Express Healthcare (Vol.9, No.4) April, 2015 by Indian Express

VOL.9 NO.4 PAGES 76

www.expresshealthcare.in APRIL 2015, `50

TATA INSTITUTE OF SOCIAL SCIENCES V.N. Purav Marg, Deonar, Mumbai 400088

School of Health Systems Studies Admission Open to Executive Post Graduate Diploma in Hospital Administration (EPGDHA) The School of Health Systems Studies (SHSS) of Tata Institute of Social Sciences in Mumbai, pioneers of Hospital Administration education in the country, invites application for their prestigious EPGDHA programme. It is a 12-month (two semesters), dual mode programme consisting of online learning and two-weeks of contact programme in each semester. The programme is intended to enhance the knowlege and skills of working personnel in the hospital. Eligibility: Graduates in any discipline with a minimum of 2 years of experience and currently working in hospital. Candidates sponsored by hospitals will be given due preference. Total Seats: 50 only. Application form and admission: Candidates are required to apply online through the E-application process only, website: www.tiss.edu. Candidate having difficulty in applying online or where there is no internet facility may contact below numbers. The application fees is Rs. 1,030/- (if being payed by Credit card / Debit card / Net Banking) or Rs. 1,000/- + bank charges (if being payed through bank by cash). The last date of receiving application is May 4, 2015. Admission will be based on the interview at TISS, Mumbai. Programme Fees: The total fees for the programme is Rs. 1,00,000/- (One Lakh Only), payable in two installments. The fees include tuition fee, learning resources, library and computer services and other programme related expenses.

CONTACT Telephone: 022-2552 5527/ 022-2552 5530 / 022-2552 5523 or E-mail: epgdha@tiss.edu

CONTENTS MARKET Vol 9. No 4, APRIL 2015

Chairman of the Board Viveck Goenka

PD HINDUJA HOSPITAL & MEDICAL RESEARCH CENTER WINS AWARD

EYE-Q RAISES RS 60-CR FUNDING

INTEX FORAYS INTO MEDICAL TOURISM

VENTUREAST INVESTS $4 MILLION IN SERIES C FUNDING IN DIABETOMICS

INVOLVE PUBLIC REPRESENTATIVES IN COMMUNICATING BEST PRACTICES - JP NADDA

METROPOLIS GETS GOVT NOD FOR H1N1 FLU TESTING

WOCKHARDT HOSPITALS BAGS GOLDEN GLOBE TIGERS SUMMIT AWARDS 2015

UNION MINISTER OF CHEMICALS & FERTILIZERS LAUNCHES ‘PHARMA JAN SAMADHAN’ SCHEME

IKEA FOUNDATION EXPANDS ITS PROGRAMMES IN INDIA

Editor Viveka Roychowdhury* Chief of Product Harit Mohanty BUREAUS Mumbai Sachin Jagdale, Usha Sharma, Raelene Kambli, Lakshmipriya Nair, Sanjiv Das Bangalore Assistant Editor Neelam M Kachhap Pune Shalini Gupta DESIGN National Art Director Bivash Barua Deputy Art Director Surajit Patro Chief Designer Pravin Temble Senior Graphic Designer Rushikesh Konka Artist Vivek Chitrakar

MAKE IN INDIAORMAKE FOR INDIA? Even as the current government raises the pitch for the 'Make In India' campaign, medical equipment manufacturers in India are struggling to use their capacity to the fullest due to the unfavuorable business environment. In such circumstances how will the concept work for the Indian healthcare sector? | P28

P12:INTERVIEW: SAMEER GARDE Philips Healthcare President, South Asia

Photo Editor Sandeep Patil MARKETING Regional Heads Prabhas Jha - North Dr Raghu Pillai - South Sanghamitra Kumar - East Harit Mohanty - West Marketing Team Kunal Gaurav G.M. Khaja Ali Ambuj Kumar E.Mujahid Yuvaraj Murali Ajanta Sengupta PRODUCTION General Manager B R Tipnis Manager Bhadresh Valia Scheduling & Coordination Mitesh Manjrekar CIRCULATION Circulation Team Mohan Varadkar

P13:INTERVIEW:

IT@HEALTHCARE

34 35

KARTAVYA HEALTHEON LAUNCHES LAB SYNC A NURSE’S REVEALING PERSPECTIVE

DR M MARIAPPAN Chairperson, Centre for Hospital Management

P33:INTERVIEW: CK MISHRA Additional Secretary & Mission Director (NRHM), Ministry of Health and Family Welfare

P41:INTERVIEW: DR PAULA WOODWARD Professor in Radiology, Univ of Utah, USA

LIFE INIMAGING

PEST-LE ANALYSIS -ULTRASOUND MARKET

ULTRAFEST 2015 WILL BE HELD IN MUMBAI

HOT SEAT: DR PRADEEP CHOWBEY

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

Innovate in India

o say that this year’s union budget was a disappointment for the healthcare sector is an understatement. Buoyed up by the stress on healthcare in the BJP's election manifesto, which was followed up with various announcements like the Make in India and Swacch Bharat campaigns, as well as the draft National Health policy, the sector was positive that the budget would delegate major funds for the sector . But it was not to be. The Finance Minister seemed to have chosen to allocate funds to other sectors and relegated healthcare a few rungs down the priority ladder. In fact there are doubts whether the Rs 33,150 crore allocated to the sector will be sufficient to fund the various national health schemes announced. (See analysis: Budget 2015: In search of an effective healthcare system, pages 26-27). The government seems to be penalising the sector for not utilising the funds allocated to it in the previous financial year, so it is imperative that all funds allocated are utilised this financial year. This is the only way to strenghten the argument for increased allocation next year. The government’s vision is laudable. As CK Mishra, Additional Secretary & Mission Director (NRHM), Ministry of Health and Family Welfare puts it, “The vision behind the National Health Mission is that no one in this country should be left without access to proper healthcare.” (Read his interview on page 31: ‘Everyone should have equal access to modern medical-care’). But while these schemes look good on paper, their implementation and interpretation is a different issue. Worse, industry has the perception that the talk does not seem to be backed by action. Our cover story section in the April issue of Express Healthcare analyses a key scheme, the Make in India campaign, asking if the vision will translate into a reality or turn out to be a delusion. (Make in India or Make for India?; pages 28-30). For sure, medical equipment companies seem to be already following the script: GE Healthcare an-

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The fact that GE Healthcare’s Revolution ACT,a stripped down version of a fourth generation slice CTsystem,has bagged five global patents for its design and engineering is the icing on the cake and proof that we can not just make but innovate in India

nounced the launch of the ‘first ever locally designed CT technology, Revolution ACTs, manufactured in India for India and the world.’ The company has been able to shave 40 per cent off the cost of the equipment, thanks in part to local sourcing or in-house manufacturing of 30 per cent of the product components and parts, including the heart of the machine – the generator and tubes. Targeting new users of CT in smaller towns, the product has a smaller footprint and uses less power so life cycle costs are also reduced. Other innovations specifically designed for first time users include a clarity panel detector, which improves image resolution, along with Smart Dose technologies to lower radiation dose by up to 36 per cent while preserving high image quality as well as an easy-to-use user interface. The fact that the product has bagged five global patents for its design and engineering is the icing on the cake and proof that we can not just make but innovate in India. GE Healthcare's stripped down version of a fourth generation slice CT system seems to be the way to go for medical equipment, and it looks like other manufacturers too will follow this path. Philips is increasing the visibility of the’ Philips Healthcare Innovation Center at Pune with this in mind. But as the Association for Indian Medical Device Industry (AIMED) has been pointing out, the government has to do its bit by levelling the playing field. Rajiv Nath, Forum Coordinator, AIMED points out that without a reversal and rationalisation of the current inverted duty structure and a export substitution policy, Indian medical device manufacturers remain at a huge disadvantage. One hopes that the government takes notice of the suggestions from industry to tweak the NHM. (See some suggestions on pages 32-33: 'Health as a justicible fundamental right', by Amit Mookim, Country Principal, IMS Health). After all, only creative policies can foster innovation. VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com

QUOTE UNQUOTE

The plans — for warnings and a picture of damage caused by smoking across 85 per cent of packets— had now been delayed. We have put the order in abeyance as the parliamentary committee wants to deliberate on some issues. We stand by our commitment to introduce new picture warnings, and its introduction would be delayed a bit

JAGAT PRAKASH NADDA, Union Minister of Health and FamilyWelfare

“Bacteria, viruses, parasites, chemicals, and other contaminants in our food can cause over 200 diseases ranging from diarrhoea to cancer. New and emerging threats such as climate change and its impact on food production; emerging biological and environmental contamination, new technologies, new foodborne infections and diseases; and antimicrobial resistance through the food chain - all pose challenges to the safety of our food”

DR POONAM KHETRAPAL SINGH, Regional Director,WHO South-East Asia

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MARKET I N T E R V I E W

â&#x20AC;&#x2DC;It would be critical to start new businesses which span the entire healthcare continuumâ&#x20AC;&#x2122; Healthcare is one of the fastest growing businesses for Philips in India. After a hiatus of sixmonths, Philips found a new leader for its healthcare business in South Asia. Sameer Garde joined Philips Healthcare as President, South Asia, in July 2014 but has kept a low profile ever-since. M Neelam Kachhap catches up with him to find out how innovative he is

You began your career at Nestle, and before coming to Philips you were heading enterprise business at Samsung. What attracted you to the device industry and to Philips in particular? Philips is a strong brand in India and the people I met during the course of my selection, made me see a cultural fit. I have worked in two industries prior to Philips, FMCG and technology, each for 10 to 12 years. I have always wanted to challenge myself in new industries, so chose healthcare and Philips being a leader in the industry, it was a natural choice. You became the President of Philips Healthcare last July. Is there anything in particular that has stood out or surprised you since you took the job? Two things stand out clearly. One, the industry. If we focus only on equipment, it is relatively small compared to the potential for healthcare in India. So, it is critical that Philips look at adjacent opportunities to expand the size of the addressable market. Also our customers are asking us to do more, beyond equipment sales. Second, the decisions are made by owners and founders who have put their personal names, sweat and money into the ventures. And since they are making big capital outlay

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decisions with Philips brand, the brand and the people who stand behind the brand need to be seen as trustworthy, reliable and with skin in the game. What is going to change under your direction at Philips Healthcare? Philips Healthcare has had a great growth journey over the last several years to become the number one player in four out of the five categories we play in. The first job is to consolidate this leadership position. And then enter into adjacent opportunities to expand our addressable market opportunity. That would mean more innovative business models, entering in to infra services, helping our customers enter in to new areas like tele ICU etc. Lastly, as Philips transitions into the healthtech arena, it would be critical to start new businesses which span the entire healthcare continuum and not just diagnostics i.e. healthy living, prevention, diagnostics, therapy, recovery and home healthcare. How does your experience in the past influence your approach to leadership today? Well, everyone develops as a leader as one gathers experience. My previous organisational experience have given me an opportunity to work in various roles in

The diagnostic equipment market is small and hence has immense potential to grow. We will continue to focus on the core while developing the new businesses

India and globally. That helps a leader to adapt to any situation. I hope that I am able to balance the tactical vs the strategic better. Execution is critical irrespective of what role you do, and I think my experience has helped me hone my expectations from my team in that area. Also, I probably spend more time on people development today, which is the key to building great organisations. Lastly, I am a firm believer in managing businesses and people with a disciplined and process oriented approach while giving them the freedom to take risks. What unique challenges and rewards come with working for a large organisation like Philips? Culturally, Philips India

and Philips Global is one of the most enriching experiences I have had till now. People are passionate about the brand and their roles. Extremely customer focused and believe in taking risks. The global leadership encourages innovation and risk taking and has a more federal structure of management, with local key markets having significantly more independence than any of my previous organisations. This responsibility comes with accountability and I think the team on the ground is extremely adept at managing the same. Which segments would be your focus for growth in the coming years? The diagnostic equipment market is small and hence has immense potential to grow. We will continue to focus on the core while developing the new businesses as mentioned above. Where will Philips Healthcare be in the next five years? Five more years older or younger I guess. We will have firm footed new businesses in the healthcare continuum, a larger footprint for R&D and manufacturing, continue the leadership in the core and continue to have the best team in the industry! mneelam.kachhap@expressindia.com

I N T E R V I E W

‘It is important to face the challenges and take risk while doing the task’ Even as the healthcare system is all about improving patients’ lives, the business side of this industry is equally important as building sustainable hospitals and practices. Dr M Mariappan, Chairperson, Centre for Hospital Management, TISS speaks about new age hospital management and its need within the Indian healthcare industry to Raelene Kambli

How has hospital administration evolved over the years? Which are the changes that have improved healthcare delivery? When we think of a hospital or a clinic, we tend to think of physicians, nurses and other caregivers. Hospitals were usually managed by physicians. It was expected that physicians are able to manage the hospital because they have clinical training. However, over the years, hospitals have changed and become a complex unit. Therefore, trained professional managers started to take care of the administration. Healthcare services particularly hospitals, have transformed into quality care centres and a huge contributor to economic development especially the corporate hospitals. Hospitals are professionally-oriented institutions which accommodate huge investment systems, process and skilled as well as unskilled workforce. Therefore, there is a need for trained professionals to manage hospitals. It is also noticed that corporate hospitals or large private hospitals have more professional management system than government hospitals or smaller hospitals. Further, the recent

development like public awareness about healthcare, advanced medical technology, information, innovation driven by competition, increasing costs, quality initiatives have led to demand for professional hospital management and overall positive reinforcement in healthcare delivery. In an highly competitive environment, which are the management strategies required today to make a hospital business profitable without compromising on quality? Hospitals are multifaceted systems, where there are hundreds of operations going on at one time. The business side of the healthcare is vital to the lifeline of the system, especially in hospitals. Hospital managers need to have top-notch business sense to run the hospital efficiently, and they focus much of their time and attention on issues such as budgeting, hospital public relations and marketing, and billing and collections from insurance companies or other payers affiliated with their network. However, the concerns of hospital managers go beyond business and directly into the delivery of care. Managers must maintain their ethical responsibilities while ensuring that all operations throughout

Healthcare services particularly hospitals, have transformed into quality care centres and a huge contributor to economic development especially the corporate hospitals

the hospital are running smoothly, from surgery schedules, patient flow, record updates and confidentiality, waste management and equipment maintenance and set up, to name a few. Hospitals are learning organisation, they continue to be innovating and adopting changes in care delivery process. This approach provides them competitive advantage. In this manner every hospital tries to match the requirement of patients, also try to do better than the other hospitals. They also try to use either cost leadership or product differentiation or both to win the competition. However, finally, the hospital continues to win the hearts and minds of patients and make profit without compromising the quality. Does running a hospital today needs a professional management degree or experience? Elaborate on it. Hospitals are not only a place to care for the patients but also creating an economy, providing employment, ensuring health and productivity of individuals and also meeting a lot of challenges from the healthcare market. Managing modern hospitals is much more complex than in the past. Therefore, professional training is must to manage

resources such as human, finance, material etc. Training should be taken from right source to achieve best outcome and output. What should be the approach - customer first or business first? Modern health organisation value patients much more than in the past. Moreover, patients are also learning very fast to demand their service requirements. The healthcare business demand certain specific requirements. It is very important for the organisation to hear the voice of customer along with the voice of business. It is necessary to treat both the aspects like two eyes of human so that a clear vision can be achieved. What is your mantra for success? People use to say that ‘try and try and succeed’ but one has to ‘simply succeed.’ Success comes with collaborative effort and positive attitude. It is important to face the challenges and take risk while doing the task. The organisation must learn to live with environment and be able to bring the environment under control to ensure success remains with them. raelene.kambli@expressindia.com

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MARKET NEWS

PD Hinduja Hospital & Medical Research Center wins award The Excellence in Community Engagement award recognises the hospital’s various community engagement programmes

PD HINDUJA Hospital & Medical Research Center was recently bestowed with the Association of Healthcare Providers of India (AHPI) 2014 award for 'Excellence in Community Engagement' in Hyderabad. This award recognises the good work done by PD Hinduja Hospital in engaging with communities and delivering quality and affordable healthcare services to all. Joy Chakraborty, COO and Mahesh Shinde, Director-IT received the award from ESL Narasimhan, Governor, Telangana and Dr Girdhar J Gyani, Director General, Association

The award recognises the work done in engaging with communi ties and delivering quality and affordable healthcare services to all of Healthcare Providers (India) on behalf of PD Hinduja Hospital. The hospital has implemented many community engagement programmes like ‘Serve with passion – Hinduja Hospital Rural Health Program’, a mobile health unit (MHU) to support the rural

and tribal areas of the state, free medical camps, health awareness programmes, amongst others. Gautam Khanna, CEO, PD Hinduja Hospital said, “The Excellence in Community Engagement award is an indication of our strong commitment and endeavour to provide

quality healthcare and our promise to regularly engage with various communities to enable healthcare access to all. Our focus now is to continue to provide the easiest and most compelling healthcare experience that allows patients to access the best technology at an affordable cost.” On receiving the AHPI 2014 award, Chakraborty said, “We are thankful to the organisers and jury members for recognising our efforts and role in providing access to quality healthcare to all.” EH News Bureau

Intex forays into medical tourism Launches healthcare management company – Intex Care INTEX TECHNOLOGIES has announced its foray into medical tourism industry with its latest venture ‘Intex Care.’ Intex Care aims to seamlessly integrate its services through its network of hospitals in India and all across the globe. The healthcare division of the organisation is looking at catering to patients globally in need of affordable world class medical treatment. In line with that objective, it has launched this service in India initially and will expand to other major locations in the world in near future. Through its current network of partner hospitals,

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The healthcare division is looking at catering to patients globally in need of affordable world class medical treatment Intex Care will look to facilitate a wide array of services such as plastic/cosmetic surgery, orthopaedics surgery, dental surgery, heart/cardiac surgery, eye/ ophthalmologic procedures, general surgery, neuro surgery, cancer treatment, liver, kidney and bone

marrow transplant and many more. Pankaj Goel, Director - Intex Care, Intex Technologies said, “One of the critical pain points in the medical treatment in my opinion is the provision of world class healthcare services at an affordable

cost. This has been a major point of contention for several years now and we at Intex feel that our organisation is in a position to contribute towards this change. Therefore, with Intex Care it is our endeavour to create the strongest bonds ensuring wellness and healthy life cutting across the age groups of people in India and the world. With this, we are committed to facilitating globally acknowledged medical care at the most affordable prices with a network of our partner multi-super speciality hospitals.” EH News Bureau

