VOL.9 NO.8 PAGES 68
www.expresshealthcare.in AUGUST 2015, `50
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CONTENTS MARKET Vol 9. No 8, AUGUST 2015
Chairman of the Board Viveck Goenka
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CANCER GENETICS IN PARTNERSHIP WITH ICON’S LABORATORY SERVICES
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NATHEALTH PLEDGES ITS SUPPORT TO PM’S INITIATIVE OF ‘DIGITAL INDIA’
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MSDE JOINS HANDS WITH MOHFW FOR SKILLED HUMAN RESOURCES
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VODAFONE TIES-UP WITH DIABETACARE
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ZOCTR HEALTH RAISES FUNDS WORTH $1 MILLION
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SIR HNRF HOSPITAL COMMEMORATES WORLD HEAD AND NECK CANCER DAY
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PORTEA MEDCONNECT HELD IN BENGALURU
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
NO RULES TO THE GAME The Indian diagnostic sector's poised for growth; however lack of regulations is a major deterrent | P42
Rushikesh Konka Artist Vivek Chitrakar, Rakesh Sharma Photo Editor Sandeep Patil MARKETING
P18:INTERVIEW: SATISH SANAN CEO, Inspirata
P35:INTERVIEW: STEPHEN CAMPBELL
Regional Heads
VP, Asia Pacific Region, Halyard
Prabhas Jha - North
GIRISH JOSHI, Business Head - India, Halyard
Dr Raghu Pillai - South Harit Mohanty - East & West Marketing Team G.M. Khaja Ali
LIFE
P37:INTERVIEW: DR BK RANA Joint Director-NABH, Quality Council of India
Ambuj Kumar E.Mujahid Arun J Ajanta Sengupta PRODUCTION General Manager
SPECIAL: WORLD BREASTFEEDING WEEK KNOWLEDGE
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DR ARMIDA FERNANDEZ Founder-Trustee, SNEHA; Former Dean, Lokmanya Tilak General Hospital, Sion
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DR ARUN GUPTA Regional Coordinator, IBFAN
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A HAND TO HOLD
B R Tipnis Manager Bhadresh Valia Scheduling & Coordination Mitesh Manjrekar
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DR SUNITI SOLOMON, HIV RESEARCH PIONEER IN INDIA, PASSES AWAY
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PRACTO APPOINTS ANSHUMANI RUDDRA & TARUN BHAMBRA AS PRODUCT HEADS
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BHAVDEEP SINGH REJOINS FORTIS AS ITS CEO
CIRCULATION Circulation Team Mohan Varadkar
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MOBILISING TECHNOLOGY TO ENHANCE MATERNAL AND CHILD HEALTH
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TRANSCATHETER THERAPIES: IMPROVING CARDIAC CARE
Express Healthcare® Reg. No. MH/MR/SOUTH-252/2013-15 RNI Regn. No.MAHENG/2007/22045. Printed for the proprietors, The Indian Express (P) Ltd. 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 © 2015 The Indian Express (P) 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
Should docs fear online pharmacies?
T
he Indian Medical Association (IMA) recently released a white paper detailing why the Indian government should not allow online pharmacies. On the surface, it would seem that an association founded way back in 1928 and claiming to represent the interests of all practitioners of the 'modern scientific system of medicine', is wary of using modern technology. After all, there is probably nothing that cannot be bought online today. So why shouldn't medicines, at least the OTC segment, go the same route? Is this merely a turf battle, with doctors trying to preserve their position in the healthcare delivery hierarchy? Not so: the Maharashtra state FDA also seems to be on the same wavelength, when it filed FIRs against e-commerce firms for selling medicines online. IMA president elect, Dr Jayesh Lele minces no words when he says that the refilling/reuse of prescriptions via online pharmacies should be banned and doctors should have complete control of the prescriptions. He gives a few examples to prove his point. Patients being treated for long term ailments like diabetes and hypertension need their medication constantly calibrated after testing sugar and blood pressure levels. In the case of infections requiring antibiotics, many patients self medicate based on their own judgment of symptoms and refill previous prescriptions to buy antibiotics off the net. Dr Lele attributes the rise in multi-drug resistance to self medication and predicts that easy availability online will only exacerbate this situation. Similarly, he points out that some medication might result in side effects which differ from patient to patient. For instance, some patients prone to acidity might need to change their medication which needs the expertise of a doctor. Besides violating the Drug and Cosmetics Act 1940, Drugs and Cosmetic Rules 1945, Pharmacy Act 1948 and Indian Medical Act 1956, the IMA white paper points out that online pharmacies pose practical issues like the inability to check the storage conditions under which medicines are stored by e-commerce players. Also, there are no checks on counterfeit or expired medicines making their way to consumers. Patients/consumers may be lured by discounts and might ultimately end up with spurious medicines. Online pharmacies, as they function today, will also disrupt the flow of information on adverse drug reactions which doctors and pharmacists are supposed to report to the National Pharmacovigilance Programme. Will online pharmacies maintain patients' confidentiality? What stops them
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India's policymakers can designate industryassociations to credentialise online pharmacies but the Ketan Desai-MCI saga begs the question: who will watch the watch dog?
