergency repair services for ventilators and other respiratory equipment
We place extraordinary premium on quality of medical equipment that we supply to our esteemed clients. As a quality driven organisation it is our avowed policy to associate ourselves with the most trusted manufacturers in the domain of medical instruments. To quench our thirst for quality we quality test the products in our in-house testing lab on the basis of critical parameters. Contact Akhand Enterprises Jatinder Pal Singh G-12, Shivlok House-1 Commercial Complex Karampura New Delhi-110015 Telefax:011-45042399 Mob:09350445559, 09717445559 Email: akhandenterprises@gmail.com info@akhandenterprises.com Website: www.akhandenterprises.com
TRADE & TRENDS
Transasia introduces Laura M urine analyser in India It is capable of measuring all routine parameters in urine along with Microalbumin and Creatinine, specific urine markers of nephropathy TRANSASIA BIO-MEDICALS is a leader in the Indian diagnostic industry, and over a period of three decades, it has set benchmarks by indigenously manufacturing and providing some of the latest and best technologies across the world. With a wide array of products in specialties such as biochemistry, haematology, diabetes management, coagulation, critical care, electrophoresis, microbiology, immunology, molecular diagnostics and urine analysis, Transasia offers total solutions in clinical diagnostics. The latest offering from the house of Transasia is Laura M, a quick and simple solution for the analysis of urine. Laura M is produced by ERBA Lachema, the Czech Republic subsidiary of ERBA Diagnostics Mannheim GmbH, of which Transasia is a part. Laura M is the next generation urine analyser with highthroughput, that is capable of measuring all routine parameters in urine along with Microalbumin and Creatinine which are specific urine markers of nephropathy. Objective evaluation of the urine samples by Laura M instrument helps to eliminate any subjective interpretation and operator bias of the colour reaction of the diagnostic pads and therefore contributes to the correct diagnosis of the patients. Laura M is designed to nullify the potential errors in urine analysis due to operator bias, operator handling, pre-analytical and sample issues. Equipped with a plethora of sensors to manage the entire work-flow Laura M ensures most accurate results along with maximum compliance with
strict quality systems prescription. ERBA Lachema with a history of path breaking technology in the field of Urinalysis has developed Laura M with features which are unparalleled.
Major features of Urine Analyzer Laura M: Smooth workflow management Laura M with its user friendly feature of continuous loading and very a high throughput of 600 measurements per hour allows efficient workflow in a high workload environment. Results are given in just 60 seconds for all its parameters. The instrument can be connected to a bar code reader to simplify work list creation and reduce hands on time. Laura M is capable of interfacing with Laboratory Information System (LIS). Efficient data management Laura M has internal memory capacity of 2000 measurements. It has a standard interface via RS232 and USB ports which enables the instrument to be connected to the Laboratory Information System (LIS) either for reporting or archiving data. Cutting-edge hardware features The sleek ergonomic design of Laura M denotes quality that the
brand Lachema stands for. The large colour touch screen makes operation easy and user friendly. Hygienic disposal of used strips is done by a waste container. It has an in-built thermal printer which flags all abnormal results. Unique dry strip detection in case of operator error of samplication on the reagent strip Multiple sensors detect the strip at different stages and ensure reliable test strip recognition. Laura M automatically recognises if the waste container is full and displays warning on the screen. Sophisticated software features Laura M provides extreme flexibility of interchanging between different metric systems for units of measurement. Laura M allows user to set critical values as per laboratory practices. The USB ports can be used for software upgradation for improved and latest features. PHAN diagnostics strips for Laura M ERBA Lachema through extensive research and development has mastered the art of manufacturing urine strips. The PHAN range of urine reagents strips are protected against the common concentration of Ascorbic Acid (200-800mg/dL), ensuring no interference with measurement of glucose, blood, or nitrates on the strip. DekPHAN Laura and MicroAlbuPHAN Laura are routine 10 parameters and two parameters specialised Microalbumin and Creatinine test strips respectively. All Phan range of strips have a uniform incubation period of 60 seconds. For further enquiry on Laura M please write to responses@transasia.co.in
SunTech Medical Oscar 2 Selected byPRAfor a Pharmaceutical Research Trial It is capable of measuring all routine parameters in urine along with Microalbumin and Creatinine, specific urine markers of nephropathy THE SUNTECH Medical Oscar 2 Ambulatory Blood Pressure Monitoring (ABPM) system has been s elected by PRA (Raleigh, N C) for use in a Phase I clinical study. The study will investigate the inhibition of degenerative mechanisms to provide improved neuroprotection for those with Alzheimerâ&#x20AC;&#x2122;s disease. SunTech Medical and PRA have signed a sevenmonth lease agreement for 23 Oscar 2 ABPM systems to be used in the study, taking place at the PRA research facility in Lenexa, KS. One of the many applications for ABPM is 24-hour monitoring and management of cardiac activity during drug therapy in pharmaceutical research trials. ABPM allows researchers to obtain a comprehensive picture of the effects of the medication on a patientâ&#x20AC;&#x2122;s daily blood pressure levels. The Oscar 2 ABPM sys-