Eye-Q raises Rs 60-cr funding IFC, Helion and Nexus are the investors EYE-Q SUPER Specialty Eye Hospitals has received an investment of Rs 34 crores from IFC, a member of The World Bank Group. The investment is part of the Rs 60-crore financing raised by Eye-Q with current investors, Helion Venture Partners and Nexus Venture Partners. Commenting on the same, Rajat Goel, CEO and Co-Founder, Eye-Q Hospitals said, “This investment by global investor like IFC and our current investors validates that we are amongst the best in class across the world and re-enforces our strategy of providing high quality treatment at affordable prices to the masses. We will use these funds to expand further by opening new centres and acquiring hospitals.” Dr Ajay Sharma, CMD and Founder, Eye-Q Super Specialty Eye Hospitals added, “We already have best in class surgical outcomes and can now support more innovations to continue to deliver the best.” “IFC’s investment in Eye-Q will help increase and improve access to affordable health services,” said Pravan Malhotra, IFC’s venture capital lead for south and south east Asia. “Eye-Q’s focus on emerging cities will help expand access to quality eye-care services, while creating skilled healthcare jobs, especially for women,” he added. EH News Bureau

MARKET

Ventureast invests $4 million in Series C funding in DiabetOmics VENTUREAST HAS led a $4 million investment in DiabetOmics, a medical diagnostics company. DiabetOmics has developed a patented non-invasive, saliva-based glucose monitoring test for diabetes patients and an early detection test for gestational diabetes (in pregnant women) and pre-eclampsia (high blood pressure in pregnant women). The investment will be used to advance product development, obtain regulatory approvals in EU, US and in emerging markets, set up manufacturing facility in India and begin commercialisation. The company plans to obtain CE Mark in the second half of 2015 and commence commercialisation in India and several other countries in early 2016. Srinivasa Nagalla, President and CEO, DiabetOmics said, “India has earned the dubious distinction of being the diabetes capital of the world. Lack of patient compliance with regular glucose monitoring is the primary cause of diabetes-related complications. Our portable, easy-to-use device helps patients and their physicians stay informed of the status of the disease. We are pleased with the investment we have received from Ventureast. We are looking to grow our presence in India to access Indian and SEAsian markets.” Venkatadri Bobba, General Partner, Ventureast, said, “An important focus area for us has been investing in companies fostering cutting-edge and breakthrough innovations in healthcare. We believe that DiabetOmics’ device is a game-changer and will definitely be successful in India.” EH News Bureau

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MARKET

Involve public representatives in communicating best practices - JP Nadda Will meet MPs soon to benefit from their insight and suggestions on ‘Mission Indradhanush’

WHILE THERE is substantial amount of good work being carried out in various institutions under the Ministry of Health and Family Welfare, there is need to communicate this to the people. The people’s representatives can be involved to carry the message of schemes of the government, the best practices evolved and the work undertaken by the different institutions. This was stated by JP Nadda, Health & Family Welfare Minister at the 38th annual day celebration of the National Institute of Health & Family Welfare. Speaking at the occasion, Nadda said that the people’s representatives not only represent the people but also interact closely with them on a regular basis. They are among the best medium to spread the message of the schemes and benefits that people can avail of under different schemes of the government. He added that in keeping with this philosophy, he is soon meeting various MPs

to seek their suggestions and views on the implementation of ‘Mission Indradhanush’ which the Health Ministry will shortly launch. The Mission Indradhanush aims to cover all those children who are either unvaccinated, or are partially vaccinated against seven vaccine preventable diseases which include diphtheria, whooping cough, tetanus, polio, tuberculosis, measles and hepatitis B. He informed that a Mission Mode has been adopted to achieve target of full immunisation coverage by 2020. Pointing out that health is a subject which is significantly influenced by various socio-economic determinants, Nadda urged the faculty and staff at the institute to think in a holistic manner while conducting research, and evaluation or monitoring of schemes. Convergence of knowledge from diverse sectors will make the research and monitoring outcomes rounded and more realistic, he stated. While one

can always learn from best practises around the world, the Health Minister encouraged the faculty and staff at the NI-

HFW to contribute to the emerging best practises in the health sector. He urged them to be attentive to the quality of re-

search, training and other services that provide to the various healthcare providers across the country. The minister also inaugurated the National Cold Chain and Vaccine Management Resource Centre (NCCVMRC) and a Skill Lab at the institute. The NCCVMRC will function as the nodal institution for supporting, facilitating and coordinating the cold chain and vaccine management functions of the Immunization Division of the Health Ministry. Whereas, the Skill Lab will provide training to improve the skills of healthcare providers and to enhance their capacity to provide quality RMNCH+A health services. Present at the function were Dr Jagdish Prasad, Director General Health Services, Dr Rakesh Kumar, Jt Secretary (RCH), Prof JK Das, Director, NIHFW and senior officers of the ministry and faculty and staff of NIHFW. EH News Bureau

Metropolis gets govt nod for H1N1 flu testing Metropolis now authorised to conduct swine flu tests in three metro cities MAHARASHTRA STATE government has decided to grant Metropolis Healthcare authorisation to conduct swine flu tests in the city. Metropolis Healthcare is now authorised to conduct H1N1 tests in three key metro cities; Chennai, Mumbai and Pune and will col-

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lect samples across other states for testing. Metropolis Healthcare has also reduced the test price in Mumbai to make it affordable for the patients. With a well trained in-logistics team and a supremely efficient accession and operation team, Metropo-

lis Healthcare is well positioned to issue reports within 8-24 hours depending on the proximity of the location and the time of collection. Only few select labs in India are authorised to carry out the swine flu test in the laboratory, as this requires specialised testing backed by

high end technology and special sample collection requirements. Dr Nilesh Shah, Group President, Scientific Services & Operations says, “Metropolis Healthcare complies with all requirements of state government. We previously used to

send all our samples to Chennai and provide reports within 24 – 26 hours. But now we are happy that our customers will get reports within 8-24 hours. We are also looking forward to applying for permission in Delhi." EH News Bureau

MARKET

Wockhardt Hospitals bags Golden Globe Tigers Summit - Awards 2015

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Malaysia and many more. Speaking on the occasion, Zahabiya Khorakiwala, MD,

Wockhardt Hospitals, said, “It’s a great honour to receive the prestigious award. These

awards demonstrate Wockhardt Hospital’s dedication and efforts to provide world-

class services of excellence in healthcare.” EH News Bureau

A spirit of

INSPIRATION

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State wise dealers required

MAR-0733-v.0.1

WOCKHARDT HOSPITALS has received nine HR awards at the Golden Globe Tigers Summit – Awards 2015, recently held in Malaysia. It’s the only hospital across the continent to be honoured with the coveted ‘Malaysia Best Employer Brand Awards’. The hospital was awarded the honour under the patronage of Dr RL Bhatia, Founder - World CSR Day, World Sustainability Congress & World Women Leadership Congress. Golden Globe Tigers Awards is all about achievers, super achievers and future business leaders. HR Leadership Awards recognises the achievements made by selected high profile corporate business leaders in Asia. Wockhardt Hospitals was conferred upon the awards in different categories, such as ‘Dream Company to Work for’, ‘Dream Employer of the Year’,‘Best Organization Development Program of the Year’ and ‘Best Training Initiative in Healthcare’. Dr Rajani Tewari- Head HR Wockhardt Hospitals is conferred with “CHRO of the year” along with “Women Super Achiever Award and Chief Development Officer Award.” Wockhardt group of Hospitals has been recognised for its commitment to provide services with compassion, respect and for consistently adhering to high standards of superior and specialised healthcare. The hospital, representing India had to compete with different industries from 32 countries across the world. Other dignitaries who had graced the occasion, involved, Prof Dr Roslan Zainal Abidin, President and ViceChancellor, Infrastructure University of Kuala Lumpur, Prakash Chandran, President and CEO, Siemens,

MARKET

Union Minister of Chemicals & Fertilizers launches ‘Pharma Jan Samadhan’ scheme Kumar also released Compendium of Ceiling Prices of Essential Medicines 2015 prepared by NPPA

THE UNION Minister of Chemicals & Fertilizers, Ananth Kumar launched ‘Pharma Jan Samadhan’ scheme. It is a web-enabled system for redressal of consumers’ grievances relating to pricing and availability of medicines, created by National Pharmaceutical Pricing Authority (NPPA). Kumar also released Compendium of Ceiling Prices of Essential Medicines 2015 prepared by NPPA. The ‘Pharma Jan Samadhan’ scheme has put in place a speedy and effective complaint redressal system with respect to availability and

The ‘Pharma Jan Samadhan’ scheme is expected to serve as a robust e-governance tool for protection of consumers’ interests through effective implementation of the Drugs (Price Control) Order 2013 pricing of medicines. It is expected to serve as a robust egovernance tool for protection of consumers’ interests through effective implementation of the Drugs (Price Control) Order 2013. ‘Pharma Jan Samadhan’ will provide consumers and others with an on-line facility,

sale of new medicines without prior price approval of NPPA, and refusal of supply for sale of any medicine without good and sufficient reason. NPPA will initiate action on any complaint within 48 hours relating to over-pricing of medicines, non-availability or shortage of medicines receipt.

Speaking on the occasion, Kumar said that the new initiative shows that the government or NPPA is not only regulator but more of a facilitator. He said that this phama-literacy initiative would create awareness among the people and would act as a deterrence against black-marketing, spuri-

ous medicines, and inflated cost of drugs. Kumar said that the pharma industry stands on three pillars- quality, availability and affordability, and ‘Pharma Jan Samadhan’ is a step in this direction. The Minister said that pharma is the sun-rise sector of the country and considering the size, it seems to be a fit case to make a separate Ministry to handle issues relating to pharma industry. Lauding the NPPA initiatives the Minister said that this would help in making the Prime Minister’s vision of ‘Make in India’ a reality. EH News Bureau

IKEAFoundation expands its programmes in India Improved lives of over 100 million children in India out of the 178 million worldwide CELEBRATING THE completion of 15 years in India, IKEA Foundation, has strengthened its commitment with previously unannounced grants to partners PRADAN, Aajeevika Bureau, Landesa, Development Alternatives and Ashoka. The expansion is an example of the IKEA Foundation’s commitment to working with smaller, local partners as well as larger humanitarian aid organisations improving the lives of children in India. The announcement came as the Foundation published its 2014 annual review, 178 million smiles, which also revealed that last year alone it gave €104 million in grants and in-kind dona-

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tions to 40 partners operating in 46 countries. During the 25th anniversary of the Convention on the Rights of the Child, IKEA Foundation made six new grants to UNICEF, amounting to €24.9 million, boosting its commitment to children. Per Heggenes, Chief Execu-

tive Officer, IKEA Foundation said, “Completion of 15 years in India is a very important milestone for us. Our current work grew from IKEA’s efforts to fight child labour in its supply chain in India. But, early on in the endeavour, IKEA learned that to prevent child labour it is

The Foundation gave €10 million in grants for disaster and emergency relief in 2014, including emergency donation of €5 million to MSF to fight Ebola in West Africa

vital to address the root causes of why children work.” Today, the Foundation’s work has ranged from simple but important initiatives, such as providing immunisations or vitamin supplements, to comprehensive programmes supporting entire communities. In India, the IKEA Foundation works with 12 partners on long term programmes that change attitudes towards child labour, provide education and healthcare and empower women so children and families can break the cycle of poverty. Other highlights from the report show that the Foundation gave €10 million in grants for disaster and emergency re-

lief in 2014, including its biggest-ever emergency donation of €5 million to Médecins Sans Frontières (MSF) to fight Ebola in West Africa, had helped 1.2 million babies get much-needed specialist care through UNICEF in India by the end of 2014, supplied 6,000 IKEA toys for UNICEF’s Early Childhood Development kits, which were sent to 11 countries in 2014, including Syria, Sierra Leone, Iraq and Afghanistan and donated a total of 150,000 IKEA mattresses, quilts and quilt covers to the UN refugee agency (UNHCR) for Syrian refugees living in Iraq. EH News Bureau

MARKET PRE EVENT

Seminar @symbiosis This year’s edition will also feature four intensive, domain specific master class sessions

THE XVII National Seminar on Hospital/Health Care Management, Medico legal systems & Clinical Research will be held on May 1-2, 2014 at Symbiosis International UniversityLavale, Pune. This edition will feature three highlight events. To begin with, under the initiative Connexions there will be a workshop combined with placement assistance for jobseekers on 20th April 2015. The main event will be inaugurated by Dr Rajani Gupte, Vice Chancellor, Symbiosis International University (SIU). To elaborate on how to create

and sustain an effective, efficient and successful business model, a pre-conference symposium on 'Successful Healthcare Models' has been structured. The other sessions on that day will include 'The Strategies for Branding and Advertising in Healthcare' and 'Healthcare and International Relations'. This year’s edition will also feature four intensive, domain specific master class sessions on topics Patient Safety in Healthcare, Expanding horizons in Diagnostic Care, Opportunities and challenges in

Health Insurance and Special laws related to Healthcare. Day 2 of the XVIIth National Seminar would have sessions like Entrepreneurship and Innovations in Healthcare, Capacity Building and Career options in Public Health and NGOs, Quality comes at a cost, Quality Systems and SOPs in Clinical trials, Hospitals of Tomorrow, The Key trends transforming the Clinical Trial Industry, Legal Aspects of Healthcare (Land mark Judgements) This year the Valedictory Ceremony will see the intro-

duction of two stellar awards, namely Healer of Mankind' award and 'Star alumni', as recognition for contributions in the healthcare field. This year the valedictory ceremony will be graced by Chief Guest – Dr Pratap Reddy, Founder & Chairman, Apollo Group of Hospitals. The guest of honour for the ceremony will be Adv Ram Jethmalani, Former Union Law Minister. The ceremony will be presided over by Padma Bhushan Dr SB Mujumdar, Founder & President, Symbiosis and Chancellor, SIU. The National Seminar

promises to provides an ideal platform for the exchange of ideas in the critical healthcare field. It is a must attend event for professionals from all verticals of healthcare. Contact Dr Rajiv Yeravdekar Dean, Faculty of Health & Biomedical Sciences, SIU Phone: 91-020-25655023, 25667164, 20255051, 08888892258, 8983323700 Email: info@schcpune.org, dep@schcpune.org, hod_academics@schcpune.org Website: www.schcpune.org

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MARKET POST EVENT

ICAI organises ‘Asian Summit on Health Care Cost Management’ The theme for the summit was touching lives through cost management in health care

THE INSTITUTE of Cost Accountants of India (ICAI) recently organised a two-day 'Asian Summit on Health Care Cost Management' in New Delhi, with the theme ‘Touching Lives through Cost management in Health Care’. The summit was attended by eminent persons from medical, pharmaceutical, health insurance, health sector, IT, consulting and cost management fraternity. The objective of the event was collective learning aiming at providing necessary solutions to healthcare industry in bringing down the cost to provide healthcare at affordable cost. CMA Dr AS Durga Prasad, President, Institute of Cost Accountants of India, G Srinivasan, Chairman-cum-MD, New India Assurance Co, CMA M Gopalakrishnan, Past President of the Institute & Chairman Cost & Management Committee, Rahul Khosla, MD, Max India and CMA AN Raman, Past President SAFA inaugurated the summit. CMA Gopalakrishnan, in his welcome address, talked about the pioneering efforts made by the institute for cost management in the healthcare sector. He expressed the need for enhancing use of IT in measuring cost, sharing data about costs and integration of cost management with financial accounting. CMA AN Raman, while introducing theme 'Touching lives through health care cost management,' expressed that cost management goes beyond measuring cost and aims at ensuring utilisation of scarce national resources in optimum manner. Cost management is still in evolving stage within

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Left to Right: CMA Rakesh Singh, Former President and CCM, ICAI, Tushar Pandey, Senior President & Country Head, Public & Social Policies Management Group, YES Bank, CMA M Gopalakrishnan, Former President and CCM, ICAI, Annaswamy Vaidheesh, Vice President, Corporate Government Affairs, Asia-Pacific for Johnson & Johnson, Singapore, CMA Dr A S Durga Prasad, President, ICAI, Dr. Nitin Verma, Senior Vice President Global Head Health Care

healthcare and far away from being developed as compared to manufacturing sector. Durga Prasad, in his welcome address, emphasised on the need for greater funding which is a major problem and interest a big burden on healthcare sector. The prevailing price disparity between large and small hospitals needs to be looked into and health insurance brought within the reach of the poor. He highlighted the need for benchmarking in healthcare and improvement in data quality. He called upon CMA fraternity to work with great zeal in association with medical profession to bring cost management in healthcare and address the issues before this sector to make healthcare

The institute released guidance note on healthcare cost management, to provide the right templates to all users to streamline tariff fixation on generally accepted principles and implementing and effective costing system in healthcare entities deliveries at affordable cost. On this occasion, the institute released guidance note on healthcare cost management, to provide the right templates to all users including heathcare

administrators to streamline tariff fixation on generally accepted principles and implementing and effective costing system in healthcare entities. The institute also brought out

'Knowledge Pack' to enhance knowledge in this emerging area, with the eminent personalities contributing their valuable experiences. Rahul Khosla shared his aspiration that healthcare should be regarded as fundamental right of every citizen and should be brought within the reach of every poor. Unfortunately, healthcare sector is facing trust deficit mainly in context of affordability and conflict of interest between various stakeholders The summit focused on 'Cost pressures on healthcare sector and measures to overcome them, harnessing technology to minimise healthcare cost and balancing technology, quality and cost.'

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Assam Health Minister launches North East Association for Road Safety at GNRC Summit GNRC to provide initial corpus from Corporate Social Responsibility CSR funds; Unveils GNRC Accident Card to provide treatment to accident victims DR NAZRUL ISLAM, Minister for Food, Civil Supplies & Consumer Affairs, Health & Family Welfare, Government of Assam,, recently launched the North East Association for Road Safety (NEARS) at the first North East Road Safety Summit organised in Guwahati by GNRC. GNRC will provide the initial corpus for the association, from the organisation’s CSR fund. At the summit, the Health Minister also launched a social service scheme titled GNRC Accident Card, which provides medical care to members – in the unfortunate event of an accident befalling them. To address the pressing need for a solution to curb road accidents in the region, GNRC organised the North East Road Safety Summit. Dr Islam inaugurated the summit, where representatives from four Es: Education, Enforcement, Engineering; and Emergency Care assembled at the NEDFi Auditorium, to formulate a roadmap to tackle the menace of road traffic accidents in the North-East. Several representatives from education institutions, enforcement agencies, media and engineering services attended the event. At the summit, Dr Atanu Borthakur, Director of Accident and Emergency department of GNRC Ltd presented the report on ‘State of Youth Health: Road Traffic Accidents – An Emerging Epidemic’, prepared by compiling and analysing data from records of over 25 years maintained by GNRC and various other publicly available sources. The report highlighted that young people aged between 15-44 years were the primary victims of road accidents in the state.