from incentivising their internal panel of doctors to ‘push’ medicines based on uploaded patient information? How will they prevent minors from buying controlled drugs? Will they be able to check that the packaging of prescription medicines has the mandated warnings? The IMA is most concerned that online pharmacies will erode the trust between the patient, doctor and pharmacist. One must admit that this trust deficit is already quite high, thanks to rogue doctors themselves. However, Dr Lele concedes that in this age of convenience, buying medicines online cannot be wished away. Therefore, he is not against online sale of medicines per se, but wants better infrastructure and regulation in place. He makes a fine distinction between 'online pharmacies' and 'epharmacies'. In the former, purchasers can reuse and upload scanned copies of prescription where as in the later, the system connects each uploaded prescription to a licensed pharmacist, either online or off line, who checks it and only then authorises the dispatch of the medicines. Dr Lele is understandably concerned that the medical profession will have to bear the blame, in terms of malpractice suits and the like, if there are tragic consequences to such sales. Hence the stridency and urgency to weed out bad practices and regulate this market model. The fact that Maharashtra FDA had to file an FIR against established e-commerce players raises concerns that the illegal will slowly wear the garb of the legal very soon, if the government does not soon crack down hard. Fortunately, the Drug Controller General (India) has said that draft rules for online sale of medicines will be ready for stakeholder review in four months. Rogue online pharmacies are not confined to India but overseas regulators have managed to put some systems in place. For instance, the US and Canada use credentialing agencies to separate the wheat from the chaff. The US uses PharmacyChecker.com, National Association of Boards of Pharmacy (NABP) Verified Internet Pharmacy Practice Sites (VIPPS) programme or LegitScript, where as Canada-based online pharmacies need to be approved by the Canadian International Pharmacy Association. India's policy makers too can designate industry associations to credentialise online pharmacies but the Ketan Desai-MCI saga begs the question: who will watch the watch dog? VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com
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JULY 2015
t is sad that competition is so high in India for any course or seat. This pushes up demand for seats. Rich parents think they are investing in their children and push prices even higher. Where is the Independence our fathers fought for? Acche din? (Refer: God incarnate or fallen angels?, EH July 2015) Benedict Raj Chief Paediatric Cardiac Surgeon, MIMS
WELL-WRITTEN PIECE
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t is indeed a very well-written piece with inputs and views from different players in the industry. What stands out is, you’ve covered different perspectives and connected it all to hospitals/healing. (Refer: Smart way of healing, EH July 2015)
I
ne of my friend’s daughter who was interested in dentistry had to undergo month-long agent calls from various institutes (read reputed), seats confirmations ranging from Rs 15 lakhs onwards... Thankfully, just before they were about to deal; the result came out and she got admission without spending a single paisa... (Refer: God incarnate or fallen angels?, EH July 2015)
Surabhi Patodia Text100 India Global Communications
Tanni Mandal Assistant Manager, PRHUB Mumbai
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MARKET NEWS
Cancer Genetics announces partnership with ICON’s Laboratory Services To offer comprehensive oncology laboratory testing and solutions CANCER GENETICS has entered into a partnership with the laboratory services group of ICON, the global CRO. ICON’s laboratory services provide global testing services to the pharma, biotechnology and medical device industries. Reportedly, the partnership will provide clients access to combined expertise ranging from complex, oncology-focused genomic testing to core central laboratory analysis, project and data management and sample logistics on a global basis. Together, the two companies will leverage their respective expertise to provide key insights to the oncology drug development and clinical trial process. The partnership is focused on providing a comprehensive, integrated and efficient solution for laboratory testing for global oncology trials from Phase 1 through Phase IV. “We are looking forward to working with the CGI team and to enhancing our client offering with complementary laboratory service programs,” said James Miskel, Executive VP, ICON Laboratory Services. “Together, CGI and ICON are uniquely positioned to provide a full range of comprehensive lab solutions for our customers with current and future oncology-focused clinical trials,” he added. “This partnership will satisfy the enormous need among biotech and pharma companies for more efficient and comprehensive testing solutions by integrating CGI's specialised, genomic testing to ICON’s laboratory solutions,” said Panna Sharma, CEO, Cancer Genetics.” EH News Bureau
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MARKET
NATHEALTH pledges its support to PM’s initiative of ‘Digital India’ Healthcare IT Taskforce formed by NATHEALTH-NASSCOM NATHEALTH HAS extended its support and appreciated PM Narendra Modi’s endeavour to go digital. Sushobhan Dasgupta, President, NATHEALTH said, “PM’s efforts to transform India into a connected knowledge economy and offering world class services at the click of a mouse through Digital India programme, is truly commendable. Initiative of using mobile and internet strategies – such as telemedicine, doctors on call and remote patient monitoring will help in improving the access of quality healthcare universally.” Anjan Bose, Secretary General NATHEALTH said, “Using wearable and mobile technology will help educate and engage citizens in healthy living and prevention of diseases…Innovations in ‘Digital Healthcare’ will enable solutions across the healthcare value chain.” Dasgupta added, “Telemedi-
NATHEALTH-NASSCOM joint initiative will try to build linkages across multiple stake-holders in healthcare and information technology sectors cine through tele-consultation, E-ICUs, remote patient monitoring, lifestyle management through education tools will further help in enhancing patient care to the next level. Through digital mode, a patient. It can also be a powerful tool for real time disease surveillance which is needed to fight the risk of epidemics such as non communicable diseases, tuberculosis, trachoma, leprosy, malaria.” Bose said, “Through our collaboration MoU with NASSCOM, our vision is to leverage technology to address healthcare challenges, in order to
improve patient care. NATHEALTH-NASSCOM joint initiative will try to build linkages across multiple stakeholders in healthcare and information technology sectors. We will try to evangelise a new class of technology solutions and service delivery platforms that enhance healthcare access, affordability, availability and therefore support the government’s aim to achieve “Universal Health Coverage”. NATHEALTH and NASSCOM have formed a Joint Council (NNJC), comprising top leaders in member companies
from both the institutions, representing respectively healthcare and IT sectors. The Joint Council will focus on: (1)Creation of central IT healthcare platform (2)Remote healthcare (3)IT enabled preventive and chronic care (4)Healthcare workforce “We aim to leverage digital technology for innovative solutions which will help both Healthcare and IT sectors grow further,” informed Bose. “As Digital India is an umbrella programme including several schemes for inclusive growth in multiple sectors through digitalisation of services, it would help us to create self-sustaining models in healthcare that will enable the rapid growth of the services, by creation of digital infrastructure and service delivery through digital mode,” added Dasgupta. EH News Bureau
Vodafone ties-up with Diabetacare Vodafone Business Services (VBS) has collaborated with Diabetacare to launch dCare Smart, a GSM SIM enabled wireless glucometer that helps people to proactively monitor their blood sugar levels. It is powered by Vodafone's Machine to Machine (M2M) embedded cellular technology. Reportedly, the device transmits blood sugar results to a secure Diabetacare server, where they are constantly monitored by diabetes specialist clinicians at the Diabetacare’s Diabetes Management Centre (DMC). In case of any abnormal blood glucose readings, both the patient and kin receive an alert/call with expert advice from the DMC immediately. dCare Smart is paired with the back-end clinical servers which connect directly to the electronic medical record system, wherein access is given to patients and their caregivers to keep them informed and better manage the condition. EH News Bureau