tem provides reliable measurement and recording of 24-hour blood pressure data. It was the first ambulatory blood pressure monitor to achieve independent validation by both the BHS and ESH protocols for testing the accuracy of ambulatory blood pressure monitors. The patented Orbit blood pressure cuff uses a form-fitting sleeve to prevent slippage while patients carry out daily tasks, leading to more reliable data. AccuWin Pro v3 software provides practical, automated and flexible analysis, interpretation and reporting of 24hour blood pressure data. Contact Kenneth Andersen SunTech Medical, Inc. Morrisville, NC 27560 USA Tel: +1 919.654.2300 E-mail: sales@suntechmed.com Website: www.suntechmed.com
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Volk launches iridotomy lens for laser glaucoma treatment Blumenthal iridotomy lens design next generation for iridectomy VOLK OPTICAL has launched a new specialty lens for iridotomy procedures. Developed in conjunction with Eytan Blumenthal MD, the Blumenthal Iridotomy Lens design increases access to the periphery for more efficient glaucoma treatment with less potential for damage to surrounding tissues. The design of the contact lens indents the cornea to open the angle and flatten the peripheral iris, delivering better patient outcomes with less post-laser inflammation. The Blumenthal Iridotomy’s precise positioning and sharply focused laser spot minimises iris tissue collateral damage and distances the cornea from the iris to reduce the risk of endothelial
cell damage. The Blumenthal Iridotomy lens improves over classic lenses, as it is the only lens with corneal indentation capability for enhanced viewing of the far periphery. Constructed using Volk’s patented aspheric optics, the lens delivers better image quality and improved laser burn. Lower energy is required, reducing thermal collateral damage. The large lens housing improves lens grip and alignment for oblique viewing of the entire chamber. Eytan Blumenthal, MD is Chairman of the Department of Ophthalmology at Rambam Health Care Campus (Hafia, Isreal). This is his second lens collaboration with Volk. Volk Optical is an industry
leader in the design and manufacture of aspheric optics. Glass lens construction and the company’s patented double aspheric technology result in the highest resolution imaging with the best stereopsis for precision diagnostic, therapeutic and surgical work. The company is based in Mentor, Ohio, US and has representatives and distributors around the world. Contact Mahadev Dhuri General Manager India (Volk-Keeler) B-1, Boomerang, Chandivali, Andheri (East), Mumbai – 72. Board: +91 22 6708 0400 Mobile: +91 99303 11090 E-mail: mahadev.dhuri@halma.com Website: www.volk.com
Transasia launches five newinstruments The new launches were done at 40th ACBICON and APCON 2013
TRANSASIA LAUNCHED five latest and technologically advanced instruments at the recently concluded 40th National Conference of Association of Clinical Biochemists of India (ACBICON) and 62nd Annual Conference of IAPM and Annual Conference of IAP-ID (APCON 2013). They are as follows: ● XL 1000- Automated random access clinical chemistry analyzer with a throughput of 800 photometric tests/hr and 1120 tests/hr with ISE ● EM 180 Destiny- Fully auto-
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EXPRESS HEALTHCARE
February 2014
mated, random access, discrete clinical chemistry analyser with throughput of 180 photometric tests/hr and 400 tests/hr with ISE (optional) ● Hb Vario- Fully Automated Liquid Chromatography Analyzer with HbA1c, HbA2/ F test ● Easylyte Xpand- Critical care analyzer offering Ca and Li parameters in addition to Na, K, Cl ● Laura M- Urine analyser with Microalbumin and Creatinine results in 60 seconds At ACBICON 2013, Dr
Arvind Lal, CMD of Dr Lal Pathlabs inaugurated XL 1000 in the presence of reputed biochemistry experts of the country. At ACBICON, Swami Sarvalokanand Maharaj of Ramakrishna Mission, Mumbai jointly inaugurated EM180 Destiny alongwith Dr KP Sinha, the Past President and Chairman of ACBICON. While Dr Praveen Sharma, Head- Biochemistry Dept., AIIMS Jodhpur inaugurated Laura M and Easylyte Xpand, Hb Vario was inaugurated by Prof Venkatesh. The first order for XL 1000
in India was placed right after the launch by Shyam Tyagi and Sunil Duggal- Founder Members, Wellness Pathcare, New Delhi. Similarly, at APCON 2013, Dr KS Bhople, Dean, Govt Medical College, Aurangabad inaugurated XL 1000 while Dr Rajan Bindu, Head- Pathology and Organising SecretaryAPCON inaugurated Laura M. HbVario was launched by Dr Sujay Prasad- Director, Anand Diagnostics, Bangalore. Dr Murtaza, another Joint Secretary of IAPM, Aurangabad,
launched Easylyte Xpand. The experts from Transasia presented a scientific session on 'Update in automation of urine chemistry analyser' and ‘Launch of high speed biochemistry analyzers.’ Their Global Product Manager, Dr Pavel from Czech Republic gave the presentation at both the conferences. With these latest additions, Transasia aims to meet the needs for reliable, affordable and innovative medical diagnostic systems for doctors and patients worldwide.
REGD. WITH RNI NO.MAHENG/2007/22045. REGD.NO.MH/MR/SOUTH-252/2013-15, PUBLISHED ON 8th EVERY MONTH & POSTED ON 9, 10 & 11 EVERY MONTH, POSTED AT MUMBAI PATRIKA CHANNEL SORTING OFFICE.
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