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EVENT BRIEF APRIL-MAY-JULY 2015 10

ULTRAFEST 2015

ULTRAFEST 2015 Date: April 10-12, 2015 Venue: The Renaissance, Mumbai Summary: Ultrafest 2015, now in its seventh edition will be organised by the Maharashtra State Branch of Indian Radiological & Imaging Association (msbiria.org). The theme this year is uro-gynaecology and obstetrics. The keynote speakers are Dr Shweta Bhat, Dr Sheila Sheth and Dr Paula Woodward, all from the US. Topics on urology, gynaecology and fetal ultrasound will be discussed and debated over the three days of the event. The regular features such as abstract and poster

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XVII NATIONAL SEMINAR ON HOSPITAL & HEALTHCARE MANAGEMENT, MEDICO LEGAL SYSTEMS AND CLINICAL RESEARCH

presentations, spotlight speakers, resident’s corner, quiz with interactive voting pads, Chuppa Rustum, scientific exhibits with new machine displays will be conducted as well. Contact Dr Sanjeev Mani 1st Floor, Jain Arcade, CD Marg, Khar (W), Mumbai 400052 email: ultrafestindia @gmail.com Ph: 022-26463666

XVII NATIONAL SEMINAR ON HOSPITAL & HEALTHCARE MANAGEMENT, MEDICO LEGAL SYSTEMS AND CLINICAL RESEARCH Date: May1-2, 2015 Venue: Symbiosis

International UniversityLavale, Pune Summary: The national seminar provides an ideal platform for the exchange of ideas in the critical healthcare field. A free flow of information and ideas will certainly enhance the march of healthcare sciences and herald the beginning of a new era in this sunshine industry. It is a must attend event for professionals from all verticals of healthcare. Contact Dr Rajiv Yeravdekar Dean, Faculty of Health & Biomedical Sciences, SIU Phone: 91-020-25655023, 25667164, 20255051, 08888892258, 8983323700 Email: info@schcpune.org, dep@schcpune.org, hod_aca-

demics@schcpune.org Website: www.schcpune.org

MEDICALL 2015 Date: July 31, Aug 1 and 2, 2015 Venue: Chennai Trade Centre, Nandambakkam Summary: Medicall brings the latest, appropriate and affordable technologies, for the benefit of all hospitals including smaller hospitals, clinics, nursing homes and physicians setting up group practice. Visitors’ profile include doctors, hospitals owners, diagnostic centres, medical directors, biomedical engineers, medical colleges, healthcare services, investors for healthcare industry, and purchase managers. Exhibitors’ profile include

MEDICALL 2015

hospital equipment, surgical equipment, hospital furniture, diagnostic/laboratory equipment, dental/ophthalmology equipment, medical disposables, facility management and support services, hospital design and construction, hospital staffing service, IT provider for hospital, communication equipment, medical waste management, medical textiles, financial and health insurance services, office automation, equipment and accreditation agencies. Contact Medexpert Business Consultants, 7th Floor, 199, Luz Chruch Road, Mylapore, Chennai Tamil Nadu, India Phone: 91 44- 24718987

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BUDGET 2015: IN SEARCH OF AN EFFECTIVE HEALTHCARE SYSTEM | PG26

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MAKE IN INDIA OR MAKE FOR INDIA? | PG28

CK MISHRA, ADDITIONAL SECRETARY & MISSION DIRECTOR (NRHM), MINISTRY OF HEALTH AND FAMILY WELFARE | PG26

HEALTH AS A JUSTICIBLE FUNADAMENTAL RIGHT | PG32

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Budget 2015: In search of an effective healthcare system The much anticipated increase in fund allocation for healthcare has taken a backseat as the current government searches for other ways to finance an effective healthcare system such as private insurance. The massive mismatch between the declared objective of universal healthcare through the public health system and the actual level of expenditure remains a serious concern BY M NEELAM KACHHAP

aking healthcare reform a priority was one of the pre-election promises Narendra Modi made to the nation, that led to his landslide victory in the last election. However, the first budget of the new government seems to back-out on the promise. A massive miss national health assurance mission announced last October has no takers. Instead the government wants to encourage private insurance with an inclination towards public-private partnership. That the government needs to allocate more funds for public health is a nobrainier, however, the current government like its predecessor continues to relegate the matter.

Allocations for the year Finance minister Arun Jaitley’s budgetary allocation for healthcare took many industry leaders by surprise. While the total outlay of Rs 33,150 crore for the sector is similar to the allocation in previous budgets it does not seem sufficient to run the various schemes of the government. Besides, the allocated amount does not trans-

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late to the much anticipated increase of GDP spend from 1.2 per cent to two per cent, which was projected as the government intent before and after the elections. “This budget for healthcare is the lowest since 2012 – 2013. This does not send the right message at all, at a time when we are talking about proportionately increasing the budget in terms of GDP,” said Ameera Shah, MD and CEO, Metropolis

Healthcare. In addition, India has had a history of underutilising the health budget and the finance minister has failed to address this. “Allocation of funds is an issue but the larger issue is that there is no proper system to make sure that the budget is used in the right arena,” added Shah. “The budget does not deliver to the expected transformation of the healthcare sec-

tor in the country under the promise of the Universal Healthcare coverage,” said Vishal Bali, Co-Founder and Chairman, Medwell Ventures. “The budget is silent on the promise of the National Health Assurance programme,” he added. However, the Union Minister for Health & Family Welfare, JP Nadda has termed the Budget as balanced, progressive, pragmatic and pro-peo-

ple. He stated that the resolve to support the health sector in a big way has been shown by the outlay for health in the Budget of Rs 33,150 crore. Further, justifying its stand, Nadda stated through a written reply in the Rajya Sabha that by the end of 12th Plan period, the government would have increased its share in public spending on health. As per Economic Survey 2014-15, the expenditure by the Gov-

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WHAT IS NHAM ernment (Central and State Government combined) on health as percentage of Gross Domestic Product (GDP) for 2014-15 (BE) is 1.2 per cent. As per 12th Five Year Plan document, the total public funding by the Centre and States, plan and non-plan, on core health is envisaged to increase to 1.87 per cent of GDP by the end of the 12th Plan. When viewed in the perspective of the broader health sector, the total government expenditure as a proportion of GDP is envisaged to increase to 2.5 per cent by the end of the 12th Plan.

Why did national health assurance mission fly out of the window? The much touted national health assurance mission which was to be the governments’ flagship differentiators has not yet taken off because it was too expensive to apply. Experts believe that the government would have to shell out an estimated $11.4 billion annually on the project which would take about 10 years to cover the 1.2 billion people in India. “The unfortunate fiscal fact is that India may not be able to have anything like doubly universal health coverage — that all people can have all medically effective treatments for all diseases,” writes Harvard scholar Lant Pritchett and Gulzar Natarajan in an article. (http://indianexpress.com/article/opinion/columns/putting-theuniversal-in-healthcare/99/) “The typical European country with doubly universal health coverage spends around $4,000 per person per year to do so — higher than the total Indian GDP per capita. Indians currently spend about $120 per capita (PPP) on healthcare each year, of which only a quarter comes from the government. Mexico, whose Seguro Popular universal insurance scheme is regarded as a model for upper middle income countries, spends nearly $1,000 per capita, with half coming from the government. Even the Mexican levels of government spending would require 80 per cent of all Indian taxes to be devoted to health —

The National Health Assurance Mission’s (NHAM) objective is to reduce out-of-pocket spending on healthcare by the common citizen. For the proposed programme, Indian government was to provide all citizens with free medications and diagnostic treatment, as well as insurance cover to cure serious ailments

PROPOSED FREE SERVICES AT GOVERNMENT HOSPITALS Q Universal Immunization of children against seven diseases, Q Pulse polio immunisation Q Family planning services, Q Maternal and reproductive health services Q Child health services that include both home based and facility based new born care, Q Adolescent Reproductive and Sexual Health (ARSH) services, Q Investigation and treatment for malaria, kalaazar, filaria, dengue, JE and chikungunya, Q Detection and treatment for tuberculosis including MDR-TB, Q Detection and treatment for leprosy, Q Detection, treatment and counseling for HIV/AIDs. Q Non-communicable diseases services Q Cataract surgery for blindness control- over six million free cataract surgeries done every year, Cornea transplant, glaucoma/ diabetic retinopathy, spectacles to poor children.

leaving almost nothing for anything else — infrastructure, police, education, defence, etc ,” Pritchett explains.

Is insurance the answer to better health? Taking a cue on healthcare financing from the US, the Narendra Modi government has, linked healthcare firmly to the private insurance sector. The finance minister proposed to increase the limit of deduction under section 80D of the income tax Act from Rs 15,000 to Rs 25,000 on health insurance premium. In case of senior citizens, the limit of deductions has been increased from Rs 20,000 to Rs 30,000. “In recognition of health inflation the enhanced tax exemption on health insurance premiums from Rs 15,000 to Rs 25,000, and Rs 20,000 to Rs 30,000 for senior citizens, will provide the much needed impetus for adoption while also encouraging people to invest appropriately in their health insurance which can adequately service their healthcare needs,” says Anuj Gulati, CEO,

Religare Health Insurance. “Additionally, with respect to ESI, the employee will now have the option of choosing either ESI or a Health Insurance product recognised by the IRDA, enabling them to select healthcare financing option basis their specific healthcare needs. We are also pleased to see the government’s positive intent and action towards ensuring a larger populace access to the benefits of insurance through the state-sponsored programmes, namely, Pradhan Mantri Suraksha Bima Yojana and Pradhan Mantri Jeevan Jyoti Bima Yojana,” Gulati added. Analysing the move Dr Alexander Kuruvilla, operating partner , Multiples Alternate Asset Management says, “It is a natural sequential process following increase in FDI into the insurance sector to allow for exemptions and increasing incentives to enable more people to buy health insurance. As a nation, we cannot be looking for subsidies and expecting to grow further. The people should be enabled to buy and increase their purchasing

power and with incentives and tax exemptions our government is trying to address this plague and enable growth.” Industry experts, however, feel that the government is nudging the middle class to opt out of public health system by incentivising insurance. Amit Sengupta, co-convenor of Jan Swasthya Abhiyan says, “Theoretically, the government should be the putting the tax money in building and strengthening a public system. Instead, they are giving incentive to people to go to the private sector.” This will also widen the gap between the haves and the have not, feel experts. “It is paradoxical as the fine print in the Budget statement will lead to increased out-of-pocketexpenses. The danger is that in-equities in healthcare will persist leading to more gaps between urban /rural areas and between North & East India vs West and South India,” says Dr Harish Pillai, CEO, Aster Medcity.

Cost burdened insurance-based healthcare As the US healthcare system has shown the road to insurance-based healthcare financing is rocky. One of the major drawback is the link between private health insurance companies and healthcare providers, which is also why the US healthcare cost is skyrocketing. If anything the situation in US calls for an inward retrospection on insurance and better regulatory environment. The health insurance nexus with hospitals and its regulation are a cause of concern in India. Still some industry experts feel that better days are ahead. “The coming days will lay stringent norms on the hospitals and insurance companies to reduce out of pocket spend which is already evident with GIPSA Tariff being followed in many cities with private hospitals,” informs Kuruvilla. The other drawback of insurance is that insurance covers only the cost of hospitalisation and not expenditure on outpatient care. National health accounts statistics show

that close to 70 per cent of the out-of-pocket expenditure of the household is for outpatient care, which will not be covered by insurance. And even then what percentage of the population can afford that insurance. Besides, what use would insurance cover be for people who cannot access healthcare. It is a fact that many rural areas in India do not have hospitals, how then would insurance even if it is public insurance help patients? Insurance should not become a hurdle to healthcare. The government should focus on improving accessibility.

Accessibility prime focus Increasing accessibility should have been the primary focus of the government, it they really wanted to transform India’s healthcare sector. Most of the new government policies focusing on transforming the economy wont work if the most important asset of India its people are not taken care off. The budget did not focus on improving the existing healthcare facilities or even making healthcare accessible by increasing its infrastructure. “On infrastructure front , it is a bit of under expectation, with only mention of five AIIMS in various states,” says Anupam Verma, President, Wockhardt Hospitals. “A centralised thrust on creation of more quality infrastructure on medical, paramedical, medical and allied education would have set clear directions,” he says. “Also, the need for healthcare policy and an indicative allocation to roll that out with clear milestones would have been appreciated. Historically there have been gaps in intentions and outcomes. We hope that this is bridged to create a healthy India this time,” he added. “A nations health is its strategic asset; we will need to wait for the day when health and education get better budgetary support as it is critical in the development of our most precious resource – people,” concludes Dr Pillai. mneelam.kachhap@expressindia.com

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cover ) ANALYSIS

Make in India or Make for India? Even as the current government raises the pitch for the 'Make In India' campaign, medical equipment manufacturers in India are struggling to use their capacity to the fullest due to the unfavuorable business environment. In such circumstances how will the concept work for the Indian healthcare sector? BY RAELENE KAMBLI

nion Finance Minister, Arun Jaitley during the Budget 2015 session reiterated PM Narendra Modi's vision of making India a global manufacturing hub. In his budget speech, the FM defined the road map for the 'Make in India campaign' which is a key pillar of the government’s strategy to rectify the country’s multiple socio-economic problems. The FM further, urged the industry to manufacture medical equipment in India and kick-start thinking on the agenda of 'Healthcare for All'. For this reason, he announced a reduction of custom duties for raw materials and unveiled many proposals to cut down delays in manufacturing projects clearance, developing infrastructure, creating a business environment and more importantly to generate employment. All to be done to lead the Make in India campaign to success. However, with Indians bearing maximum of their healthcare spending out-ofpocket and with most medical equipment being imported for India, will the Make in India concept work for healthcare? We seek to find out....

The Make in India vision India's overall mainufacturing sector contributes to about 16-17 per cent to the GDP out of which the medical device manufacturing contributes only 0.2 per cent. The campaign which

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was launched last year September aims to increase the overall manufactuirng share to 25 per cent by 2022. The vision behind this campaign is to put the country on the global manufacturing map and, in turn, facilitate the inflow of new technology and capital, while creating millions of jobs. Under this flagship campaign, the government has identified 25 sectors that have huge scope to draw foreign as well as Indian companies to manufacture in India. Pharma

and healthcare are amongst them. According to the PM, the campaign can act as a catalyst to make healthcare accessible and affordable in India. During the Make in India conference organised by the Dept of Industrial Promotion and Policies (DIPP) on December last year, the PM said, “Make in India" vision is realised even in the medical devices field which is close to 35,000 crore industry with over 80 per cent import dependency. We are all hopeful with new initiatives

like 100 per cent FDI for both green and brown field projects, right incentives for domestic manufacturing and Buy India policy, medical devices also will grow like pharma industry starting from 2015 and become import independent by 2020”.

Industry's viewpoint Currently, the Make in India campaign has picked up momentum in areas of defence and electronics manufacturing. Where the healthcare and pharma sectors are con-

cerned, industry experts opine that the move can certainly act as a catalyst for change. Rajiv Nath, Forum Coordinator AIMED feels, “The idea is simple, yet powerful and visionary. India is in transition and for the next level of development to happen. India needs to create new avenues for growth and employment. Unfortunately, despite potential, manufacturing lagged behind due to myopic policies pursued by governments over the years. Result has been that on one

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India is in transition and for the next level of development to happen. It needs to create new avenues for growth and employment

We can also learn from the models adopted by other countries successful in this area. Ireland is an example

FOCUS:POLICY

The current fiscal policies and tax structure favour imports and there are no incentives for manufacturing in India

FDI is key and since it’s allowed in both ‘greenfield’ and brownfield’ projects; this is a much needed fillip for the industry

Rajiv Nath,

Anjan Bose,

Forum Coordinator AIMED

Secretary General NATHEALTH

Dr G SK Velu,

Dr Ramakanta Panda,

MD, Trivitron Healthcare

VC-MD, Asian Heart Institute

hand we stumped domestic manufacturing and on the other, we became heavily import dependent in critical sectors like medical devices. Make in India vision aspires to correct certain anomalies and be an answer to many challenges facing the country”. Elaborating further on how the medical device industry can play its part in realising the vision of the campaign, he says, “The medical device sector has been identified by the government task force as one of five key sectors which can be a driver for the ‘Make in India’ campaign. And there are valid reasons for this conclusion. The industry is already the size of $ five billion and expected to grow to $ 30 billion by 2022. Additionally, manufacturing and employment opportunities are huge as this sector is import dependant of over 70 per cent. Moreover, within the electronic medical device segment the import dependency is almost 90 per cent.” On the same lines Anjan Bose, Secretary General NATHEALTH, says, “Make in India is an excellent concept, which should result in many benefits for healthcare and pharma industry as well as citizens of India”. Explaining further the idea behind the campaign he goes on, “The idea of this campaign is to create the

right products for the Indian market at the right price levels. Also this will result in increased local employment that will certainly help the economy and the nation. These products can also be considered for export which will increase our forex (foreign exchange) earning. ‘Brand India’ will go more global!” Medical technology manufacturer and industry leader, Dr G S K Velu, MD, Trivitron Healthcare also feels that the concept is a good initiative to boost manufacturers within the healthcare sector. He states, “There are some significant benefits to this move which will bring down the cost of medical equipment and devices by 30 to 50 per cent and also the uptime of equipment in tier 2/3/4 towns will improve due to easier availability of spare parts. Local production will also lead to additional employment generation, local R&D and local skill development programmes. Moreover, the PM’s vision has already attracted some major MNC players are attracted to set up low cost manufacturing units in India to serve emerging market. The first step has been taken by American conglomerate, General Electric (GE) who has already started shipping ultra low-cost medical devices made in India to emerging markets

globally. These products will be up to 40 per cent cheaper and is expected to address 10-15 per cent of the global healthcare equipment market. While industry analysts and equipment manufacturers feel that this campaign can give an impetus to the industry, healthcare providers hope that this campaign will improve basic healthcare indicators and sanitation and infrastructure needs in rural India. Dr Ramakanta Panda, VC-MD, Asian Heart Institute states, “Make in India has to be a way of life. As manufacturing facilities will get set up in the remotest parts of our country, people will begin to enjoy the benefits of basics such as access to sanitation.” Explaining how diagnostic

sector can be a part of this initiative, Ameera Shah, MD Metropolis Healthcare, shares, “From a diagnostic industry perspective, our business is hit very badly due to rupee depreciation because 30 per cent of our P&L goes in chemicals to conduct tests. These chemicals are imported and are heavily taxed. We pay almost 25-30 per cent of tax on these imported chemicals. Today the problem is that as the rupee fluctuates, our cost of importing these chemicals goes up and we can’t pass on the cost burden to our patients. The other problem is that we don't have good indigenous chemical manufacturers in India from whom we can buy these chemicals and reagents. So, if the industry is encouraged to produce these chemicals in India, it will not only benefit these manufacturers but also the entire diagnostic industry and offcourse patients at large as this will even help in reducing the cost of diagnostic tests. Therefore, the Make in India campaign should not only focus on equipment but also diagnostic chemical and reagents.” Adds, Rajan Datar, Founder, Datar Genetics, “From Jaipur foot to Embrace Global’s low cost infant warmers and incubators, India has always shown a strong tradition to make in India. The ini-

The medical devices industry which is close to 35,000 crore is over 80 per cent import dependent

We don't have good indigenous chemical manufacturers in India from whom we can buy these chemicals Ameera Shah, MD Metropolis Healthcare

tiative has two parts to it, one is technology and the other is manufacturing”. Citing some more success stories, Dr Panda, says, “Sustainability is the key. No enterprise can survive if it is not sustainable. There are inspiring models like Aravinda Eye Care, which has been manufacturing its own intraocular lenses (IOLs) used in cataract surgery and providing service to millions of people who cannot afford it. Or Kanungo Diabetes in healthcare, a set up in Odisha that caters to rural populations. The scale of impact is something that will be built with time. The seeds have to be sown at the earliest. Any entrepreneur who can commit to a certain healthcare need, and build economies of scale in volume terms around it, will surely succeed.” Experts further believe that hospital furniture, such as trolleys, beds, wheelchairs, stools, common usage items such as syringes, needles catheters, gloves, ventilators, pumps, simple diagnostic machines such as X-rays, low-end sonography machines, glucose monitors etc; should definitely be manufactured in India. The vision of Make in India is indeed acceptable by the industry, but do we have the wherewithal to realise it? Do we have favourable policies

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cover ) and tax structures to encourage manufacturers or is this campaign's pro-business reform propaganda, a political gimmick?