MSDE joins hands with MOHFWto address industry’s need for skilled human resources MoU signed to ensure short term skills training in agreed job roles to a minimum of one lakh people, in both the public and private sector THE MINISTRY of Skill Development and Entrepreneurship (MSDE) has signed an MoU with Ministry of Health and Family Welfare (MoHFW), to address the need for skilled human resources in the health sector. Besides achieving the national goals of skilling youth so as to increase their employability, this MoU shall also seeks to
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upgrade the quality and reach of human and infrastructural resources that is at the core of a quality healthcare system. Reportedly, some of the more significant outcomes of the MoU would be as follows: ◗ Significantly increase the present capacities in areas of health sector to a minimum of lakh trainees ◗ Make significant savings of
MoU also seeks to upgrade the quality and reach of human and infrastructural resources
public resources by way of leveraging the existing infrastructure of government and private sector healthcare institutions to provide training against various short term job roles ◗ Explore pooling of financial resources of the two departments and allow for international partnerships to provide greater financial muscle to the programme
◗ Create a framework of certification by Health Sector Skill Council of select job roles and for absorption of the trainees in the health sector ◗ Create a framework for recognition of prior learning ◗ Allow for seamless vertical and horizontal mobility of trainees at various levels of skill development EH News Bureau
MARKET
Zoctr Health raises funds worth $1 million This is the second round of funding raised by the company in three months
ZOCTR HEALTH Network, a Mumbai headquartered disruptive healthcare startup that integrates home health, tele health, remote health and health support services on the back of proprietary health technology and standardised care protocols to deliver holistic patient solutions in the post acute and chronic care segments, recently raised a $ one million funding round from four investors; namely Sandeep Parwal, Founder & MD of SPA Capital Group, Krishan Guptaa, Founder & MD of Organic Wellness, Anil Khandelwal and Dr Arun Purohit. This is the second round of funding raised by the company in three months. Reportedly, with this new fund infusion, the company seeks to sharpen its positioning, complete and launch iZoctrTM, its tech platform, enhance hiring and training activities, launch operations in the Delhi/ NCR region and generate further market traction partnering with leading hospitals and ICUs across Mumbai and Delhi. Zoctr seeks to add 20,000+ doctors and health service providers and service five million+ Indians in the next few years, while making healthcare affordable, accessible and on-demand. Parwal believes, "Zoctr is a new, exciting and disruptive home healthcare concept with unlimited potential. I believe, with the right customer acquisition model and execution capabilities, we can revolutionise the healthcare delivery model in India and globally." Guptaa states, “Zoctr aims to address the unmet needs in the home healthcare space in India by providing an efficient and state of the art home healthcare solutions to the Indian consumer at affordable prices.” Says Nidhi Saxena, Founder and serial healthcare entrepreneur, "We look for-
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ward to an action-packed journey to scale in the next few years – our aspiration is to be
the Flipkart of healthcare." The company is now gearing up for scaling to a level where it will
initiate pan India operations and further eyeing to raise a Series A funding round to the
tune of $10-15 million in the next few months. EH News Bureau
MARKET POST EVENTS
Sir HN Reliance Foundation Hospital commemorates World Head and Neck Cancer Day Conducts symposia on ‘Thyroid Cancer: Current concepts of management’ SIR HN Reliance Foundation Hospital commemorated ‘World Head and Neck Cancer Day’ with a symposia on ‘Thyroid Cancer: Current concepts of Management’ at the hospital. World Head and Neck Cancer Day was introduced in 2014 in the US by International Federation of Head and Neck Oncologic Societies (IFHNOS). The Union for International Cancer Control (UICC) supported the effort. Medical luminaries like Dr Anil D’Cruz, Medical Director, Tata Memorial Hospital; Dr Vijay Haribhakti, HOD,
Eminent medical experts at the Cancer Symposium held on World Head and Neck Cancer Day at Sir HNRF Hospital
HNRF Hospital; Dr Gustad Daver, Medical Director, HNRF Hospital; and Dr Rahul Modi, Harvard Medical School, participated in the sessions. Reportedly, noted doctors and oncology students based in Mumbai attended this knowl-
edge feast. Latest guidelines from American Thyroid Association were presented at the symposia. HNRF Hospital and Reliance Foundation initiated a campaign against oral cancer, as a build-up event, by address-
ing the issue at grass root level. A free oral cancer detection drive was held at Sir HNRF Hospital and a day long free oral cancer detection programme was held in Koli Wadi, Girgaon. Senior cancer experts were engaged in
assessing the risk parameters and educating people on preventive measures. Reportedly, more than 230 people availed benefits of the oral cancer detection drive and got themselves checked by cancer experts.
Portea MedConnect held in Bengaluru Debut edition of industry event was reportedly attended by top medical experts and more than 50 practitioners DR SUGANTHI IYER, Senior Medico-Legal Expert & NABH Assessor, Deputy Director, PD Hinduja Hospital – Mumbai; Dr Somashekar, Chairman, Surgical Oncology, Manipal Hospitals; and Dr Udaya Kumar Maiya, Medical Director, Portea Medical were among leading medical experts who addressed the inaugural Portea MedConnect held in Bengaluru recently. Portea MedConnect is a Portea initiative that brings medical professionals together to share ideas and insights. Hinduja Hospital’s Dr Iyer
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who addressed the audience on doctors’ liability under the Consumer Protection Act of 1986 stressed that clarity of clinical procedure and documentation were sacrosanct in treating patients. She noted that doctors’ liability could arise from deficiency in treatment and non-adherence to protocol. Minor lapses could be ruled as negligence, she said, even after doctors’ had made a proper diagnosis. “Documentation is the Line One defence in the court of law,” she noted, highlighting not only
the importance of clear and detailed notes from physicians, but the role that nurses’ notes had to play in cases where medical negligence had been alleged. Manipal Hospitals’ Dr Somashekar spoke on the boon that the homecare option had provided his patients and noted that medical care delivered at home had revolutionised healthcare, and was “a ‘win-win’ for all”. He cited analysis undertaken at Manipal Hospitals’ that underlined how the cost of patient care had been reduced significantly when there was a
tightly integrated homecare offering available to patients. “Hospital resources are better utilised for critical care and specialist consultation, while post-op recovery for patients can take place in the comfort of their homes,” he said. Meena Ganesh, Co-Founder & CEO of Portea Medical said that close coordination with hospitals and adherence to medical protocol prescribed by consulting specialists were crucial elements of successful homecare. “At Portea, we effectively harness technology to ensure that
specialist doctors at more than 40 hospitals we work with are kept in the loop on the treatment we provide to patients referred to us,” she said. Reportedly, Portea MedConnect witnessed the participation of more than 50 leading doctors from hospitals including Columbia Asia, Naryana Hrudayalaya, Bhagwan Mahaveer Jain Hospital, Excel Care Hospital, MS Ramaiah Memorial Hospital and Kidwai Memorial Institute of Oncology. The speaker presentations were followed by an interactive Q&A session.
MARKET
Sutures India conducts CME programme in Bengaluru The event for the OB/GYN fraternity was reportedly attended by 150 doctors from the city SUTURES INDIA, manufacturer and exporter of surgical sutures in India recently held a CME programme for the obstetric and gynaecological fraternity at Bengaluru. The talk was addressed by Dr Michael Stark, President of Berlin-based New European Surgical Academy. He spoke about evidencebased cesarean section and ten-step vaginal hysterectomy – A modified operative technique for vaginal hysterectomy. High point of his talk centred around benefits of modified Misgav-Ladach technique and comparison of the modified Misgav-Ladach technique with the traditional cesarean technique. The audience debated over Dr Starks’ remarks on non-closure of the rectus mus-
Dr Michael Stark,President, New European Surgical Academy addressed the audience cle and subcutaneous fascia during cesarean and skin repair with three large sutures. The audience also debated on uterus repair in single layer vs double layer. Dr Stark also introduced his anticesarean section campaign. "Our aim is to make caesarean section safer and easier for the mothers. We could not imagine that this method would become one the reasons for over-usage of caesarean section. We strongly believe that caesarean section should have a valid indication," said Dr Stark. The event was attended by 150 doctors from Bengaluru.