Dreams or Delusion? India has enough fundamental strength that will help foster this vision. A huge domestic market, technical expertise, plentiful natural and financial resources as well as a large pool of entrepreneurs who wish to contribute to this cause. But without government backing this dream will only be delusion. As a note of caution, Reserve Bank of India Governor Raghuram Rajan during a lecture organised by Federation of Indian Chambers of Commerce and Industry (Ficci) said, “Too much focus on manufacturing and an export-led growth path may not work in India as it has done for China. I am cautioning against picking a particular sector such as manufacturing for encouragement, simply because it has worked well for China… India is different and developing at a different time. We should be agnostic about what will work. Such a strategy will not pay for India due to the tepid global economic recovery. Other emerging markets could absorb more, and a regional focus for exports will pay off. But the world as a whole is unlikely to be able to accommodate another export-led China.” Further on, he goes on to say, “Instead, the focus should be ‘Make for India’, which will produce for the internal market”. He says this because, China whose strategy we seem to follow under this campaign, has moved away from the export-led growth model and is concentrating on production geared to domestic demand. “Indian manufacturers should also cater to domestic demand. This is because the global scene is not as upbeat as before and external demand coming from US and the EU is weak and not enough to sustain export led growth”, he sums. Meanwhile, industry experts also express certainly ambiguities associated with realising the big Make in India vision.

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Says Dr Velu, “Firstly, there should be a fair play field as the current fiscal policies and tax structure favour imports and there are no incentives for manufacturing in India”. Nath, explains, “The current inverted duty structure whereby the import of medical devices is at 0 per cent basic and 0 per cent special additional duty (SAD) in most cases and five per cent basic and O per cent SAD in some cases whereas the import of raw materials and components are at peak duty rates – hence the lopsided tax regime does not make the projects viable”. “Why will foreign companies invest if they can easily access and exploit Asia’s 4th largest market with negligible duties and build their brand image without having the headaches of putting up greenfield projects at considerable, investment costs and efforts ?”, Nath further questions the government. He then goes on to say, “There has to be ease of business policies by bureaucracy and a strategy by political leadership need to be on the same page of the Prime Minister’s vision. Mere sloganeering and lip service are not going to yield results. Small doses of reforms and policy facilitations for public consumption are also not going to yield results. Government needs to take some concrete, hard long term decisions which will truly make India a manufacturing powerhouse”. With lack of favourable tax policy accomplishing the goals of the campaign will be arduous. Nevertheless, the industry is making efforts to speak with the government and negotiate on the tax policies for medical devices.

Measures for success Nath informs that the AIMED prior to the Union budget 2015 had sent some recommendations to the FM on revising the tax structures to simplify medical device manufacturing in India. Although these recommendations were overlooked during the budget, the ministry has promised to consider them soon. Some of these recommen-

INDIAN PLAYERS Majore Indian players include: Hindustan Syringes & Medical Devices, Opto Circuits (India), Wipro GE Healthcare, 3M India, Medtronic, J&J, Becton Dickinson, Abbott Vascular, Bausch & Lomb, Baxter, Zimmer India, Edwards Life Sciences, St Jude Medical, Stryker, Boston Scientific, BPL Healthcare India, Sushrut Surgicals, Trivitron, Accurex Biomedical, Biopore Surgicals, Endomed Technologies, Forus Health, HD Medical Services (India), Eastern Medikit, Harsoria Healthcare, Nidhi Meditech System, Philips Medical, Wipro, HCL Tech and Texas Instruments.

dations are listed below: ◗ Reversal and rationalisation of inverted duty structure: If government really wishes to encourage ‘Make in India’, it has to remove this anomaly at the earliest. ◗ Absence of export substitution policy: Due to an aggressive export substitution policies followed by countries such as China, Indian manufacturers/products are simply unable to compete on lowest price criteria alone in any public tender. AIMED have been demanding an encouraging export substitution policy for subsidising a Brand India export promotion (not OEM) along with domestic preferential public procurement policy to create a level playing field between imports and domestically manufactured goods. ◗ Domestic preferential public procurement policy: Countries such as China are not only the leading manufacturers of medical devices but they also follow a ‘domestic preferential public procurement policy’ whereby they give 15-20 per

cent price preference to domestically manufactured goods in public procurement. India follows no such policy. Government of India needs to formulate a 15 per cent price preferential ‘Buy Indian Procur ement Policy” in Indian public healthcare system which will also be in sync with policies followed in countries such as US and China and will also be in line with Prime Minister Modi’s vision of ‘Make in India.’ This needs to be put in place at the earliest. ◗ De-clubbing of medical device sector from drug and cosmetics sector: Currently, medical device industry in India is incorrectly and incompletely governed under the provisions of the Drugs & Cosmetic Act 1940 & Rules 1945 and nodal regulatory authorities are Drugs Controller General (India) and Directorate General of Health Services, Ministry of Health and Family Welfare! At present, there is no nodal or separate body for regulating or supporting medical device industry. So, this sector is nobody’s baby but everyone’s business! World over this does not happen as medical device industry is different from drugs and cosmetics. We have demanded changes in the Act and creation of a separate regulatory authority and also a Department to support medical device industry on the lines of Ayush. Medical device sector should never have been and should not be clubbed with drugs and cosmetics. Apart from this, Dr Panda suggests that FDI is key and since it’s allowed in both ‘greenfield’ and brownfield’ projects; this is a much needed fillip for the industry. The creation of SEZs with tax incentives will also help, but these have to be identified carefully. Healthcare is a fundamental right; we need to do a deep evaluation on the impact of this move. “India is a smouldering cauldron of inequities, a rapidly developing economy with a very small super-rich class, fast expanding middle class and 22 per cent still under the poverty line. I have said this before. India has

to talk health in terms of infant mortality rates (IMR), maternal mortality ratios (MMR) and life expectancies. The “Make in India” campaign has to look at how to improve these basic indices which are a reflection of our healthcare- with better reach and accessibility. If every child has to walk 2 km for a toilet and 5 km for a clinic, it is best that we start with making toilets, medicines and hospitals in India”, he adds. Bose sums up saying, “India still imports around 80-85 per cent of its medical technology. With judicious plans and efficient implementation, the private sector and government need to work hand in hand as one team to make further progress and make India one of the global hubs of innovation and manufacturing in healthcare particularly medical technology. We can also learn from the models adopted by other countries successful in this area. Ireland is an example”.

Moving ahead So, what should be the way forward? According to experts, the coming few months are critical as the government will fully unveil its reform agenda and roadmaps for implementation. There is no doubt about the potential and opportunities this initiative possesses. But Indian manufacturers, foreign investors and the government will also have to focus very seriously on the risk side of the equation. All in all, a prerequisite for the success of this campaign will be assessing, understanding and working towards mitigating the road blocks. Last but not least, it’s important to ponder over the fact that does India only needs its manufacturers to make in India or also to make for India? Going by the current situation, the way forward should be low-cost quality devices manufactured in India for India. This will not only increase affordability and availability of healthcare products but will also eventually lower market prices for medical equipment. raelene.kambli@expressindia.com

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I N T E R V I E W

‘Everyone should have equal access to modern medical-care’ CK Mishra, Additional Secretary & Mission Director (NRHM), Ministry of Health and Family Welfare, shares details about the National Health Mission, its objectives, ICT usage, benefits of telemedicine and more, in conversation with Anoop Verma

What are the key objectives of the National Health Mission? The National Health Mission has been formed by merging NRHM and NUHM. The NRHM was essentially conceived to provide primary healthcare in rural areas, which did not have adequate coverage of healthcare services. Subsequently, we realised that there were pockets in urban areas too where the healthcare services were not available to the poorer sections of society, even though most towns and cities may have many big hospitals. So to cover the poorer sections of the urban population, we launched the National Urban Health Mission was created through a Union Cabinet decision on May1, 2013. In order to improve the efficiency, we have now merged the two missions into a single mission. Our goal is to increase access, provide services, improve infrastructure and provide more finances for better healthcare to various states. At times the people who move from rural areas to the urban areas lack proper documentation for identification. What can be done to ensure that their medical data can be kept track of through a easy to access system of identification? We are now planning to provide health cards to the

beneficiaries of our schemes. Many states have already done it. Lot of work still needs to be done in the area of health cards, but this is the general direction in which we want to move. They will take some time to fructify, but this is the general direction in which we plan to move. The NUHM was specifically created to cater to the health needs of the migrant population that keeps moving to urban areas temporarily or on a permanent basis. The vision behind NHM is that no one in this country should be left without access to proper healthcare. Everyone should have equal access to modern medical-care. We intend to use Aadhaar as a platform for identification of the beneficiaries for our healthcare schemes. This is because we don't want to be in situation that other states are where one application is not speaking to another application. Aadhaar will ensure inter-operability and unique ID for everyone. If the records are kept in electronic format, they would be more easily accessible. Is there work being done on this aspect? Many states are currently experimenting with keeping records online. Electronic health record will ensure that a person’s health records remain with him. The records can reside somewhere in the cloud, so that they can be accessed

Telemedicine is a very important system for providing healthcare to people living in remote areas, but unfortunately many of such areas also face the problem of poor connectivity

when he goes to another facility. For instance, I live in X city where I get a treatment done from some hospital. From here I move to town Y, where I go to another hospital. The hospital in town Y should be able to access my medical records, depending on my choice because confidentiality and privacy are the major issues. The ministry has already notified standards, and now within the system of the mission we are trying to develop the methods for facilitating exchange of medical data between hospitals while ensuring that the privacy related safeguards are adhered to. We are speaking to the states on this. The important point is that NHM is there to impose the ministry’s standards and guidelines from the top, its main function is to enable states to achieve the target of universal healthcare. Are you satisfied with the level of ICT usage in the healthcare space ? If you look at the ICT implementations in the healthcare sector, I would say that we have done reasonably well. Our HMIS system is capable of capturing the facility level data. We have access to the PHCs in smaller towns around the country. We can communicate with the various PHCs through our HMIS. We have created the web based system called MCTS, which is

the Mother & Child Tracking System, on which more than 14 crore mother and children registered. MCTS was introduced in 2010 to capture details such as name, address, mobile number, etc., of every pregnant woman and child up to five years of age and of health services provided to them. The scheme aims to ensure that every pregnant woman gets complete and quality antenatal and post natal care and every child receives the full range of immunisation services. The system is already in place, even though it is still learning as many of the states are having problems in fully implementing it. We are trying to resolve all these issues. My personal view is that the MCTS should start working well during the next year or year and a half. The Kilkari Yojana has been started for mothers and children. What are the benefits of this scheme? The health ministry has started Kilkari Yojana for mothers and infants. Under this scheme, mothers will be informed through an audio about how to look after infants, vaccinations, and other such information. For instance, if the mother is in the sixth month of her pregnancy, the system will send her a message that this is your sixth month and you need to undergo this medical test or treatment. These will be preContinued on page-33

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cover ) INSIGHT

Health as a justiciable fundamental right

AMIT MOOKIM Country Principal, IMS Health

Amit Mookim, Country Principal, IMS Health evaluates the draft National health Policy and talks about how it can be improved

he draft policy intends to increase the healthcare budget to 2.5 per cent of GDP in the next five years. Ideally, four per cent of GDP would have been realistic to achieve its stated objectives of universal and affordable healthcare, while reducing the burden of out-ofpocket expenditure. The constraints on government resources makes it imperative to utilise the resources more judiciously by identifying much more focused interventions and policy measures. Robust and good governance mechanisms shall be established to ensure equitable health access to all cadres of population (including vulnerable and marginalised) in order for the country to achieve its goal of universal healthcare.

Engaging the private sector The role of the private sector in healthcare could be a key, especially in addressing areas of lower coverage. While the NHP recognises the contribution of the private sector in the overall delivery infrastructure and the need for private sector to bridge the gap, the NHP has remained silent on the role of private sector in the same, and outlining concrete steps for involving the private sector and creating a mechanism for deeper partnership and engagement. The role of private sector in health has been acknowledged and engaging them in procuring care such

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Schemes like RSBY may be expanded to include preventive and promotive health activities while enhancing the limit of coverage considering the rising healthcare costs. It is critical to re-calibrate the category of illnesses covered under RSBY as ambulatory care, imaging and diagnostics, and tertiary care has been spelt out evidently in the draft policy. Conversely, the mode of and mechanisms to engage the private sector in health requires greater clarity. Globally, many health systems work closely with private practices at GP level, healthcare players and outsourced agencies for managing and operating infrastructure and some of these opportunities need to be assessed and discussed in more detail.

Financing mechanisms The draft policy intends to levy health cess and sin taxes on tobacco, alcohol, and other products as a means to provide thrust to additional resources for health. However, the impact of such a health cess will be greater on those in the lower income group as compared to those in the higher income bracket. On the other hand, mechanisms to expand the ambit of income tax coverage are a probable alternative to the regressive health cess. Perhaps,

the government may explore mechanisms of leveraging the existing taxation pool and expanding the ambit of its tax coverage as currently a mere 2.89 per cent of the population is filing income tax returns. Expanding the scope and scale of financing mechanism such as social health insurance will offer greater financial risk protection beyond the health services delivered in public health facilities. Schemes like RSBY may be expanded to include preventive and promotive health activities while enhancing the limit of coverage considering the rising healthcare costs. It is critical to re-calibrate the category of illnesses covered under RSBY by scientific means and systematic use of health expenditure data. Additionally, enhancing the provider panel by empanelling more number of private providers which comply with guidelines on service delivery, infrastructure, manpower, etc., is expected to increase access to financial risk protection. Moreover, defining the roles and responsibilities of employer in occupational health/health-

care worker safety policies is expected to cover under its ambit the large section of people in the unorganised sector.

Pricing and procurement Healthcare and medical technologies finds a notable mention in the draft policy, highlighting the significant role of technologies in improving health and health system. However, medical equipment along with invitro diagnostics continue to come under the ambit of Drugs and Cosmetics Act, 1940, notwithstanding the differences between the medical equipments and drugs industry. Effecting price controls in medical equipments belie the fact that healthcare providers determine the prices far more than the industry. The current rates of purchasing health services from private sector CGHS and ECHS could cause over prescription of diagnostics and drugs without significant quality of care. Additionally, procurement policy that exclusively relies on lowest bids potentially sidesteps quality, company track record, etc.

Focus on manufacturing medical devices India is also presented with an opportunity to engineer innovation in the medical devices manufacturing industry. Low-cost quality devices as part of the ‘Make in India’ initiative will further the cause of improving access, affordability and availability of healthcare. Attracting investments in this sector requires improved intellectual patent protection, easing barriers to start a business, setting up of medical devices/ IVDs hubs economic zones and necessary manpower training centers to support the these activities. Just as India came to be known as the ‘pharmacy of the south’, India has the potential to cater to the needs of the developing world for low-cost medical devices through exports. The government could extend support for exports in areas such as testing, design and development centres and component manufacturing.

Technology Knowing the patterns and trends in causes of death by age and sex in a population is critical to understanding how to target interventions and maximise population health. Thus, there is a requirement for scientific effort to quantify the comparative magnitude of health loss due to diseases, injuries, and risk factors by age, sex, and geography for specific points in time. Use of

( technology tools and health informatics could be encouraged at both central and state level of health planning. Real-time evidences may be generated to determine specific requirements of services/infrastructure gaps/manpower constraints/etc., for a particular geography and then identifying the appropriate intervention. The NHP talks about alignment with various stakeholders and capacity building in health technology and health technology assessment and also outlines an approach to assessing technology needs for healthcare. This is an encouraging statement but at the same time, there is a need to establish large scale information platforms, core technology infrastructure at the clinic level and linking health infrastructure to the extent possible to create more efficiency in the care pathway.

Quality of Care A push towards improving quality of care is visible with the guidelines for hospital infection control being made a mandatory. This should ideally spur the creation of a new national data registry (similar to CDC) for data-driven and evidencebased decision making and formulating policies and solutions. Benchmarking standards for quality of care is critical along with mechanisms for effective monitoring to ensure compliance. While NABL and NABH accreditation standards have

contributed to the overall quality of healthcare but they are not the panacea for ensuring quality in all types of health facilities. It is imperative to benchmark the quality of care standards against global best practices and healthcare worker safety guidelines on customary basis, along with effective capacity building and monitoring mechanisms to ensure adherence. Ensuring safe environment for healthcare providers (like prevention of needle stick injuries, unwanted body fluid/blood exposure, etc) may also be prioritised for efficient healthcare service.

There is a need to establish large scale information platforms, core technology infrastructure at the clinic level

Human resources in health

tative bodies like nursing councils, IMA, etc; coupled with strict selection and monitoring criteria (including accreditation mechanisms) for training delivery centres to ensure highest standards of education and uniform quality across the country. Other alternatives such as skill-based certification (and not just education based), regular recertification, online courses for continuing professional education, participation in academic conferences for safety measures, etc may also be explored to bridge the skill gap.

The gap in demand and supply of healthcare infrastructure and human resources is widening. Provisioning for skill upgradation of nurses, healthcare professionals, para-medical professionals is critical. There should also be continuous focus on the quality of trainings and education through benchmarking and monitoring mechanisms. The requirement of allied health services professionals in the healthcare industry is rising. Investing in creating more healthcare professionals will have a direct bearing on improving availability and access to quality healthcare. It is important that curriculum and course material for training is approved by authori-

Leveraging corporate social responsibility CSR flows to healthcare may be leveraged in a much more defined and targeted manner. This could be a very important

FOCUS:POLICY

source of funding and management bandwidth across corporate India and needs to be detailed. The government could prepare ‘shelf of projects’ based on the needs for health infrastructure upliftment, improved service delivery, manpower augmentation, etc for a particular region. Private sector could be encouraged to invest and take up some of those projects, based on their willingness and local regional presence.

Fostering industryacademic collaborations There is a prudent need to create public platforms for promoting higher engagements among industry, academia and R&D labs by encouraging centres of excellence for research and education through private sector participation. A common sector innovation council for the health ministry could be strengthened and made functional. Innovative strategies of public financing and careful leveraging of public procurement is desirable.

Access to diagnostics under national health programmes Expanding the disease surveillance and screening programmes to include communicable and non-communicable diseases such as hepatitis, diabetes, cancers, etc., could assist in enhancing the health system’s response to rising burden of diseases. Mandatory annual or

two-yearly baseline diagnostic tests could be implemented to create an early alert system for citizens’ health as a step towards preventive healthcare. Another important aspect is uniformity in diagnostic standards such as types of tests across laboratories in different levels of healthcare that could improve quality assurance, infrastructure, technologies and skills under a new National Lab Strategic Plan. Moreover, understanding the causes of IMR and MMR through robust health information system could provide the evidence to plan and deliver interventions in minimising these health burdens. Proven interventions such as capacity building for the management of key issues like sepsis (IMR), PPH and obstructed labour could be encouraged at all levels of healthcare. Mandatory screening of new born, including those born inside and outside health facilities, could help in assessing their health status as well as the possibility of genetic disorders in the area of Inborn Errors of Metabolism. In addition, raising public awareness about key healthcare issues is an important preventive health intervention. The public sector IEC apparatus could be leveraged to mobilise the population for disease screening/diagnosis and subsequent treatment in partnership with key stakeholders such as the media.

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Everyone should have... recorded messages. A successful pilot has already been done on this project and we plan to roll it out this year. What is your opinion on using telemedicine to provide healthcare services to people living in far-flung areas of our country? Telemedicine is a very important system for providing healthcare to people living in

remote areas, but unfortunately many of such areas also face the problem of poor connectivity. Unless the problem of connectivity is solved, we can’t make much progress in telemedicine. However, now we are launching telemedicine in a big way, particularly for specialised consultations. We have tied up with four medical colleges to facilitate the expansion of

telemedicine in the country. In order to ensure that everyone in the country has speedy access to medical care, we are taking the “time to care approach,” which means that a citizen should not have to walk for more than 30 minutes for reaching a healthcare facility. Today it is stipulated that you need to have a healthcare subcentre for a population of 5000, but if the terrain is rough, we

allow additional sub-centres to come up in the same area. What are the benefits of the Mission Indradhanush programme? Mission Indradhanush, which depicts the seven colours of the rainbow, will cover all those children by 2020 who are either unvaccinated, or are partially vaccinated against seven vaccine preventable

diseases which include diphtheria, whooping cough, tetanus, polio, tuberculosis, measles and hepatitis B. The programme was launched on the Good Governance day. As of now we have identified 201 high focus districts in the country. These districts will be targeted by intensive efforts to improve the routine immunisation coverage. computer@expressindia.com

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IT@HEALTHCARE HIGHLIGHTS

Kartavya Healtheon launches Lab Sync Lab Sync reaches out to smaller towns and rural pockets that face immense dearth of qualified pathologists KARTAVYAHEALTHEON has launched Lab Sync, a concept of standardising the quality of pathology services in India. Lab Sync has the provision of monitoring and maintaining the quality standards of a synchronised lab by enrolling them to an external quality control programme. It uses state-ofthe-art infrastructure, user friendly web-based application for sample registration and reporting. With the setup of the virtual lab, Lab Sync reaches

out to smaller towns and rural pockets that face immense dearth of qualified pathologists. The concept helps existing labs or collection centres to upgrade their services by collaborating with Lab Sync which provides latest web based LIMS, infrastructure up gradation, qualified pathologist, external quality control,

timely and accurate reporting and marketing support. Anil Nayak, Director and Co-Founder, KartavyaHealtheon said, “We are happy to introduce a lab that would make one’s life easier especially when there is a need of multiple tests to be performed. Lab Sync follows NABL certification guidelines and efficiently

empowers labs to combat the acute shortage of qualified pathologists in India. It virtually connects pathology labs across metros, smaller cities and rural pockets to central super labs, equipped with technology and qualified experts, to ensure appropriate diagnosis under keen supervision. Lab Sync with its advanced ap-

proach rules out the possibility of in-correct reports and prospective violation of MCI guidelines.” Vikram Srivastava, Director and Co-Founder, KartavyaHealtheon said, “Lab Sync allows us to create a virtual web of pathology labs, nationwide even in far-flung places. It links processing labs, anywhere in the country, through its main central facility in Mumbai or its nearest processing hub via web-based lab information management system. Additionally, Lab Sync has an elaborate link with processing hubs to bring out required reports minus errors and on time. We have a team of qualified pathologists verify and authenticate the reports to ensure highest standards. Also, authenticated and validated reports are made available online as per predefined TAT to its clients, doctors and patients to avoid time lapse.” EH News Bureau

Dell Services positioned as leader in Everest Group’s PEAK Matrix 2015 Healthcare Payer BPO Report Dell is the only vendor to receive a ‘High Assessment’ in all categories EVEREST GROUP has positioned Dell’s Healthcare Services in the leader category for its inaugural Healthcare Payer Business Process Outsourcing (BPO) — State of the Market with PEAK Matrix Assessment report. Dell is reportedly the only vendor to receive a ‘High Assessment’ in all categories (scale, scope, technology capability, delivery footprint, and overall market success).

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Dell’s expertise combines leading automation technology, and a globally certified workforce to provide a full range of health plan BPO services in front end processing, claims administration, member management, provider management, financial performance improvement and care management business processes. “Our customers face new and complex challenges and

look to Dell to provide worldclass services to help them navigate their business environment. It is an honour to be positioned as a leader in the first ever Everest Group PEAK Matrix report for our market success and overall service and delivery capabilities,” said Sid Nair, Vice President and Global General Manager, Healthcare and Life Sciences, Dell Services. “We are focused on impacting the core business of our

health plan customers. Not only do we help them cut costs, but actually enable them to lead the change through a renewed focus on patient care. This report reflects and validates the long-standing BPO relationships we have with our healthcare customers,” said Tanvir Khan, VP for Dell’s BPO services. “In the rapidly evolving healthcare payer market, service providers’ ability to im-

prove operational efficiency, deliver tangible value through analytics, and enable top-line growth through seamless member enrollments are key differentiators. As per our assessment, Dell Services has been able to respond to some of these changes effectively and efficiently, which helped it achieve this recognition,” said Rajesh Ranjan, Partner of Everest Group. EH News Bureau

IT @ HEALTHCARE

Anurse’s revealing perspective Jigish Modi, Proprietor, Modi Medicare talks about having a good EHR system in place to increase nurses' efficiency and satisfaction

IT DEPARTMENTS, CIOs, CNIOs! Did you know that your nurses are not happy? The results of a survey by Black Book Market Research were just released and it isn’t good. More than 13,000 nurses were surveyed for Black Book’s EHR loyalty poll and, I’ll warn you, what they had to say may be very tough to hear. Nurses’ dissatisfaction with their electronic health record system is at an all-time high with 92 per cent saying they were unhappy with the EMR system in their healthcare facility. That’s a shockingly high number! Why are they so unhappy? The survey sheds some light on the same. 98 per cent of RNs said that they have never been included in hospital technology decisions or design. Nurses complete 80 per cent of documentation in the patient’s record and are the largest group of end-users. Why would any organisation not include them in the selection, building, and implementation of one of the largest investments they will ever make? Maybe they were willing to help but were not given time away from their normal work duties to make it possible. Maybe they were asked, but just didn’t step up and participate. Or perhaps they were never asked. Doug Brown, Managing Partner, Black Book Market Research, said “Technology can help nurses do their jobs more effectively or it can be a highly intrusive burden on the hospital nurse delivering patient care. Many compounding nurse productivity problems can be sourced to the failure of those selecting and implementing an EHR to involve direct care nurses in the process.” Ideally, the clinician should be able to do all necessary documentation in the most efficient manner possible. In other words, the best documentation

systems are designed so we can get in, do what we have to do, and get out and back to our primary focus—the patient. Undoubtedly, documentation is important but it should be balanced with patient care. The survey revealed that 84-97 per cent of nursing administrators felt the impact on nurses workloads including the efficient flow of direct patient care duties were not considered highly enough in their administrator’s final EHR selection decision. Documenting our care should fit in to the natural flow of our work, not create speed bumps that slow us down diverting our attention from caring for patients.

Another startling finding when nurses were asked to describe their IT departments, 69 per cent said they were 'incompetent' in their level of knowledge and expertise regarding the EHR software. Whoa! As a nurse who also worked in IT, that hurts! And it should make all IT professionals cringe. If I may be so bold, I would like to offer some advice to my fellow IT professionals. When embarking on the

daunting task of choosing and building a new EHR, ask yourself who is going to use and interact with the system every day? Who is your end user? Who is your customer? What is the ultimate goal/purpose? You may spend months building upon the documentation, but it will be the end users, primarily nurses, but also respiratory therapists, patient care techs, physicians, and other hospital staff, who must live, work, and interact with it every day—hundreds of times throughout their shift. So, please, include them in the planning and building of the system! Bring together and meet with end users regularly throughout the build process. Ask them what they’d like to see and show them what you’re building to get their opinion on how it will work for them. They have the real world experience. They know the workflow of each of their units. They are the experts! And it’s far easier to make changes during the build phase than it will be after golive. To find the best candidates, ask the leaders in all the different areas. They know who of their staff will be best for the project. Also ask the nursing

leaders to allow these people time away from their typical duties to fully participate. Don’t forget your “customers” after go-live! Keep in touch and meet with them periodically to continue to ask for their feedback. What’s working well? What could be improved? Are there new elements or additional items they need to document?

Rounding Don’t be afraid to get away from your desk and walk through the units you help support and talk to the nurses! You’ll find out about issues they find aggravating but might not be important enough to take the time to call into the IT help desk. Many times a little tweak can fix it. This is a big staff satisfier! They will quickly recognise you really care about what they have to say and it will elevate their opinion of the IT or IS department. If you do receive a problem call, do your best to take the least amount of time necessary with the nurse to get the information you need to start to solve the problem. Remember, they are very busy! Their main focus is taking care of their pa-

tients! They don’t have time to take away from patient care to stay on the phone with you as you try to troubleshoot the problem. If you think it will take an extended period of time to gather the information you need, ask if they have time. If it’s a bad time, find out if there is a better time to call back. I’ve even given out my personal phone number so they could call me back when it was a better time for them. Please understand, if they have a patient who is going downhill, it is not a good time! Device integration is also a great way to help streamline the documentation by clinicians as well as provide more accurate and timely data capture. Has your organisation implemented device integration? If so, do you have all of the devices capable of talking integrated? If not, please consider doing so. Auto-gathering of data from physiological monitors is a great start but how about ventilators? Dialysis machines? Balloon pumps? All of these devices output a huge amount of data that takes precious time to document. Again, this is a big staff satisfier and allows them to take the time used to manually key in this data and reinvest it into doing what they do best, caring for patients. Okay, I’ve said my piece and will step off my soapbox for now. I know it can be difficult for those in IT to comprehend how much of their role contributes to quality patient care. In the best healthcare organisations, IT and clinical staff are partners in achieving the best care possible for the patient, leading to happy nurses and, ultimately, happy patients. Contact details Jigish Modi , Proprietor Modi Medicare, e-mail : modimedicare@gmail.com

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IN IMAGING REPORT

PEST-LE ANALYSIS – ULTRASOUND MARKET Vijayshankar R Andani, Independent Management Consultant & Health Economics Analyst, focuses on the current healthcare situation, macro/socio economic factors influencing ultrasound market, technology trends, competition, and customer behaviour. Excerpts from the report

Over the last four decades, ultrasonography has emerged as one of the most important imaging techniques in modern medicine. The bettered and newer applications, declining costs, in this modality have resulted in the proliferation of the ultrasound machines, especially in developing countries. India alone boasts 35000 clinics, whose business is built around using ultrasound sonography. However, the knowledge of administering ultrasound studies has not caught up its pace. The lack of international guidelines and diversity (applications) in its utilisation has led to poor usage, sometimes misdiagnosis. Developing countries such as China, India where the usage of ultrasound is questionable have been taking series of steps to improve the diagnosis knowledge. In India multiple teaching centres have been setup in governmental and private sector. The Indian Federation of Ultrasound is very active and well-disciplined; it organises many courses/seminars and workshops are arranged on district and national levels. China has both general and advanced ultrasound training programmes, and can he attended at various stages of the medical career. Thus in

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POLITICAL

ECONOMIC

SOCIAL

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Government’s commitment to NRHM/NUHM ■ Stable/declining import duties ■ Streamlining ultrasound education by the govt. ■ Strong policy support

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Public/private investments in healthcare ■ Increased competition in mass ultrasound market ■ Investments in pecialty/preventive healthcare

■

LEGAL

TECHNOLOGY

ENVIRONMENTAL

Review of PNDT policy apparatus ■ IPR protection framework for medical devices ■ Device compliance with health-IT standards ■ No guidelines for usage of ultrasound tech

■

Technology advancements for treatments ■ Miniaturization influencing market ■ Frugal innovations for mass market ■ Automation for increasing diagnosis accuracy

■

order to ensure the successful uptake of ultrasound, the device manufacturers should work with governments to deliver training programmes, issue license and accreditations and impart continuous education demonstrating improved/new applications usage. Ultrasound has been associated with the skewed demographics landscape in many nations, mostly infamously. The ill-use of ultrasound modality to determine the sex

of an unborn child has been one of the main reasons for skewed demographics, as experts proclaim. Most of the governments have been ostensibly condemning such unethical acts by authoring many laws, rules and regulations. These include the stricter implementation of the Prenatal Diagnostic Tests Act (PNDT) in India, to prevent the deliberate abortion of female foetuses. Central schemes such as Janani Suraksha Yojna, ASHA

Insurmountable foetal sex selection ■ Increase in chronic diseases ■ Women’s health most impacted

Localization of ultrasound equipment ■ Equipment readiness for all-weather, rural usage ■ Tele-sonography due to lack of experts

(Accredited Social Health Activist) have been launched to promote antenatal checkups and institutional deliveries for pregnant women living below the poverty line in India where infant mortality is high. Chinese law to make sure the sex of the foetus is ‘not revealed’ mandates two doctors to be present and the exam to be recorded on closed-circuit TV while performing ultrasound study on pregnant women. Although these actions certainly help improve

demographic balance, however, restrain the potential growth of ultrasound market. Import duties on medical devices and equipment have a significant importance in Indian medical diagnostic industry. On one side it is argued that higher import duties may stymie the growth of diagnostic market and transfer of sophisticated technology in India. On other side, lower import duties may reduce competitiveness and growth potential of the local medical technology industry. Recent report argued that the current duty structure in India for medical devices and equipment favours imports, Unlike China, which encourages manufacturing of medical devices and equipment, Indian laws indirectly reward trading by charging higher duties on raw materials than on finished goods. For instance, titanium sheet/rod imported for making implantable pacemakers attracts a total import duty of 23.89 per cent, while import of the pacemaker itself attracts a duty of little more than nine per cent. As a result, in many cases, cost of a finished product manufactured within the country remains higher than an imported product. Imports of about 75 per cent in the Indian medical technology mar-

IN IMAGING

ket profess this fact. The strong policy support from union government has been crucial in development of healthcare sector, which subsequently has had a significant influence on diagnostic market:

million under the scheme JSY by sponsoring 100 per cent maternal expenditure of women under certain conditions. More ultrasound machines have been instrumental in ensuring good maternal health in such programmes, although the utilisation has

● Encouraging the private sector ◗ The benefit of section 10 (23 G) of the IT-Act has been extended to financial institutions that provide long-term capital to hospitals with 100 beds or more ◗ Government is encouraging the PPP model to improve availability of healthcare services and provide healthcare financing ● Encouraging investments in rural areas ◗ The benefit of section 80-IB has been extended to new hospitals with 100 beds or more that are set up in rural areas; such hospitals are entitled to a 100 per cent deduction on profits for five years ● Tax incentives ◗ Custom duty on life-saving equipment has been reduced to five per cent from 25 per cent and exempted from countervailing duty ◗ Import duty on medical equipment has been reduced to 7.5 per cent ● Incentives in the medical travel industry ◗ Incentives and tax holidays are being offered to hospitals and dispensaries providing health travel facilities

been a meager 20 per cent in public hospitals. Burgeoning middle class incomes, active participation of insurance companies (which grew at CAGR of 39 per cent between FY06-1024), and favourable FDI norms (100 per cent) have cata-

pulted the private healthcare sector in countries like India. Quality healthcare, better facilities have encouraged upcoming middle class to opt for private hospitals. In India, private healthcare accounts for almost 68 per cent of the country’s total healthcare ex-

penditure. When it comes to ultrasound the utilisation has been around 90 per cent to 120 per cent in private hospitals; maternal, pregnancy packages have been a boon to private hospitals including nursing homes sometimes exceeding demands for such

Moving UP!

Economic Despite the slowdown in the economy across the world, there has been no significant reining in the healthcare expenditure in emerging economies such as India and China. In contrast there has been a spur in public healthcare spending. As part of its 12th Five-Year Plan (2012-17), Planning Commission of India aims to increase spending in healthcare sector to 2.5 per cent of the GDP from around one per cent at present via programmes such as NRHM and NUHM. For instance to curb infant mortality and morbidity, central government spent more than $200

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April 2015

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IN IMAGING

services. OB/GYN scans for as low as $10 compared to around $100 in developed countries vindicates the proliferation of ultrasound equipment leading to economies of scale thereby lowering the usage cost. The steady influx of lowcost ultrasound machines from due to reduced import duties, increased local production due to surge in demand and easily available technology has heightened competition pushing down the procurement cost in India thus forcing major players to reduce their margins. The goodness of ultrasound technology has been overshadowed by its misuse. As a result, there has been a conscious/controlled growth of this modality, especially in developing countries such as India and China, where illegal sex determination is rampant. However, the use of ultrasound in other areas such as Emergency Medicine (EM), cardiology, anaesthesiology, radiology, and musculoskeletal applications apart from OB/GYN has shown the importance of this modality. This variety of applications of ultrasound may significantly influence the market growth in future.