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MARKET I N T E R V I E W
‘Inspirata is posed to be our legacy and greatest success’ Recently, Inspirata, a US-based cancer diagnostics solution provider launched its India operations with their first R&D facility in Bengaluru. The company plans to help speed up cancer diagnosis, research and teaching by providing doctors and patients with predictive data that will change the way cancer is diagnosed and treated. Inspirata plans to hire 50 high-end software product development engineers, scientists and informaticists from the healthcare domain in the next two months. Satish Sanan, CEO, Inspirata tells M Neelam Kachhap more about the company and its plans for India
Tell us about Inspirata? Inspirata is an emerging company focused on transforming cancer diagnostics by developing and delivering innovative solutions. These solutions should be affordable, scalable and create new opportunities to have a global impact on the speed and accuracy of cancer diagnoses. What is the size of the company in terms of turnover/revenue/ investment? Inspirata has secured a sizeable investment and intends on growing very quickly. Just months after the launch of Inspirata’s 10,000 sq ft office in the US, a new R&D office has been opened in Bagmane Park, Bengaluru. Inspirata will start off with very modest beginnings and aspire to become a billion dollar market Cap company. Inspirata is posed to be our legacy and greatest success. Which geographies do you operate in and what is the main focus of your growth? Inspirata is currently operating in both the US and
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India, but recognises that cancer is a global epidemic. The products and solutions we offer easily cross geographic boundaries and can be distributed worldwide. Inspirata will focus its development growth in North America, Europe and India but has the long term vision of making its solutions available anywhere in the world, from the smallest villages to the most metropolitan cities. This is, in part, the power of coupling digital medicine with inexpensive tests to democratise cancer diagnostics to ensure every patient has access to a rapid and accurate diagnosis. Tell us about data mining, data analytics and predictive software algorithms in the healthcare space? Many governments and companies alike are interested in using Big Data for medical applications. Inspirata has identified a number of key differentiators which will add significant value to the existing databases available in the market today. These are very challenging problems with a massive upside for the
consumers i.e. the patients. Learning more about how an individual’s cancer may progress or how they may respond to therapy is extremely powerful. This is the goal of precision medicine and the goal of leveraging data mining, data analytics and predictive software algorithms to transform cancer diagnostics and therapy design.
Inspirata believes the Indian market will be able to adopt the right solutionswhich must be tailored to the Indian economy and culture
Do you think India is ready for this? What is your outlook for the Indian market? Unfortunately, the rates of cancer findings in India are increasing rapidly. The country and its people are screaming for cheaper, more reliable cancer diagnoses. India is beginning to invest in better cancer care; however, it is also in a very unique position to take advantage of some of the newly emerging ‘leapfrog’ technologies in medicine. Inspirata believes the Indian market will be able to adopt the right solutionswhich must be tailored to the Indian economy and culture. What are your plans for Inspirata’s India operations
and investment? Currently, Inspirata’s efforts in India are focused on research and development. These are not only software development jobs but very challenging biomedical engineering and algorithm development research which are both exciting to scientists and impactful for the Indian community who would consume these products. Inspirata has adopted a philosophy of making products in India for Indians. We believe this is important and Inspirata has committed an initial investment of three million dollars towards this first initiative. Where do you see Inspirata in the next five years? Inspirata will never be 15-20,000 employees. Rather this company is based on a portfolio of select intellectual property which is capable of being delivered to millions of people anywhere in the world. Inspirata will be massively successful as a standard in cancer diagnostics. mneelam.kachhap@expressindia.com
EVENT BRIEF OCTOBER 2015 08
INTERNATIONAL MUSCULOSKELETAL ULTRASOUND CONFERENCE
IT,ATNF, 9th Floor, Health Street Building,
INTERNATIONAL MUSCULOSKELETAL ULTRASOUND CONFERENCE Date: October 8-11, 2015 Venue: Vivanta by Taj, Dwarka, New Delhi, Summary: It would focus on the application of ultrasound to the entire range of musculoskeletal imaging. It would dispense information on the anatomy, techniques and interventions applicable to the musculoskeletal system using ultrasound, while defining its role as a major modality in musculoskeletal imaging Contact Conference Secretary , Dr Nidhi Bhatnagar, E-7, East of Kailash, New Delhi Mobile: +91 - 9810884378. nidhibhatnagar63@gmail.com
TRANSFORMING HEALTHCARE WITH IT Date: October 16-17, 2015 Venue: The Lalit Ashok, Bengaluru Summary: The conference aims to bring together experts from both healthcare and IT to meet, discuss and disseminate the latest happenings in the field of Healthcare IT. This conference is being held along with the 5th International Patient Safety Congress at the same venue. Organisers: Apollo Group of Hospitals Contact: Suresh Kochattil Conference Secretariat, Transforming Healthcare with
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TRANSFORMING HEALTHCARE WITH IT
Apollo Health City, Jubilee Hills,
Hyderabad – 500 096 Ph: 040- 23606868 /
09849011006 E: mail@transformhealth-it.org
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Dr DS Rana Chairman, Board of Management and Emeritus Consultant-Nephrology, SGRH
SGRH: TRACING A SUCCESS SAGA Healthcare ventures in the private sector in India have always been for-profit entities but some charitable hospitals in India have managed to focus on growth and impact society without altering their philanthropic DNA. Sir Ganga Ram Hospital (SGRH) is leading the pack, practicing charity as a belief and not as a statutory compliance BY M NEELAM KACHHAP
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675-bed multispeciality, state-of-the-art hospital in the heart of Delhi, Sir Ganga Ram Hospital (SGRH) needs no introductions. The hospital is known for clinical excellence and its work has achieved national and international recognition. The hospital is also widely recognised for its postgraduate teaching and academic activities. "Amongst the hospital’s regular clientele are many public figures like the Prime Minister, Chief Ministers, Governors and senior politicians, CEOs of multinational and public sector undertakings, sports and media personalities and from time to time, even the first citizen of the country,” says Dr Dr DS Rana, Chairman, Board of
Management and Emeritus Consultant-Nephrology. “The hospital has been decorated with many awards like International Outstanding Hospital Award in Community Care and Infection Control Practices and Community Service; and its consultants have been awarded the highest national awards like Padmabhushan, Padmashree, BC Roy Awards, and other professional and industry awards,” Dr Rana adds. SGRH's vision is to be a leader in healthcare delivery, medical education, training and research and to meet the changing expectations of the community. Keeping this vision in mind, the hospital has managed to focus on a comprehensive long-term value proposition rather than short-term,
financial-driven perspective. SGRH ensures cutting edge technology, community health programmes, and facility enhancements; all focused on the patient.
Deep rooted belief What differentiates SGRH from other private hospitals is their belief in charity coupled with clinical excellence. This means that the 60 year-old-hospital invests in technology and talent at par with other private hospitals, at the same time catering to all strata of the society, irrespective of their paying capacity. Apart from the 20 per cent beds that the hospital keeps aside for patients belonging to financially weaker sections of the society, it also provides 40 per cent of its beds at a subsidised rate.
The hospital is the legacy of renowned philanthropist Sir Ganga Ram who lived in Lahore during the pre-independent era and sought to use his wealth to make his hospital a vehicle for social change. Later, a trust was created in his memory which till today runs the hospital. A Board comprising staff doctors manages the dayto-day operations of the hospital under the aegis of the Trust.