Social Usage of ultrasound for maternal care in the developing countries represents a double-edged sword; on one hand ultrasound technology is beneficial in identifying potential anomalies pertaining to maternity leading to curtailment of maternal, infant mortality and morbidity. On the other hand ultrasound equips the community with technology that can be misused to determine sex of a fetus that may lead to female feticide. In the male dominant societies such as India and China, where a girl child is looked upon as a social stigma, the unscrupulous act of aborting girl child has skewed the gender equity in population. Earlier, studies had mentioned about five to seven lakh girls a year, or 2,000 girls a

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be dubbed the singular imaging modality that is ‘a girl’s best friend.’ Today, ultrasound is being utilised effectively and safely for a host of health challenges across the entire scope of female anatomy — breast, vaginal, abdominal — and at every stage of a woman's life. OEMs with the consensus from healthcare providers may consider the following that would fortify ultrasound as girl’s best friend: creating or accelerating women health wellness programmes that address potential maladies --such as PCOD, FSAD breast cancer --- and, focusing on innovations that can eliminate or improve women problems such as infertility treatments.

Technology

day go missing in India due to female foeticide. The 2011 census figures showed that India's child sex ratio has dipped to 914 girls as against 927 per 1,000 boys recorded in the 2001 census — the worst dip since 1947. Latest census in China shows on an average 120 boys are born for every 100 girls. While the spread of ultrasound technology certainly is not the root cause of the increase in reports of female foeticide, the compact, portable and relatively lowcost nature of this technology does increase the complexity of administratively overseeing and prosecuting medical practitioners, companies or other individuals who transgress the legal boundaries and misuse the technology to assist in sex-selective abortions. The ultrasound modality market has to surmount such social curse in order to accelerate its growth in developing countries. Hence, there is a need for OEMs and the importers to go beyond the dynamics of technology and taking required legal actions to address this repress together with the governments. Participating or commencing campaigns, programmes that pro-

COMMON CAUSES FOR MISDIAGNOSIS ■ Do not commit the time

required ■ Allow the presence of

outsiders review ■ Lack of training ■ Lack of knowledge ■ Lack of medical data ■ First ultrasound is late ■ Team obsolete or inadequate ■ Lack of illustrative prints ■ Lack of professionalism ■ No assistant ■ Improper technique ■ Wrong study ordered

mote rights of girl child pertaining to survival and development would positively influence the society. GE Healthcare’s drive in opposing this misuse of technology and pro-girl child campaign in last decade has saved its brand delusion and resuscitated its ultrasound sales in

both India and China. When considering women’s health, the top five concerns in India are breast cancer, stroke, polycystic ovarian disease (PCOD), FSAD, and weight gain. Experts believe fascination towards alcohol-smokingdrugs, lesser body resistance, late marriage, and delay in having the first child and hypertension are few among many causes of these concerns. Demographic trend of decreasing fertility rate --2.71 at present vis-à-vis 5.5 in 1970 (India), 1.6 (China) --- and increasing emotional stress, changing lifestyle are becoming leading factors in expanding maternal phase. Due to the economic trend of increased participation at work, women especially in urban areas are able to spend less time taking care of their maternal health. However, these increasing disease patterns in women, especially in emerging economies due to macroeconomic changes, could be staved off via preventive actions. Ultrasound as a modality plays an important role in women’s health wellness. From the reproductive years to menopause to postmenopause, ultrasound could

Ultrasound technology images muscle, soft tissue and bone surfaces very well and is particularly useful for delineating the interfaces between solid and fluid-filled spaces with no known long-term side effects and rarely causes any discomfort to the patient. However, the method is operator-dependent. A high level of skill and experience is needed to acquire good-quality images and make accurate diagnoses. Due to its small size, flexibility, easy operability, and relatively inexpensive exams that can be performed at anyone’s bedside, the ultrasound has been widely adopted, used by many doctors, practioners sometimes to serve remorseless section of society that prefer only male child. There are about 44,000 registered ultrasound machines and around 9000 registered, equal number of unregistered radiologists in India at present. WHO and several countries such as India and China have been relentlessly trying to assure the required knowledge for successfully diagnosing using ultrasound technology by offering trainings, accreditations and making available manuals. OEMs can contribute to improve the knowledge of using ultrasound technology by deploying learning software on the

IN IMAGING

machines and/or by automatingresults, in plausible examinations, for instance number and volume of hypoechoic structures, such as ovarian follicles, in a volume sweep, thereby reducing the room for manual interpretations. The growing trend of miniaturisation and increasing trust in portable systems has led to a significant increase in the market of hand-carried ultrasound systems in the recent years. Although the western countries were the first ones to adopt this technology, yet other regions of the world such as Eastern Europe, Latin America and parts of the Asia Pacific including India, are now beginning to show significant interest in this equipment. In the traditional ultrasound systems market, colour doppler equipment with 3D /4D capabilities accounts for a major chunk, while black and white scanners are now beginning to slowly fade out. When it comes to ultrasound technology advancement in India, “The Indian ultrasound science is at par with the global standards. The manufacturers have responded in a very positive way and growth is evident in all segments,” says veteran Dr Kishor Taori, President, Indian Radiological & Imaging Association (2010). Apart from economic viability of ultrasound technology, it is the excellent diagnosis, patient awareness and local support services have been the key growth drivers. The major technological trends in recent times include advent of fusion imaging (wherein real-time ultrasound images are fused with the high resolution), contrast-enhancing images produced by modalities like computerised tomography scans, and magnetic resonance imaging. Another recent medical innovation is the use of intravascular ultrasounds to assess vascular diseases like stenotic blood vessels, by placing an ultrasound probe on the tip of a tiny catheter that is inserted into the lumen of the vessel. This produces crosssectional images and yields information about the composition of plaques that may have formed on the vessel walls. Applications where higher intensities are warranted, the safety (heat/cavitation) is being questioned often.

Artifacts are commonplace in ultrasound. Often, these errors in image display are unavoidable and occur secondary to intrinsic physical properties of the ultrasound beam and its echo and to limitations of the display equipment. Recognition of these unavoidable artifacts is important because they may be clues to tissue composition and aid in diagnosis. The ability to recognise and remedy potentially correctable artifacts is important for image quality improvement and optimal patient care. These artifacts can be understood with a basic appreciation of the physical properties of the ultrasound beam, the propagation of sound in matter, and the assumptions of image processing. Hence training the users on continuous basis to improve diagnosis (becomes challenging when half of the radiologists are not registered in India) and signaling obvious mistakes of usage (automatic triggers) becomes the important part of ultrasound modality.

Legal The use of sex-selective abortion was banned in India in 1994 and in China in 1995. But since it is almost impossible to prove that an abortion has been carried out for reasons of sex selection, the practice remains widespread. An ultrasound scan costs about $10, which is within the scope of many— perhaps most— Chinese and Indian families. United Nations recently laid the blame for an overwhelming majority of the 117 million ‘missing’ girls in Asia are from India and China, squarely on the ultrasonography machine. The Indian legislation enacted in 1994 – the Pre-Conception and Pre-Natal Diagnostic Techniques Act – seems to have failed to act as a deterrent to potential parents and doctors. Ultrasound machines that were meant to be sold only to registered clinics are probably being sold to unauthorised entities. OEMs of ultrasound machines have been criticised for producing the compact, portable and relatively low-cost nature of this technology, which is believed to have contributed to sex-selective abortions. Addressing these allegations has required companies such as GE take a proactive approach to working with stake-

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IN IMAGING

holders to prevent misuse, and implement a long-term, multifaceted approach to help encourage societal changes in support of human rights. To rein the dwindling sex ratio, India may bring more amendments to strengthen the PNDT Act, which currently allows anybody with a six-month training or oneyear experience in sonography or image scanning to use ultrasound machine. If the latest amendments go through, the act will allow ‘gynecologist and obstetricians possessing medical qualifications recognized under the Indian Medical Council Act and medical practitioners with Diplomat of National Board (DNB)’ to use ultrasound machines. CSB (Central Supervisory Board) is also expected to make it mandatory for all mobile ‘genetic clinics’ — under Section 2 (d) of the Act — to be registered. A ‘genetic clinic’ refers to a clinic, institute, hospital, nursing home or any place — by whatever name it is called — that is used for conducting pre-natal diagnostic procedures. Government drive on ensuring minimum standards at hospitals, laboratories via accreditations such as NABH, NABL would also help in curbing the misuse of ultrasound technology. The diffusion of ultrasound in India may correspond to a sex-selection story. However, a recent study by IZA (Institute for the Study of Labor), Germany, finds consistent evidence that the rapid rise in ultrasound use in India in the 2000s cannot have caused a rise in sex-selection. Rather, the findings suggest that the states of India with a faster growth in ultrasound use are the states with a relative decline in sex-selection. Therefore the report argues that ultrasound has been increasingly used for health care rather than sex selection. Ambivalence due to such contrasting observations and further strengthening, strict implementation of PNDT Act may slow the market growth. The manufactures hence shall be conscious and careful while dealing with the customers of

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ultrasound machines; initiatives that promote saving girl child, continuous auditing of the dealers/users, and frequent trainings about technology would help become mainstay in the ultrasound market.

Regulation Currently there is no separate regulatory status in India for medical devices, and CDSCO (Central Drugs Standard Control Organization) is principally responsible for its regulation. A concrete regulatory framework for the Indian medical devices industry is under development. Ministry of Health and Family Welfare (MoHFW), has taken the initiative to include a separate chapter on medical devices which is considered as a proposed amendment in the Drugs & Cosmetics Act, and may include a clear definition for medical devices. Medical devices are high on innovation and hence appropriate framework for IPR protection is required to promote innovation and R&D. Once such regulations are rolled out, imitations leading to substandard medical device would be subdued; cheap imitations of ultrasound technology may have been partly responsible for unwarranted proliferation promoting illegal sex-selection.

Compliance Driven by the change in the healthcare sector globally and the need for operational transparency in order to achieve higher performance efficiency, India is witnessing an increased need for harmonised sets of compliance control measures pertaining to healthcare. There is little use of IT in clinical healthcare – for instance, keeping electronic medical records remains a guideline and it is not mandatory. However, increasing competition, government intervention, and hospitals growth has been warranting for integration of dissimilar systems. Device compliance with all health-IT standards such as HL7, HIPPA and DICOM would soon become a norm in Indian subcontinent.

Safety The safety issue is made more

MoHFW, has taken the initiative to include a separate chapter on medical devices which is considered as a proposed amendment in the Drugs & Cosmetics Act, and may include a clear definition for medical devices complicated by the problem of exposure conditions. Clearly, any bio-effects that might occur as a result of ultrasound would depend on the dose of ultrasound received by the foetus or woman. But there are no national or international standards for the output characteristics of ultrasound equipment. The result is the shocking situation described in a commentary in the British Journal of Obstetrics and Gynecology, in which ultrasound machines in use on pregnant women range in output power from extremely high to extremely low, all with equal effect. Indian authorities currently formulating regulatory, compliance policies for medical devices, may also include these types of safety regulations; with ultrasound modality creating so much furore in India, ultrasound safety may become next issue.

Environmental With more than 72 per cent of total country’s population spread across 638,000 villages, rural India is still deprived of basic health facilities. The delivery of healthcare services in rural areas is hampered by a dire lack of infrastructure. To take

one basic example: around 20 per cent of the 600,000 inhabited villages in India still have no electricity at all. And this official estimate understates the extent of the problem, as it defines an electrified village— very generously—as one in which at least 10 per cent of households have electricity; two km is the average distance to roads in rural places. Mobile hospitals, make-shift camps, although the exact size cannot be ascertained, have been instrumental in reaching out healthcare deprived areas across India, be it urban or rural areas. The product adaptability to such environments becomes important. Manufacturers would have to adapt medical devices to be effectively used in local context; for example, designing devices which can withstand hot and dusty climate and operate effectively in areas with insufficient electricity supplies. Ultrasound being one of the modalities used in almost all health centres, mobile hospitals, and medical camps the machine requires to be robust-all weather/terrain, reliable and consistent in providing diagnosis. In summary, PEST-LE analysis reveals that following are the factors that influence the growth of ultrasound market. ◗ Healthcare expenditure in India is expected to increase by 12 per cent per annum from 2011 -15. Rising incomes, greater health awareness, lifestyle diseases and increasing insurance penetration will contribute to growth. There has been a wide array of policy support in the form of reduction in exercise duties and higher budget allocation for the healthcare sector. Greater investment in healthcare infrastructure is needed to increase the number of doctors and hospital beds to meet the demand gap. ◗Government’s increased expenditure on public healthcare would ensure more accessible maternal care. Education on using ultrasound has also been on prime radar for governmental agencies. OEMs focusing on these

two aspects would benefit from opportunities. Import duties would drive the direction of the medical diagnostic market in India although 2012 budget left duties unchanged for medical equipment, but reduced duties on raw materials (8.5 per cent). ◗ Ultrasound has become one of the victims of foetal sex selection. The goodness of ultrasound technology has been overshadowed by its misuse. More applications addressing more number of diseases would encourage the usage of ultrasound. Featuring it as primary modality would attract attention from smaller hospitals especially in Tier-II and Tier III cities. ◗ Insurmountable foetus gender selection has only made government to relook at the policy apparatus to subdue such acts. The usage of ultrasound would come under microscopic scanner, which means slowdown in procurements of such machines. Ultrasound manufacturer’s commitment to policy and generating awareness would be litmus-tested by NGO and activists. ◗ Rising incomes, increasing awareness about chronic diseases has spurred demand for preventive checkups. Factors such as increased participation at work, lesser body resistance, late marriage, and delay in having first child, have significantly influenced women’s health. Women programmes for pre-screening of diseases are gathering steam in urban areas. Ultrasound is perceived as important modality for such preventive check-ups. ◗ Equipment makers who are able to customise or develop systems that suit local conditions are winning more contracts from healthcare providers. Miniaturisation, low-cost, portability, power backups, robustness are the features influencing the market most. Mass market comprises of primary, secondary hospitals that prefer valuefor-money systems. Technology advancements are helping incumbents to retain loyal premium customers.

MARKET I N T E R V I E W

â&#x20AC;&#x2DC;Accurate diagnosis has vital implications for foetal, maternal and neonatal careâ&#x20AC;&#x2122; Dr Paula Woodward, Professor in Radiology, Univ of Utah, USA in an interaction with M Neelam Kachhap, speaks about the evolution of diagnostic radiology in India and what future changes can be observed in foetal imaging

How has diagnostic radiology evolved and what difference do you see in the practice in the US as compared to India? Ultrasound in general and foetal imaging specifically has changed dramatically. When I began we had B-mode images which we developed in the darkroom. Now there are sophisticated computer workstations where we view and reconstruct 3D images. Probes and software have ever improving resolution allowing us to view normal embryologic development (sonoembryology) in a way we never dreamed possible. Many anomalies, especially severe ones, can now be detected in the first trimester. High speed MRI sequences have also advanced the field of prenatal diagnosis. It is a wonderful adjunct to foetal imaging particularly for CNS malformations. Since I have not had the opportunity to visit India before, I donâ&#x20AC;&#x2122;t think I can appropriately answer the second part of this question. I look forward to speaking with the course organisers and participants when I am there to learn about regional practices. What are the challenges faced in imaging first trimester pregnancies? There have been major changes in both terminology and treatment recommendations in first trimester pregnancies in the last few years. Both the Royal College of Obstetrics and

Gynecology in the UK and the Society of Radiologists in Ultrasound in the US have adopted far more conservative guidelines for the diagnosis of a failed pregnancy. The same holds true for the diagnosis of ectopic pregnancy. The hCG used to be an important parameter in diagnosing an ectopic pregnancy. Now, a single measurement, regardless of its value, should not be used to determine management in a haemodynamically stable patient. It has been a major paradigm shift in diagnosis and patient management, with the focus being on not intervening on a potentially viable pregnancy. What are the complications of twinning? Determining chorionicity and amnionicity is critical for managing a twin pregnancy. Twins that share a placenta (monochorionic) are at far greater risk of complications than those with separate placentas (dichorionic). It is important to monitor monochorionic twins for the development of twin-twin transfusion syndrome, the result of a placental artery-tovein anastomosis. The donor (pump) twin becomes oligemic resulting in oligohydramnios, while the recipient twin develops polyhydramnios. Specific staging criteria are established to identify which cases would benefit from intervention with laser coagulation of the anastomotic vessels. Left untreated there is a 70-90 per cent mortality rate,

High speed MRI sequences have also advanced the field of prenatal diagnosis. It is a wonderful adjunct to foetal imaging particularly for CNS malformations

with the donor dying first in 2/3 of cases. Another more rare complication of monochorionic twins is twin reversed arterial perfusion (TRAP), the result of an artery-to-artery anastomosis. Deoxygenated blood from the donor flows into the recipient via the umbilical artery (reversed from normal flow which is away from the foetus). The recipient is often severely hydropic and very dysmorphic in appearance. This is the result of preferential flow to the lower extremities. The upper portion of the foetus is under developed and there is often no heart, leading to the term acardiac twin. If twins are monoamniotic (share a single sac without an intervening membrane) they are at risk for cord entanglement and in utero demise. What are the challenges in imaging foetal tumours? Foetal tumours, while uncommon, pose a very unique circumstance in the care of an obstetric patient and create significant medical and ethical dilemmas. Although the diagnosis of any foetal anomaly is a devastating event for a family, the presence of a foetal tumour carries with it additional diagnostic and therapeutic challenges. The prognosis is generally poor, although there are some notable exceptions. An understanding of the different tumour types and their

biological behaviour is necessary for appropriate counseling and care of these patients. Accurate diagnosis has important implications for foetal, maternal and neonatal care. The biologic behaviour of tumours in the foetus may differ dramatically when compared to the same tumour detected later in life. Teratomas are the dominant histologic type and comprise the majority of both extracranial and intracranial neoplasms. Although often histologically mature, they may prove lethal based on location and metabolic demands on the foetus. Large solid tumours may lead to cardiovascular compromise and hydrops fetalis. Extracranial teratomas are most commonly located in the sacrococcygeal area followed by the head and neck, chest, and retroperitoneum. Foetuses with intracranial tumours have a poor prognosis regardless of histologic type. There are, however, two notable exceptions: lipomas and choroid plexus papillomas both of which have a more favorable outcome. Neuroblastoma is the most common fetal malignancy. It may be either solid or cystic and is more often located on the right side. It typically has favourable biologic markers and stage at presentation. The prognosis for prenatally diagnosed cases is excellent. Other foetal neoplasms include soft tissue tumours Continued on page 42