Independent governance SGRH rode to success largely on the strength of its clinical excellence and has gone on to make a lasting impact on Delhi's healthcare landscape, the patients as well as the world at large. What's particularly fascinating is how each machinery working at the hospital is in tandem to bring out
the best in clinical practice, teaching and research. “The hospital is governed by a Board of Management comprising medical consultants of eminence, some with international standing. The Board of Management operates under the overall guidance of the Sir Ganga Ram Trust Society,” says Dr Rana. SGRH is for-purpose rather than forprofit organisation, insists Dr Rana. "The Trust has no financial interest in the hospital. It functions as a watchdog or guardian and does not interfere with the working of the hospital," he adds. "We (the Board Members) are managers for the people. We just manage the funds and see that the hospital runs smoothly. We don’t get remunerated for this. All Board positions are honorary posi-
Dr DS Rana, Chairman, Board of Management and Emeritus Consultant-Nephrology
SIR GANGA RAM HOSPITAL IS FOR-PURPOSE RATHER THAN FOR-PROFIT ORGANISATION
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Transparent pricing
tions," explains Dr Rana.
Cornerstone of SGRH The foundation of SGRH healthcare service lies in the belief that affordable access to healthcare can be provided by cross-subsidy where highincome individuals contribute to the financing of healthcare services needed by low-income individuals. "The upper class patients subsidise for the middle class, middle class subsidise for the lower class and the hospital compensates for the below-poverty-level (BPL) patients," says Dr Ajay Swaroop, Honorary Joint Secretary-cum-Treasurer and Senior Consultant, ENT. "This allows even the poorest patient to avail of cutting edge technology and latest treatment options with dignity," he adds. Although in Delhi, hospitals are obligated to provide free treatment to economic weaker section (EWS) of the public not all hospitals follow through. Patients of EWS category are entitled to 10 per cent of total in patient beds and 25 per cent of out patient facility completely free of charge. SGRH has been profiding free facilities to 20 per cent of patients. SGRH also provides 40 per cent of its beds at a subsidised rate. "At SGRH, 20 per cent of the beds are earmarked for EWS people," says Dr SP Byotra, Honorary Secretary and Emeritus Consultant, Medicine. "On these beds, all facilities (boarding, lodging, investigations, medicine and operative procedures) are free. In addition to that the hospital has a specialised outpatient department for all disciplines in which patients are seen free of charge. These facilities are provided strictly on a first-come first serve basis," he adds. At any given time the hospital has over 95 per cent occupancy rate, one of the rare hospitals in the private sector to have this high occupancy rate. "When the hospital started, the forefounders were very clear that SGRH is a charitable hospital. Even with changing times we have been able to stick to that practice religiously," adds Dr Swaroop.
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Even before the world started debating on price transparency, SGRH has gone ahead and made it a regular feature at the centre of their practice. “Hospitals need to be increasingly transparent about costs. It’s becoming a trend that is already taking hold but
hasn't yet reached critical mass,” says Dr Swaroop. “We help patients understand our pricing and are available to answers their questions about healthcare prices. Patients should compare prices among providers, and manage their out-of-pocket costs," he further adds.
Consultants’ contribution A distinguishing feature of SGRH is their unique model of governance. The day-to-day hospital management is handled by the Board of Management, consisting of hospital clinicians. The consultants share the revenue earned by them to contribute towards the
development and growth of the hospital. "At SGRH, the doctors contribute a percentage of their earnings to the growth of the hospital. This is a novel way to nurture the workplace and engage the employee at a higher level," says Dr Rana. This gives a unique sense of belonging and pride amongst
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cover ) the doctors. "Staff contributes 12-15 per cent of their total earning to hospital development, they feel part of the hospital,” says Dr Swaroop.
Coordinated care One of the reasons for SGRH’s success is the availability of coordinated care at the hospital. The hospital provides coordinated care throughout the entire continuum of care — from outpatient office visits to inpatient stays and post-acute rehabilitation. The hospital has also been developing a standardised care path for some of the most common conditions treated at SGRH. “An interdisciplinary team of doctors within each centre of excellence collaborates to develop a care pathway to reduce unnecessary variability,” said Dr Rana. This will ultimately reduce costs and help manage time more effectively both for patients and doctors,” says Dr Rana.
SGRH ATAGLANCE
1st
BONE BANK IN INDIA
96.2% 25% SGRH's Dharam Vira Heart Centre has one of the highest incidence of Off Pump Surgeries in the country at 96.2 per cent of total coronary artery bypass surgeries
SGRH's in-vitro fertilisation unit has the highest success rates in the country with pregnancy rates of 25 per cent
At par with changing times Another important consideration at the hospital is to keep current. Whether its a stateof-the-art hospital management software or a latest radiology equipment or a robotic surgical enhancement, SGRH has always been engaging current technologies to stay relevant to its patients. There are several departments of the hospital that have been recognised as Institutes and Centres of Excellence. "This represents the collaborative effort between the hospital, industry, university and academic bodies and the government," says Dr Byotra. SGRH strives to keep current by frequent upgradation. “When you [upgrade], patient visits and volume increase. People like to go to a modern, more efficient facility. It makes a difference.” says Dr Rana. Regular upgradation of the facility results in better indoor environmental quality, improved patient safety, more efficient and flexible facilities, and higher patient and staff satisfaction. “Hospitals must renovate to achieve optimisation of existing infrastructure
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SGRH has always been engaging current technologies to stay relevant to its patients
which results in achieving functional excellence required for the healthcare needs of public and service provider,” reiterates Dr Rana.
Community engagement The hospital is committed to deliver long-term value to both their stakeholders and society. The hospital is adding to societal investment programmes to become more strategic and innovative, and infuse purpose throughout the entire organisation. SGRH engages with the community through its Ladies Welfare wing. Many activities like the TB eradication programme, mobile clinics and disaster management are the working of the Ladies Welfare wing.
Long-term value to employees It is a known fact that HR costs are about 30 per cent of the total hospital cost and it is very tricky to retain good talent in
India. Average attrition rate in hospitals is about 15 to 25 per cent, yet SGRH has managed to keep most of its talent intact. "Most of the doctors who joined us initially were looking for a good teaching environment with impetus for research along with competitive salaries. We were able to provide all three requirements," says Dr Rana. Of course, the hospital also suffered some setback when their celebrated Minimal Access, Metabolic and Bariatric Surgeon decided to part ways and their busy liver transplant surgeon found a new job, however the hospital seems to have recovered from the setback, says Dr Rana. "When an employee leaves, the relationships that he/she built for the hospital are severed, which could lead to potential customer loss. Also, continuity of care is severed, which causes a lot of discomfort for the patient leading to dissatisfaction. However, we
The hospital is adding to societal investment programmesto become more strategic and innovative, and infuse purpose throughout the entire organisation do not have problems like that at present," informs Dr Rana. The hospital is creating fully integrated opportunities to engage a the employees, says Dr Byotra. “People who work here (SGRH) have the passion to teach, share knowledge and are content with their clinical work,” states Dr Byotra who has been with the organisation for more than 30 years. “Give the best to life and you will get the best,” he says philosophically. “I've been working here
since 1984 and find working here very comfortable,” says Dr Swaroop. “There is a steady and gradual growth path for all employees and there is a hierarchy system. However, the management does not set any financial goals for its doctors. One gets to do absolute ethical work here,” explains Dr Swaroop.
Investing in future Having a self-sustaining business model has its disadvan-
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WE ARE MULLING OVER EXPANSION PLANS FOR OTHER LOCATIONS LIKE DELHI-NCR, NOIDA, GURGAON tages. The pace of growth slows down as growth capital for expansion to other locations are limited. “Our unique model of tertiary healthcare delivery is good for self-sustenance, the hospital does not depend on any financial contributions of any external agency," says Dr Rana. "However, it limits us in a way that we cannot reach other locations," Dr Rana adds. "Many hospitals have approached us in the past to lend our name to them. We could have had a chain of franchise based hospitals under our name, but we were sceptical of their intent and did
not want to spoil the brand so we did not move forward," shares Dr Rana. "However, we do feel that we need to have some critical mass in terms of number of beds or hospitals. We are mulling over expansion plans for other locations like Delhi-NCR, Noida, Gurgaon," informs Dr Rana. These will be a mix of greenfield and brownfield projects, he says.
Expansion plans The hospital has been facing space constrains as the number of patients visiting the hospital has been on the rise. "There is
a shortage of space, and we want to extend our services. There are still patients whom we cannot accommodate. We want to expand our facilities and education. The present day facility doesn't allow that," says Dr Rana. In its endeavour to provide state-of-the-art facilities and to meet the increasing demand of patient beds, the hospital has undertaken phased renovation of old blocks and will soon start construction of four new blocks and an 11-storey car parking, around five lakh sq feet of additional area. “In the first phase of the master plan 2021,
to be completed in the next three years, the hospital intends to add around 250 beds in addition to a multi-level car parking to accommodate 1100 cars," says Dr Rana.
In times to come Today, SGRH remains at the forefront of healthcare. It is the first hospital in the country to have a bone bank and the only hospital with a genetic diagnostic department performing genetic studies and providing counseling. It houses nationally recognised centres of excellence, including those in critical
care and emergency medicine, child health and renal sciences and it provides groundbreaking programmes that improve access and quality of care to the most vulnerable populations. In partnership with Guru Gobind Singh Indraprastha University, SGRH provides valuable training for future leaders in health care. With the hospital block in the pipeline, SGRH capabilities will continue to grow, serving diverse patients with some of today’s most complex and chronic problems. mneelam.kachhap@expressindia.com
SPECIAL: WORLD BREASTFEEDING WEEK I N T E R V I E W
‘Human milk banks are a tool by which we can reduce IMR’ What is the best measure to bring down infant mortality? Experts across the globe say that the answer is to encourage breast feeding. But what happens to babies whose mothers for some reasons cannot provide them with adequate milk? The solution to this issue is human milk banks. The concept was brought to India by Dr Armida Fernandez who helped in establishing India's, in fact Asia's, first human milk bank at Lokmanya Tilak Hospital, Sion, Mumbai in 1989. This initiative has today become the need of the hour. Raelene Kambli meets the visionary to understand the importance of a human milk bank and ways to promote this concept in India
What are the benefits of breast milk, especially for premature babies? Breast milk is superior infant food. There are many benefits to breast milk. It has many essential components such as proteins, carbohydrates, fats, vitamins, minerals and many anti-infection properties that provides different kinds of defence against diseases among new born babies. Especially, among premature babies, it help them from contracting infections which is the biggest cause of mortality among such babies. Do you see a trend where Indian mothers these days are lactating less? Human beings are mammals so it is a natural process for mothers to lactate for their new born babies. It is only when the hormones are hampered that a mother may have less or no milk to provide her baby. There could be several reasons for the same. One could be emotional stress where the mother is worried about how much she can feed her baby. Lack of confidence could be another reason and thirdly it could lack of emotional support from the family.
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All of these emotions can make a mother feel that she does not have enough milk to provide her baby. This is mostly with city mothers, and especially with working mothers. How important is the concept of human milk bank? How was the concept accepted globally? Human milk bank plays a very important role in providing breast milk to new babies of mothers who cannot provide their babies with adequate breast milk. It is a tool by which we can reduce infant mortality in India and is the need of the hour. Globally, in the late 80s there were milk banks in America, Australia and many other European countries. However, the spread of HIV/ AIDS suddenly led to the shut down of many milk banks across the globe. Nevertheless, the concept has picked up momentum again. Currently, Brazil has the largest network of human milk banks in the world, followed by South America, Spain, Portugal etc. How did you start this breast milk bank at Sion hospital?
Paediatrics and neonatologists have got together and formed a group where we are setting guidelines for milk banks
In 1977, I took over the department of neonatology at Sion Hospital. We looked after babies right from their birth up to four weeks of life. At that time, nearly six to eight thousand babies where born at the hospital. Amongst them, I saw that the hospital also registered many high risk pregnancies, where mothers had complications such as high blood pressure, heart diseases or lung diseases. In around 30 per cent of these, the mother or the child would have been at risk. Also, there were mothers who had the risk of delivering premature babies. When these babies were born, they were either sick or their mothers were sick and so these babies were separated from their mothers and were admitted in our neonatal intensive care. In such circumstances, mothers were not in a position to breast feed their babies. These babies were then given formula milk which actually kept them at a higher risk of contracting infections. We also knew that these babies needed breast milk to survive. So, we gave these babies breast milk of another mother who would be willing to donate her milk. We continued this practice for
sometime. In 1987, I visited Oxford on a fellowship and I saw breast milk banks in Birmingham and Oxford for the first time. Here the breast milk was scientifically collected, pasturised and stored. This is a safe way to provide breast milk to babies. The idea immediately appealed to me and I decided to introduce a breast milk bank at the Sion Hospital. How did you manage to get funds to start a milk bank? Well, initially I found it very difficult to convince people of this concept. Especially to the officials from the BMC. The idea of storing human milk and providing babies with milk of another mother did not bode well with these municipal officials. I had to cite them examples from the Mahabharata wherein Krishna was fed and looked after by Yashoda who was not his biological mother. That's how I got the permission to start the milk bank at the Sion Hospital. However, they did not give me the funds for the same. So, it took me two years to get a sponsor. Then, Taj Group of hotels donated funds to start this milk bank.
What is the process of storing breast milk? Unlike milk banks abroad, at Sion Hospital we had only in-house donors or mothers who came back in outpatients. Mostly, these mothers come from the slum areas and so we need to take care of hygiene. Our rule at Sion Hospital was that donors will have to come to the hospital to donate milk where our nurses would hygienically help mothers to collect milk. After the milk is collected, some portion of it is sent for testing and remaining is pooled as we have donors who donate milk in 20cc or 30cc. Thereafter, the milk is pasturised at 62.5o for 30 minutes then we cool it at -23o Celsius. This milk is stored in stainless steel containers. We label the container with the date of collection. Each of these milk containers can last for upto six months. We store these milk containers in the freezer and use the milk containers in the first-in first-out basis. Whenever we require milk for babies we defrost the milk containers and not boil the milk as boiling can destroy all the nutrients present in the milk. Why stainless steel? Does stainless steel have any kind of specific properties? Abroad they use Pyrex or polythene glass containers which are very expensive. And there is huge risk that the glass containers can break. Stainless steel containers are easily available in Indian homes. It is easy to procure, easy to sterilise and clean. And its the most safe way to store. How many human milk banks are operational in Mumbai? Right now we have these milk banks at Sion Hospital, Cama Hospital, JJ Hospital, KEM and Navi Mumbai. The good news is that the government is also thinking of starting human milk banks across the country. In fact, recently the government of Rajasthan started a human milk bank. So, slowly the government is also realising the benefits of having milk banks. Who else is involved in promoting milk banks in India? PATH, an organisation who has been working in this field for a long time, is constantly negotiating with the government to take its concept forward.