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IT@HEALTHCARE PRE EVENT

ULTRAFEST2015 will be held in Mumbai The theme for this year's event is uro-gynaecology and obstetrics

ULTRAFEST 2015 will be held in Mumbai from April 1012, 2015. The event will be organised by the Maharashtra State Branch of Indian Radiological & Imaging Association (msbiria.org). The theme for this year's event is uro-gynaecology and obstetrics. The keynote speakers are Dr Shweta Bhat, Dr Sheila Sheth and Dr Paula Woodward, all from the US, and topics on urology, gynaecology and foetal ultrasound will be discussed and debated over the three-day event. Faculty members who will take part in the event are Sheila Sheth, Associate Professor, John Hopkins, USA; Paula Woodward, Professor in Radiology, Univ of Utah, USA; Shweta Bhatt, Univ of Rochester, New York, USA; BS Ramamurthy, Radiologist, Ban-

The keynote speakers are Dr Shweta Bhat, Dr Sheila Sheth and Dr Paula Woodward, all from the US, and topics on urology, gynaecology and foetal ultrasound will be discussed and debated over the three-day event galore; Nitin Chaubal Radiologist, Thane, Mumbai; Asif Momin, Radiologist, Prince Aly Khan Hospital, Mumbai; Bhupendra Ahuja, Radiologist, Agra; Bimal Sahani, Radiologist, Aurangabad; S Boopathy, Radiologist, Coimbatore and Dr Moon, HOD - Breast Imaging, Seoul University Korea. The first day of the event will see speakers provising inputs for the following topics. Nitin Chaubal will speak on USG in urosepsis and reflux

nephropathy; Mohit Shah/ Bhupendra Ahuja on understanding the renal artery spectrum and give a demo; Chaubal on transplant kidney; Shweta Bhatt on the acute scrotum and testicular and extra testicular tumours; S Boopathy on work up of the infertile male; Shah on pearls: renal doppler update; Bhatt on imaging the endometrium; Boopathy on acute female pelvis; Sheila Sheth on imaging the myometrium; Aniruddha Kulkarni

on pearls: fibroid mapping; Boopathy will give case-based reviews. On the second day, Sheth will speak on US Characterisation of adnexal masses- I; Bhatt on Endometriosis: Are we diagnosing it quick enough; Sheth on Problem solving in GYN US with 3D: case based appr; Chaubal on follicle monitoring: get involved!; Bimal Sahani on 1st Trimester NT Scan; Woodward on first trimester: amnions, chorions and ambryos;

Bhatt on usual and unusual ectopics- Imaging spectrum; Woodward on terrible twos: complications of twinning; Sahani on pearls: soft markers: 2nd trimester. On the third day BS Ramamurthy will speak on Fetal CNS: How I do it and Fetal CNS; Woodward on foetal tumours: uncommon but important; Ramamurthy will give a demo on foetal echo. He will speak on cardiac anomalies: try not missing these; Woodward on GI & GU anomalies; Ahuja on quick review of fetal thoracic anomalies. Besides this, the regular features such as abstract and poster presentations, spotlight speakers, resident's corner, quiz with interactive voting pads, scientific exhibits with new machine displays will be conducted as well.

Continued from page 41

Accurate diagnosis has ... (both benign and malignant), leukemia, mesoblastic nephroma of the kidney, and liver tumours (haemangioendothelioma, mesenchymal hamartoma and hepatoblastoma). Could you talk about GI & GU anomalies and how best report on them? Anomalies of the foetal gastrointestinal (GI) and genitourinary (GU) tracts are a complex group of anomalies,

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many of which are incorrectly diagnosed. It is imperative that when diagnosing and reporting on these anomalies that ancillary features be described to come to the most specific diagnosis possible. Urinary tract malformations are the most common cause of a cystic abdominal mass in a fetus. When dealing with a cystic renal mass it is important to determine if the cysts are noncommunicating, as in a

multicystic dysplastic kidney, or if they communicate centrally, in which case they arenâ&#x20AC;&#x2122;t cysts at all but are dilated calyces. If only the upper pole of the kidney is involved think about a possible duplicated system and the bladder should be carefully interrogated for a ureterocele. Gender matters as a dilated bladder in a male foetus is most likely posterior urethral valves; however, prune belly can have a similar appearance so

ancillary findings such as undescended testes and flaccid musculature should be evaluated for and reported. Other cystic malformations such as an ovarian cyst and cloacal malformation are only seen in female foetuses. GI tract dilatation is generally from atresia but it is important to report on any complications. Always look for intraperitoneal calcifications or meconium pseudocyst formation which would

indicate perforation. A choledochal cyst is an uncommon cause of a cystic mass but can be confidently diagnosed if bile ducts can be shown to be entering into it. While cystic abdominal masses are a diverse group of disorders analysing and reporting on specific features, using the age of the foetus at presentation, and foetal gender can be combined making a specific diagnosis possible. mneelam.kachhap@expressindia.com

LIFE

DOCTOR

COOL There is nothing that can trill Dr Pradeep Chowbey as much as conducting surgeries. He is always looking to innovate BY RAELENE KAMBLI

HOT SEAT From passionately performing minimal access surgery and breaking records to training practitioners and being a part of the core team in formulating guidelines and recommendations for minimal access surgery Dr Pradeep Chowbey, Executive ViceChairman, Max Healthcare and Director, Max Institute of Minimal Access, Metabolic and Bariatric Surgery, Saket, New Delhi (India), is much at ease in the OT as in his office. The journey from Jabalpur Medical College to Max Institute of Minimal Access and Metabolic Surgery illustrates his sheer determination and adherence towards his vocation. A Padma Shri from the President of India, a Bharat Jyoti award in 2006, Indira Gandhi Priyadarshini Award for Excellence in

the field of laparoscopic surgery, a Gem of India Award, Arya Award for most compassionate doctor, and many more such prestigious honours now adorn Dr Chowbey's mantelpiece. He is the first doctor to perform laparoscopic cholecystectomy in North India. Along with his team, Dr Chowbey has performed more than 60,000 minimal access surgeries between 1992-2013 and features in the Guinness Book of Records 1997 and the Limca Book of Records in consecutive editions 2000 â&#x20AC;&#x201C; 2014. He had the honour of operating on his holiness, The Dalai Lama in October 2008 and the President of India, K R Narayanan in March 2001. Moreover, Dr Chowbey is one of the first surgeons to recognise and acknowledge the increasing prevalence of obesity in India. His deepened under-

standing and tenacity bore fruit with a large number of patients benefiting from bariatric surgery. What turns our spotlight on Dr Chowbey is not only his success, but his experience that spells out different phases of his life that has brought about a revolution in the filed of laparoscopy and minimal access surgeries. He has graphed his career with a single vision to develop, evaluate and propagate minimal access, metabolic and bariatric surgery in India.

Early life and vocation Delving into his life story, one can understand that Dr Chowbey is grounded by his roots. His child life was spent picking up lesson from his father, who in those days was the only surgeon in

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LIFE

R-L: Dr Chowbey with R K Narayan , ex-president

their neighbourhood. As a child, he has gone through the ups and downs of living a small town. He studied at a municipality school that functioned by spreading out taat patti on the floor. Having books was not possible. They used a small slate and chalk to write. Recalling memories of his childhood days, he says, “We come from a small town called Burhanpur in Madhya Pradesh and my childhood was full of fond memories of spending time with my father who was the only qualified surgeon in the area, respected and loved by everyone. I always wanted to follow suit. I spent many hours in his dispensary, helping him make mixtures in small pudiyas (pouches) which is how medicine used to be in those days. One advice that I hold close to my heart is to never forget who has helped you and to not remember those who hurt you. Following this path, I have always managed to simplify relations and move on with a positive outlook towards life.” Growing up having his father as his role model, Dr Chowbey chose to walk on his footsteps and went on to study medicine at Jabalpur Medical College. After completing this medical education, he moved to Delhi to find a job. Moving from a smaller town to a metropolitan city like New Delhi was a big step for anyone at that time. His first job was in 1977 as a registrar at the Holy Family Hospital that catered to the upper classes, elite families and

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April 2015

patients from the embassies. Working at the hospital was very much a cultural shock for him. There, he worked for almost two years, gathered a phenomenal amount of exposure and learnings that he cherishes even today. Moving on, in 1984, he joined Sir Ganga Ram Hospital as a consultant surgeon. During this period, his field of interest was haepatobiliary, pancreatic and breast surgery. However, all through his blossoming surgical career, there remained a large void within him for his inability to alleviate post-operative sufferings from large surgical incisions. Surgical cure was being obtained at the cost of tremendous postoperative pain and suffering to the patient. Few years later in 1989, Dr Chowbey attended a presentation at the American College of Surgeons in New Orleans that focused on endoscopic gall bladder surgery. That was the turning point in his career. “It almost instantly changed the path of my career, exploring something new and challenging. Initially it was thought to be a surgery for the upper class, but I always believed that it was a surgery for the masses in India who survive on daily wages. With a quick recovery time and less post-operative care, the patient could resume work within a matter of a few days as opposed to the previous recovery time of close to a month, this would in turn, cut down the suffering of the family simultane-

Operating on the Dalai Lama was one of my most exciting and satisfying experience.We achieved the highest possible success rate with excellent clinical outcomes ously. Bringing this procedure to the country not only changed my life, but countess others,” he acknowledges. So was this a tough call? “Shifting my area of speciality from the drastic and destructive surgeries in hopes of curing cancer to the gentle and kind cuts of laparoscopic surgery that causes very little pain and discomfort has been the toughest decision at the beginning of my career, but it proved to be worthwhile in the long run,” he confesses.

Struggle period Like any new idea is not easily accepted Dr Chowbey's idea of minimal incision surgery was also mocked and called impractical by many industry people.

He calls to mind his struggle period and says,“In the beginning, there was a lot of resistance from the senior surgical communities, who followed a standard thinking that if a surgeon does not put both his hands inside the abdomen, there would be no successful recovery. We reversed the ideology of 'Bigger surgeons make big cuts and smaller surgeon make small cuts', even changing the cuts to mere punctures! Besides this, there was a need for very high financial investment, long training hours and a huge learning curve that changed the surgeons’ outlook from the three dimensional open surgery to the two dimensions of laparoscopic surgery”.

Nevertheless, his toiling was over. Then began the phase where innovations brought in new learnings and there on Dr Chowbey knew he had to go on without a stop.

Witnessing the era of high-tech cameras While he treaded on his way to success he witnessed many transitions in his field of expertise.“With advances in technologies and the reducing size of punctures that we make for the procedures, one of the most important evolutions has been that of the cameras that we use. We started with poor quality of cameras, with very low resolutions and colour definitions, increasing the time

L-R: Dr Chowbey with The Dalai Lama

that was taken to complete one operation. But the industry kept up with the quick pace, providing us with high-resolution cameras and instruments that increased precision as and when there was an upgrade in technology. This has definitely been one of the key areas of advancements in minimal access surgeries,” he informs. As the field of minimal access surgeries advanced in India, Dr Chowbey put in his best efforts to promote this discipline of medical procedures. He tried to utilise the capacity of this technique in every possible way. “Along with cutting down recovery time of the patients, we have been successful in adding more and more surgeries in this field,

teaching with experience and increasing exposure. One of the most dramatic achievements has been the pioneering work that we have undertaken in the area of scarless neck surgery and building a team of people who believe in the results and have accepted the challenge of learning the high-tech surgery,” he reveals.

Strengths, memories and more... Well, hardwork always pays well. Today, with so many records and reward in his kitty, Dr Chowbey exemplifies modern day medical sciences worldwide. At the same time, the stardom he has earned does not cajole him at all. He

still remains humble and warmhearted. How does he manage to stay composed? “Records and achievements are all recognitions that have come along the way, but the crux of it all lies in hard work, with firm foundations on being grounded. Even though the recognition and success is important, it is more important to remember the efforts that go behind it, making it easy to maintain the composure at the end of the day,” he replies. Albeit that rewards and recongnitions wont flatter Dr Chowbey, it can certainly cause some constriction in order to keep up to goodwill earned so far. “Contrary to what one

might believe, for some unknown reason there was very little anxiety in operating His Holiness the Dalai Lama, it was in fact one of the most exciting and satisfying experience. We achieved the highest possible success rate with excellent clinical outcomes, unmatched in the surgical field. Since he is considered to be an incarnation, it was like operating on God!”, he negates the possibility of any kind constriction. So, what's his best prize in life? Surprisingly, its just a smile on his patient's face. “Seeing the patients smiling a few hours after complex surgeries and going back to their families and workplace with minimum suffering after major procedures is one of the most rewarding experiences. Talking about some special memories, he shares an anecdote. “It would have to be following strict protocols while operating the then serving President of India, KR Narayanan who was in his early 80s, with quite a few comorbid conditions and difficult complex diseases. An extremely soft and generous person, as a gesture after recovery he invited team members and greeted them at the Rashtrapati Bhavan, from the lift-operator to the top consultants, making it an evening we cherish to date”, he recalls. When asked about his hobbies and fascinations, he told us that he unwinds from his hectic schedule usually in the presence of art, either by attending

an exhibition or by spending an evening with an artist. “ I always find time to pursue my love for art”, he concedes.

Vision for the tomorrow Going forward, what does Dr Chowbey aspire of? He says, “I desire to create a dedicated centre for highest standards of training and teaching for the younger generation of surgeons, with all the modern facilities and latest technologies that would aide for a better quality of learning”. Moreover, as an industry leader, he shares a word of advice to the industry and policy makers saying, “The healthcare industry in India should try and keep pace with developments that take place. They should spend time and concentrate on putting in more efforts in research and development so as to provide us with safer equipment and instruments. Also, we are already catching up with the world in the area of healthcare, but there is a lack of competency and integrity in the doctors that needs to be increased in degree along with a plan to provide affordable medical care without the compromise of quality. Finally, We need to develop more hospitals, starting from prioritising their need in tier-II cities and then moving onwards to the villages in a systematic manner, while keeping in mind a need to maintain quality in each and every setup”. raelene.kambli@expressindia.com

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LIFE PEOPLE

Indian scientist appointed VP-Elect of Asia Region of the International Society of Cell Dr Anish S Majumdar is the Chief Scientific Officer and Executive VP at Stempeutics Research

DR ANISH S Majumdar, Chief Scientific Officer and Executive VP at Stempeutics Research - A MEMG Group Company in Bengaluru was elected as the Vice PresidentElect of Asia region of the International Society of Cell Therapy to represent India and Asia.Dr Majumdar has been with Stempeutics Research since 2010 and leads the R&D for Mesenchymal Stem cell research and therapy. The internationally

known stem cell researcher also has been working since 20-25 years towards elucidating the potential of various stem cells and their applications for incurable diseases at Indian and US organisations. Being nominated a member of the Industry Committee of the International Stem Cell Research and Therapy, this Indian scientist has also delivered more than hundred lectures on various aspects of his research at various na-

tional and international conferences.“Stem cell research and therapy will eventually reshape the healthcare industry and I am honoured to be a part of the International Society of cell Therapy to be representing India as well as Asia at an international level. At Stempeutics Research, we have the opportunity to deliver breakthrough solutions which will bring value to our investors, clients and stakeholders,” said Dr Majumdar.

Dr K P Haridas awarded Padma Shri Dr Haridas' illustrious career spans 43 years DR. K. P. HARIDAS has been awarded the Padma Shri, India's fourth highest civilian honour, for his contribution to the field of surgery and medicine. CMD of Lords Hospital, Thiruvananthapuram, Dr Haridas ‘ illustrious career spans 43 years. Hailing from the capital city of Kerala, the affable surgeon has the credit for conducting the first Liver Resection in Trivandrum Medical College. In his over four decade surgical experience, he has performed thousands of minimally invasive gastrointestinal surgeries, most of them declared inoperable. Last year he was honoured with a lifetime achievement

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award for his outstanding contribution to healthcare, social work and philanthropy at the UK South India Business Meet 2014 held at the Houses of Parliament, Westminster, London on July 10. He is a Fellow of Single Incision Surgery, Obesity and Metabolic Surgery and Minimal Access Surgery, besides being attached to the Obesity and Metabolic Surgery Society of India. Over the years, he has participated and presented papers in high-profile conferences, such as the Colorectal Congress in Switzerland (2009); Congress of Endoscopic and Laparoscopic Surgeons in Japan, and Advanced

He has tconducted the first Liver Resection at Trivandrum Medical College Course in Colorectal Surgery, France (2008), to list a few. In the coming years, Dr Haridas wishes to be actively involved in charitable projects that benefits large sections of the society, such as building an orphanage and geriatric home. He is equally keen on bringing robotic surgery to Lords Hospital.

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TRADE & TRENDS DHL GLOBAL FORWARDING

Setting new standards in temperature controlled shipping Samar Nath, Chief Executive Officer, DHL Global Forwarding, India share insights about DHL Thermonet, a new temperature controlled air freight product tailored to the life sciences and healthcare sector

IN THE past few years, the Indian pharmaceutical industry has continued to be one of the most attractive investment destinations in the world with an expected CAGR of 14 per cent1 and anticipated to reach a turnover of `2.91 trillion ($47.06 billion) by 2018. Presently, valued at `1.6 trillion ($ 25.87 billion)2, it is also expected to grow in the local market with aggressive rural penetration by pharma manufacturers, increased government spending on health and growing awareness among people. The drug manufacturing industry, one of the top contributors to the country’s exports, is a focus area for the government’s ‘Make in India’ campaign. Taking in view the governments ‘Pharma Vision 2020’, it is expected to reduce the approval time for new facilities so as to boost further investments. In recent years, temperature controlled products for the pharma industry have gained significantly in importance. The driving force has been the biotechnology products, which

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generally must be kept within a strict temperature range during transportation. Transporting and warehousing temperature controlled shipments securely and safely requires a unique combination of skills and expertise. DHL Thermonet, a new temperature controlled air freight product tailored to the life sciences and healthcare sector is an addition to DHL’s network of life sciences and healthcare facilities. This global service offers customers a transparent and a regulatory compliant platform, enabling DHL to manage their temperature sensitive shipments of pharma products and medical devices. It does so by bringing together several technical and product offerings from the Group, including the exclusive IT platform, LifeTrack and the

SAMAR NATH Chief Executive Officer, DHL Global Forwarding, India

DHL SmartSensor, the temperature monitoring technology developed by DHL Solutions & Innovation. Samar Nath, Chief Executive Officer, DHL Global Forwarding, India said, “You need a partner who can bring together dedicated infrastructure, global standard operating

procedures designed around your specific needs, trained staff who work to identical protocols, and leading edge monitoring, tracking and reporting technology.” DHL Thermonet provides seamless temperature visibility along the supply chain, 24/7 proactive monitoring and in-

DHL’s investment in the Free Trade Zone aims at simplifying trade and encourages foreign trade and warehousing activities in India, thereby creating more employment

tervention based on pre-determined touch points and DHL’s RFID SmartSensor technology, that is GDP certified. Temperature data and logistics events can be accessed via the proprietary LifeTrack IT platform that also houses all product-specific SOPs, facilitating early intervention and simplifying document control. Additionally, DHL’s Free Trade Zone (FTZ) facilities offer one stop solution for all logistics and inventory management needs. They also include dedicated temperature controlled facilities for life sciences and healthcare products with temperature and humidity-controlled storage chambers which are GDP compliant. DHL’s FTZ facilities thus provide end to end cold chain management under a controlled environment and speedy clearances from Drug Controller office, including customs on site. Being the first global logistics company in the country to have two advantageously located sites within FTZ areas — at Panvel, Mumbai which handles 55 per cent and Sriperumbudur, Chennai handles 25 per

cent of India’s container inbound and outbound traffic, DHL Global Forwarding has the first mover advantage of being able to offer a number of benefits to customers. “With cost-effective skilled labour, transportation facilities, integrated warehouse management and sophisticated equipment, we are well positioned to capitalise on the rapidly growing domestic market,” said Amit Dawar, Director – Value Added Services, DHL Global Forwarding India. DHL’s investment in the Free Trade Zone aims at simplifying trade and encourages foreign trade and warehousing activities in India, thereby creating more employment and providing a platform for overseas entities to transact from and into India. DHL’s Temperature Management Solutions are customised to protect the integrity of life sciences and healthcare products during global transportation.

References 1. www.ibef.org 2. Care Ratings

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TRADE & TRENDS

National Assembly on Paediatric Emergency Medicine organised The theme of this conference was ‘Timely care for timely cure’ THE 7TH National Assembly on Paediatric Emergency Medicine, an international conference was recently organised by the Indian Academy of Pediatrics, Coimbatore Chapter in association with the Society for Trauma & Emergency Pediatrics (STEP). Over 500 paediatricians from all over the country participated in the conference. The theme of this conference was ‘ Timely care for timely cure.’ India has been fighting

against communicable diseases, and has been recently declared polio-free. Although our neonatal and under-five mortality show tremendous improvements in their numbers, the morbidity and long term effects of ill health on a sick child affect our economy and productivity. Renowned international and national paediatric emergency medicine faculty emphasised on the early and timely recognition of a sick child and the appropriate treatment plan.

The Department of Pediatrics, Kovai Medical Center & Hospital, Coimbatore hosted the 7thNational Assembly on Paediatric Emergency Medicine

The Department of Pediatrics,KMCH KMCH provides outstanding educational opportunities, delivers high quality comprehensive clinical care and service, advocates vigorously for children and adolescents THE DEPARTMENT of Pediatrics at KMCH was established in 1993 and promotes the health of children and adolescents with a balanced programme that seeks new knowledge through research, provides outstanding educational opportunities, delivers high quality comprehensive clinical care and service, advocates vigorously for children and adolescents, and is responsive to the changing needs of our community and society. Our dedicated faculty have earned national and international recognition for their accomplishments.

Education Today’s training programmes provide optimal preparation

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The institute offers highly regarded training programmes and continuing medical education programmes.They have a successful Diplomate of National Board training programme for young aspiring doctors

experience focuses on strengthening communication with families, strengthening physical examination skills, learning the judicious use of diagnostic tests and working efficiently in a fast-paced environment. This experience also focuses on skills vital to the treatment of serious medical problems and on the rapid stabilisation of patients with lifethreatening illness.

Paediatric emergency services for tomorrow’s leaders . The institute offers highly regarded training programmes and continuing medical education programmes. They have a successful Diplomate of National Board training programme for

young aspiring doctors. Their curriculum and training is focused on learning a systematic and complete approach to evaluating children who have unexplored complaints. The paediatric emergency medicine

The Department of Pediatrics at KMCH provides comprehensive emergency services for over 6000 children and adolescents annually. Services are available for a wide variety of complaints including:

◗ Fever ◗ Respiratory and gastrointestinal illnesses ◗ Poisonings, including environmental toxins ◗ Major and minor trauma, including head injury ◗ Suspected child abuse and neglect ◗ Abdominal emergencies ◗ Behavioural and psychiatric emergencies Our areas of expertise include the initial stabilisation and management of critically and acutely ill paediatric patients with medical, traumatic and surgical illness. This includes, but is not limited to: respiratory distress, fever, fractures, laceration repair, abdominal pain, vomiting,dehydration, and seizures.

TRADE & TRENDS

Transasia Bio-Medicals introduces new range of biochemistry reagents In over 35 years of its existence, Transasia has provided doctors world over, with quality systems backed with superior services AT INDIA’S leading diagnostic company, all efforts are directed towards reinventing the available technologies as well as develop new products/ chemistries, with an aim to improve the quality of healthcare. In more than 35 years of its existence, Transasia has provided doctors world over, with quality systems backed with superior services. Recently, Transasia has expanded its product portfolio of biochemistry reagents by adding three new products: ◗ ERBA Lipase XL system pack ◗ ERBA Enzymatic Creatinine system pack ◗ ERBA Bilirubin DCA (Total & Direct) system pack

ERBA Lipase XL S ystem Pack High amount of lipase in the blood could be a result of damage to the pancreas or a blockage in the tube leading from the pancreas (pancreatic duct) to the beginning of the small intestine. A lipase test is done to: ◗ Check for pancreatitis and other diseases of the pancreas ◗ Ensure that the treatment for pancreatitis is working ◗ Check for cystic fibrosis or evaluate if the treatment for it is working Benefits of ERBA Lipase XL system pack: ◗ Readily adaptable, ready to use liquid stable assay-ideal for most open chemistry analysers ◗ Preferred chromogenic substrate 6’ methylresorufin ester used as a direct assay without second reaction, unlike the 1 and 2 diglyceride method ◗ Compatible with both serum and plasma samples ◗ Ten fold reduction in interference from triglycerides in comparison to 1 & 2 triglyceride method ◗ Virtually no interference from

cholesterol ◗ Results in ten minutes only ◗ Economical cost per test Pack Presentation- R1-2 x 44 ml/R2-2 x 11 ml

ERBA Enzymatic Creatinine system pack Creatinine has been found to be a fairly reliable indicator of kidney function. The kidneys maintain the blood creatinine in a normal range. Elevated creatinine level in the blood signifies impaired kidney function or kidney disease. It is for this reason that standard blood tests routinely check the amount of creatinine in the blood. Routine clinical biochemistry laboratories use several methods for the estimation of serum and urinary concentrations of creatinine, most of which are based on the Jaffe’s reaction. However, there are major analytical problems associated with the use of the Jaffe’s reaction, in particular those relating to positive and negative interference by chromogens. More than 50 chromogenic interfering substances have been documented. Common among them are glucose, acetoacetate, bilirubin, and cefoxitin. Both glucose and bilirubin inhibit the reaction between creatinine and alkaline picrate. Glucose slowly reduces picric acid to picramate. While bilirubin, under alkaline conditions, is oxidised to biliverdin, causing a decrease in absorbance at 520 nm. Acetoacetate and cefoxitin, conversely, react directly with alkaline picrate and cause positive interference. Acetoacetate in fact, reacts more rapidly with picrate than creatinine. Enzymatic creatinine, a new method for estimation is widely accepted as one of the most accurate routine methods currently available. Several studies have concluded that enzymatic

method is suitable for routine measurement of serum creatinine, particularly for diabetic ketotic patients, neonates, and patients receiving cephalosporins. Comparison (by independent ‘t’ test) and the agreement between two methods (ICC) of the Serum Creatinine values obtained by Enzymatic Methods and Kinetic Jaffe’s method The ERBA enzymatic creatinine system pack offers◗ Improved specificity

◗ Smaller sample volume ◗ High throughput ◗ No interference by glucose, acetoacetate, and cefoxitin ◗ Negative interference by bilirubin, which depends on both creatinine and bilirubin concentrations. Pack Presentation: R1- 5 x 30ml/ R2-5 x 10 ml

ERBA Bilirubin DCA (Total & Direct) system pack Conventional methods for the estimation of bilirubin have limitations when it comes to the di-

Mean± SD(mg/dl)

Group I(Normal)

Group II(Bilirubin)

Group III(Glucose)

Enzymatic(n=167)

1.18 ± 0.965

Kinetic Jaffe’s(n=167)

1.23 ± 0.989

Enzymatic(n=33)

1.20± 0.452

Mean differences± SD(mg/dl)

agnosis of neonatal samples. One of the major disadvantages of the routine Diazo Sulfanilic Acid method is that the sulfanilic acid has to be diazotized each time a series of bilirubin determinants are performed. This process is apparently a benign procedure, leading to discrepancies in bilirubin determination. On the other hand, In the DCA method, the salt is already diazotised. Hence, it proves to be highly stable and accurate in performance. The new DCA method does not interfere with Hb and TG and is an exceptionally simple technique, easily adaptable to all automatic analysers. The new ERBA Bilirubin DCA system pack offers: ◗ Liquid-stable, ready-to-use reagent ◗ Linearity upto 14.75 mg/dl ◗ Measuring range- 0.064-14.75 mg/dl ◗ No interferences by lipemia, hemoglobin and ascorbic acid ◗ Convenient reagent packing Pack Presentation: R1-6x44 ml/ R2-3x22 ml

‘p’ value

ICC

0.565*

0.995

0.186*

0.915

0.577*

0.997

0.401*

0.995

-0.042±0.129

-0.158±0.228

Kinetic Jaffe’s(n=33)

1.35 ± 0.503

Enzymatic(n=118)

1.52 ± 1.581 -0.116±0.134

Kinetic Jaffe’s(n=118)

1.63 ± 1.610

Enzymatic(n=318)

1.31 ± 1.207

Kinetic Jaffe’s (n=318)

1.39 ± 1.239

All Groups(Total)

-0.081±0.150

EXPRESS HEALTHCARE

April 2015

TRADE & TRENDS

Hb–Vario The latest system for diabetes management Mahendra Paranjape Sr Product Manager, Transasia Bio-Medicals speak about the advantages of Hb-Vario

TRANSASIA BIO-MEDICALS, India’s leading in-vitro diagnostic company has been offering the highest quality diagnostic solutions for precise disease detection since more than thirty five years across various segments. The newest addition to the Transasia family is our latest HbA1c & HbA2/F-Fully Automated Analyzer. India has earned the dubious distinction of being the ‘Next Diabetes Capital of the world.’It is estimated that millions of diabetics in India are carrying the disorder and hence having complications of uncontrolled diabetes. HbA1c is related directly to risks for diabetic complications and hence used routinely to monitor long-term glycemic control in people with diabetes mellitus. Transasia’s newly introduced Hb-Vario comprises HPLC with unique CLE technology. The patented CLE technology enables complete elimination of labile glycohemoglobin thereby ensuring accurate HbA1c results. This product has been developed in Europe after years of research and HbA2 is in the final stages of development. High Performance Liquid Chromatography (HPLC) is still considered as the ‘gold standard’ method for determination of HbA1c. The key features of the instrument include: ◗ The analyser measures HbA1c in approximately 3.5 minutes. ◗ Sampling from multiple sizes primary tubes, including micro capillary collection tubes.

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April 2015

◗ Dual pump technology providing meticulous system control, resulting in exceptional accuracy and precision ◗ Unique CLE technology enables complete elimination of labile glycohemoglobin thereby ensuring accurate HbA1c results. ◗ Capable of giving true HbA1c values in presence of Hb S, Hb C, HbD, &Hb F ◗ No interference of Hb F up to 10 per cent ◗ CE, NGSP-certified and traceable to IFCC reference

method. ◗ Large colour touch screen, in a compact footprint enables user friendly operation ◗ Automatic barcode identification of samples and RFID identification and tracking of reagents ◗ IFCC traceable calibrators and controls. ◗ On board quality control functions with Levey Jennings and statistical calculations. ◗ Unlimited storage of calibration, QC data and chromatograms.

TRADE & TRENDS

Farmer Type Chamber FAR 65-GB Applications ◗ Absolute dosimetry in radiation therapyPhotons and High Energy Electrons. ◗ Traditional chamber construction for absolute dosimetry in x-rays ◗ Standard reference detector for reference dosimetry and scientific applications

Features ◗ Air ionisation chamber ◗ Chamber with graphite wall, for all applicable radiation conditions ◗ Non waterproof ◗ Vented through waterproof sleeve ◗ Guarded upto 15 mm from base ◗ Supplied with individual factory ◗ Calibration certificate and

◗ User’s guide (Provisional)

Material

◗ outer electrode Graphite (1.82 g/cm3) ◗ inner electrode Aluminium (2.70 g/cm3) ◗ build-up cap for 60Co Delrin (1.42 g/cm3)

Active Dimensions ◗ volume (nominal) 0.65 cm3 ◗ total active length 23.1 mm ◗ inner diameter of cylinder 6.2 mm ◗ wall thickness 0.4 mm ◗ diameter of inner electrode 1.0 mm ◗ wall thickness of build-up cap for 60Co 3.9 mm

Cable & Connector ◗ Connector type: TNC triaxial ◗ Cable length : 1.40 m

Operational Data ◗ leakage current : < ± 10 x 10-15A ◗ sensitivity: 21 x 10-9 C/Gy ◗ radiation quality (e-): 1.3 MeV - 50 MV ◗ polarising voltage : + 300 V ◗ reference point w/o buildup cap : 13 mm from the distal end of the chamber ◗ reference point with buildup cap for 60Co : 17 mm from the distal end of the build-up cap Contact James Marzelo : 127, Bussa Udyog Bhavan,T.J Road, Sewri (W) Mumbai 400 015. INDIA Tel : 91 22 24166630 E-mail: support@rosalina.in www.rosalina.in

EXPRESS HEALTHCARE

April 2015

TRADE & TRENDS

Carestream Unveils its Innovative Radiology Solutions at IRIA2015 Enhanced product features of four recently launched systems ensure faster diagnosis and treatment CARESTREAM HEALTH India, the leading provider of medical imaging systems, continues to develop new radiology products and advance IT systems for the healthcare industry. In this endeavour, the company has recently unveiled its state-ofthe-art radiology systems and solutions at India's largest radiology conference - the IRIA 2015 - in Cochin. Carestream has a proven record of customer-focused innovations in the field of analog as well as digital medical imaging technology. The company uses various networking platforms to introduce its innovations to medical imaging professionals and ed-

ucate them about their benefits; IRIA congress has been one such medium. At the recently concluded IRIA 2015, Carestream launched its four innovative products and solutions: Carestream Vita Flex CR System, DRX Revolution System, DryView 6950 Laser Imager and MPS, its managed print solutions. Carestream Vita Flex CR is a complete plug and play CR solution. It delivers excellent image quality and can be positioned virtually anywhere in a healthcare facility. This new system’s flexible design enables it to operate vertically as well as horizontally, so it can process CR cassettes sitting on the floor, or on

tabletop or even from the back of a van. Second product Carestream revealed was the DRX Revolution, which is a digital X-

ray machine on the wheel. The DRX-Revolution provides wireless access to high-quality images in as less as five seconds;

features a collapsible column that improves visibility during movement and positioning; and provides the ability to easily maneuver the system in tight spaces. "We also showcased Dry View 6950 -- our third new product -- which is a high quality, high productivity medical printer. Fourth in the line was MPS - our managed print solutions. MPS allows customers to focus on their core business while Carestream takes care of their all medical printing needs," informed Kinra. With every passing day the interest among customers about Carestream's products and solutions that were showcased at the IRIA 2015, grown manifolds. "We have received encouraging response from customers for our new solutions that have been revealed at the IRIA 2015," concluded Kinra.

Carestream Health India sells 100th Vita Flex CR System within two months of its launch Customers appreciate user-friendly features of this new system CARESTREAM HEALTH India has sold its 100th Vita Flex CR System, which was launched in January, 2015. Carestream Health’s engineers used innovative design methods and components for the Vita Flex CR platform, which combines high image quality with reliability, a compact footprint and an affordable price tag. “Sales have exceeded our expectations and our company has boosted production capacities to keep pace with the increasing demand. Our customers appreciate the improved performance and image quality offered by this tabletop CR system. Easy instal-

EXPRESS HEALTHCARE

April 2015

lation and reduced service cost add to customers' delight,” said Sushant Kinra, MD, Carestream Health India. The company’s Vita Flex CR system is being used by independent imaging centres, clinics, multi-physician offices, hospitals and orthopaedic facilities who want an affordable, compact CR system that is also easy to use. “These facilities want to implement digital imaging technology and many are choosing the Vita CR platform to make that conversion,” Kinra added. The Vita Flex CR system weighs just 25 kgs and is smaller and lighter than many other

tabletop CR solutions. It is flexible enough to be operated vertically as well as horizontally, and can process CR cassettes sitting on the floor, a tabletop or desktop or even from the back of a van. The compact nature and simplicity of use of the machine is what appeals to Dr Abhijit Agashe an orthopaedic surgeon from Agashe Clinic, Pune, one of the users of Vita Flex CR System. “VITA Flex CR system is suitable for both centralised and decentralised workflow environments and can be used right in the exam room,” said Dr Agashe. The capability to increase quickly and cost-efficiently pa-

tient-handling throughput was the decisive factor for Dr Saji Varghese, Director - Mangalam Diagnostic Center, Kottayam Kerala, another user of Vita Flex CR. “We chose Vita Flex CR system because it provides fast and easy access to quality images allowing us to manage increase in patient throughput. It’s small footprint made it best for diagnostic imaging functions at point of patient care,” he commented. Worldwide, Carestream Health has been serving the diverse digital imaging needs of healthcare providers by offering a comprehensive portfolio of CR and DR solutions, along with

healthcare IT solutions. Carestream Health India is currently the country's largest horizontally integrated provider of medical imaging systems and healthcare IT solutions. It has a direct presence in India with over 120 employees, four regional offices, 33 warehouses, and a network of about 90 channel partners across the country. These strategically located sources ensure quick response to maintain the peak performance of its products and customers’ operations.

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.