What are the challenges in starting and running a human milk bank? When you start a new thing, there will always be some challenges associated with it. Everything new is not accepted easily and so was the concept of human milk banks. It was a tall task to convince people to accept this concept, especially the municipal corporation officials. I had to tell people that when it was easy for us to provide milk of another animals to our children why not the milk of another mother. The other challenge is the hygienic collection of milk, safe pasturisation process and post that, the microbiology test. Since we have maximum mothers coming from the slum areas, screening them for infections becomes a must, so we need trained nurses who would maintain hygienic standards. Are there appropriate guidelines to run human milk banks? There are no guidelines and regulations from the government side. Nevertheless, in the last one year, paediatrics and neonatologists have got together and formed a group where we are setting guidelines for milk banks. Are there any gaps in maintaining our milk banks as compared to the global standards? The standards abroad is slightly different then ours. There, mothers are very vocal about disclosing their habits such as smoking , drinking etc whereas in India, mothers are not vocal about their habits. The other difference is that the way of collecting milk is different for ours. There, mothers collect the milk at home and drop it at collection centres established everywhere. Also, milk banks abroad do not pool milk, so each mother’s milk is stored separately in a separate container. Additionally, the equipment used to pasturise the milk and store it is more expensive and of high quality. Ours is a more low-cost model which is similar to Brazil. They also has a low-cost model and have milk bank across the country. But their quality and methodology to store milk is touted about. Our team has recently visited Brazil and has learnt some lessons which we can certain duplicate in our practice. raelene.kambli@expressindia.com
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SPECIAL: WORLD BREASTFEEDING WEEK
I N T E R V I E W
‘Breastfeeding rates can go up only if we invest in policy and programmes’ Dr Arun Gupta, Regional Coordinator of International Baby Food Action Network (IBFAN) Asia, and Member, Prime Minister’s Council on India's Nutrition Challenges, shares valuable insights on the importance of breastfeeding in improving maternal and infant health indices in the country, in an interaction with Lakshmipriya Nair
How important is breastfeeding in maternal and child health? Breastfeeding is too important as far as mother and child health is concerned. A baby who is breastfed within one hour has 2.6 times lesser chance of newborn infection and deaths during this period. Exclusive breastfeeding during the first six months reduces diarrhoea, respiratory infections, and undernutrition making it the number one intervention for child health and survival. Exclusive breastfeeding also reduces risk of hospitalisation in diarrhea and pneumonia cases. There is concrete evidence that breastfeeding also provides protection against obesity, and adult diseases such as diabetes, hypertension, and malignancies. For mothers, breastfeeding provides protection against ovarian and breast cancer. Exclusive breastfeeding is important for birth spacing too. Can breastfeeding play a role in meeting the MDG goals? Certainly breastfeeding can play a role, if coverage is scaled up to 90 per cent or more for three indicators: early initiation of breastfeeding within one hour, exclusive breastfeeding for the first six months and adequate and appropriate complementary feeding with continued breastfeeding for two years or beyond. As much as 22 per cent newborn mortality can be cut down for example if all mothers were enabled to breastfeed within an
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hour of birth. Further breastfeeding exclusively reduces diarrhea mortality by 10 times and pneumonia mortality by 15 times in children 6-23 months of age. More recent evidence points on that breastfeeding also leads to higher earning capacity later in life through increasing IQ, educational attainment with increasing breastfeeding duration As per WHO statistics, India lags behind in breastfeeding. Why is it so? Recent World Breastfeeding Trends Initiative (WBTi), policy assessment has revealed that India lacks a clear policy, plan of action and budget for interventions on breastfeeding. Lack of coordinated response reduces the priority it needs. There are several policy areas needing urgent attention such as maternity protection, enforcing the law to protect breastfeeding from aggressive promotion of baby foods, health system support to women and breastfeeding during disasters etc. to mention a few. Breastfeeding rates can go up only if we invest in policy and programmes. What are the major challenges to tackle? Aggressive promotion of baby foods through the health systems pushes mothers to adopt artificial feeding. Lack of maternity protection measures for majority of women especially in the unorganised sector and in the private sector who have to combine work and breastfeeding
is a major challenge. Health system being unsupportive to mothers at time of birth or later to ensure exclusivity of breastfeeding pushes women to adopt unwanted harmful practices. Confusing messages from several quarters in the absence of state interventions and lack of proper information on risks of formula feeding makes good feeding choices a huge challenge.
Breastfeeding exclusively reduces diarrhoea mortality by 10 times and pneumonia mortality by 15 times in children, 6-23 months of age
What are the steps to better our breastfeeding stats? Government of India should ‘move’ the existing national committee on breastfeeding and develop a plan of action for five years at least with assured funding. Policy and programmes should be reviewed every three years. Some one should review the plan every six months. Data on three indicators of breastfeeding should be reviewed annually from every State; if US can do it, why can't we? The most recent Government of India’s Rapid Survey of Children data shows mere 44 per cent mothers are able to breastfeed within one hour. Is it not a gross failure of our health system support towards mothers, a system, which claims that 78 per cent mothers deliver in institutions. Exclusive breastfeeding rate at 64 per cent is an improvement from NFHS 3 data but complementary feeding rate at 50 per cent is a fall from NFHS-3. What we need to do is rapidly scale up coverage of these three indicators to nearly universal. Who is looking at these?
How does BPNI work with the government and other agencies like UNICEF? The Breastfeeding Promotion Network of India (BPNI) was founded in 1991, to protect promote and support breastfeeding in India. It works with government and UNICEF like agencies through advocacy. BPNI carries out an India assessment of policy and programmes every three years using World Breastfeeding Trends Initiative (WBTi) tools, in line with Global Strategy for infant and young child feeding. BPNI has also developed a world-class four-in-one skilltraining programme for health workers that combines all kinds of skills required on breastfeeding counselling or growth monitoring. BPNI advocates for such training to be mainstreamed. BPNI also helps in monitoring the law enacted for regulating the marketing of baby foods and feeding bottles. BPNI advocates for sustainable solutions to child malnutrition through comprehensive food based approaches not through market product based ad hoc solutions. BPNI has a clear ethical policy on conflict of interest for its own funding and does not accept funds from the companies manufacturing baby foods, feeding bottles etc., and from organisations/industry having conflict of interest. BPNI raises conflict of interest concerns in policy and programmes at all levels. lakshmipriya.nair@expressindia.com
SPECIAL: WORLD BREASTFEEDING WEEK I N T E R V I E W
‘We need to establish milk collection centres in India’ Dr Jayshree Mondkar, Professor and HODNeonatology; & Director, Human Milk Bank, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, recently visited Brazil to understand how they run their milk bank and understand their guidelines. Raelene Kambli meets Dr Mondkar to know more about her learnings from the trip
What is the significance of a human milk bank? A human milk bank is vital for premature babies and for babies whose mothers are not able to provide them milk due to delayed lactation, illness or even abandonment. How many milk banks in India? Currently, we have 20 milk banks across India. What was the purpose of your visit to Brazil? The reason why we visited Brazil is because they have the largest human milk bank networks in the world. They have about 213 milk banks and 199 collection centres. Not only this, but they are also in cooperation with 23 countries especially, Latin American, Central American, Portugal and South African regions. Brazil provides these countries with technical know-how for milk banking. It follows a low-cost, milk banking model which is what India requires. From India, we were three neonatologists, one dietician who looks after the milk bank in Pune and three people from PATH, an NGO. What are differences in the milk banking techniques of Brazil and India? What were the learnings from your visit? We saw their system and realised that it is similar to ours. They were very happy to hear that we have been
banking milk for the past 25 years now. The difference lies in the way milk is collected. Our mothers donate in the hospitals and their mothers collect the milk at home, freeze it and drop it at collection centre. Milk banking is ancillary support to breastfeeding when mothers are not able to provide breast milk to their babies. The whole focus should be on breastfeeding and that's what Brazil is doing. They have a very good breastfeeding support programme as a result of which they have this network of milk banks across the country. They also have a lot of community mobilisation process in place. Also, in Brazil, this network of milk banks are instituted by the government. Our other aim in visiting Brazil was to convince the Indian government to have an MOU with the Brazilian government to promote breastfeeding and milk banking in India. The other interesting learning from Brazil is that they have already met the MDG goals in this area two years in advance. So, we are just hoping that our government supports this cause and we can increase the number of milk banks in India. Do you see a reduced rate of lactation among Indian mothers? At the time when mothers deliver their babies and they are in the hospital, they do breastfeed their babies.
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SPECIAL: WORLD BREASTFEEDING WEEK But it’s only after they return home that the problem begins. If mothers face a problem in breastfeeding the babies at home, some of them stop feeding their babies due to ample number of advisors who actually confuse the mother. Human milk has anti-infection properties that can reduce neonatal mortality.
20o C can last for six months. Are there any states in India that have done better in terms of milk banking? Maharashtra has done well. Nine out of the 20 milk banks are in Maharashtra. Six are in Mumbai only, followed by Gujarat and the rest of the Western region of India. Rotary Club runs the maximum milk banks in India.
Are there any guidelines so far in India? Guidelines have been formulated in 2013 by the Indian Academics of Paediatrics and now the government is in the process of drafting initial guidelines. According to PATH, an NGO, the Ministry of Family and Health has been preparing a zero draft (initial draft) for milk banking. PATH is negotiating with the government on this. What is the process followed for storing milk in India? Milk is first pasteurised and then it is stored at -20o C. We use the low temperate, long time method which is the older pasteurisation technique. So
Is there enough government support in this area? Till now we did not get enough support but slowly there is an awakening.
Human milk bank at Lokmanya Tilak Municipal Medical College and General Hospital, Sion
we pasteurise the milk at 62.5o C for 30 minutes and
rapidly cool it at 4o C and then store it. Milk that is stored at -
What are the challenges in running a milk bank? There is a need for more trained nurses in this area. We also need to establish collection centres. We need not have have many milk banks but if we have many collection centres, milk can be easily transported to all neonatal care centres. This could also be cost saving. Is it difficult to find donors? At Sion Hospital, we collect
around 1200-1400 litres of milk each year. But this only suffices for our babies. So, if we need to share this milk with our neonatal centres then we need more donors. Here comes the role of media who should spread awareness about this concept and encourage more mothers to come and donate milk. What should be the standard operating procedures (SOPs) for milk banking? In India, each milk bank has a standard protocol. We follow a Hazard Analysis & Critical Control Points (HACCP) protocol which includes every aspect of milk banks right from screening of mothers, to testing the milk to storing and donating it. So, how do we get the private sector also be part of the human banking system? Private sector hospitals who have mother and child units can serve as collection centres, provide donors as well as space for milk banks etc. raelene.kambli@expressindia.com
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SPECIAL: WORLD BREASTFEEDING WEEK OPINION
A hand to hold
DR BANDITA SINHA Gynaecologist and Obstetrician, Fortis Hiranandani Hospital, Vashi
Dr Bandita Sinha, Gynaecologist and Obstetrician, Fortis Hiranandani Hospital, Vashi, elaborates on the importance of breastfeeding and says that women are more likely to achieve their breastfeeding goals if they are supported appropriately and adequately
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e all know that breastfeeding is the best gift that the mother can give to her baby. But, despite being one of the most natural processes, it can be riddled with difficulties and challenges – some avoidable and some not so. Women are significantly more likely to achieve their breastfeeding goals if they are supported prenatally, in the maternity care facility and after discharge. Health promotion and disease prevention are effective methods to reduce the incidence of acute and chronic illnesses in the childhood itself. In order to increase immunity and enhance the nutritional value, breastfeeding has been identified as the cost-effective means of disease prevention with the accompanying reduction in healthcare spending. Informed women are initiating breastfeeding at an increasing rate. However, many new-age mothers struggle to maintain breastfeeding for as long as it is medically indicated and thus fail to feed the baby appropriately. Consequently, healthcare spending increases on treating diseases and conditions that could have been effectively prevented by breastfeeding. In order to appropriately address this preventive healthcare gap and the excessive costs that results due to it, consumers, healthcare providers, insurers and employers need to be able to identify and access qualified lactation consultants to provide services and protect
quality of care. When women have trouble breastfeeding, they are often have to giveup and go for the bottle-and-formula route. In earlier days, a woman’s breastfeeding problems were left to the family physician. A new mother can be hormonally liable, recovering from surgery or birth, suffering from fatigue and learning how to fit a baby into their lives. Difficult breastfeeding is gruelling, and if support is not initiated immediately, the breastfeeding relationship can be lost within a matter of days or sometimes even hours, affecting the mother, child and family’s future for the rest of their lives. Changing times show that hospitals offering help through well-meaning lactation consultants urging the
new-age mothers to try harder. The support can be limited to a few visits in certain cases, with rare cases requiring prolonged assistance. These lactation consultants provide personal assistance to the mother of a new born child, helping her with technical issues, such as improving the baby’s latch, solving common problems faced by new mothers from engorged breasts to blocked ducts, making the mothers understand about the best way to ensure that their baby is getting enough milk, finding the causes for low milk production and relieving the engorgement of the breasts by using a breast pump. These lactation consultants also provide appropriate care for the babies and their mothers by providing a
holistic approach during antenatal and postnatal stage of child birth.
Breastfeeding support These lactation consultants in India and abroad are trained through the International Board of Certified Lactation Consultants (IBCIC) to conduct free support group meetings and give telephonic and e-mail help to pregnant and breastfeeding mother voluntarily. They undergo extensive training in basic breastfeeding management. They visit maternity homes for antenatal and postnatal breastfeeding counselling and also undertake home visits. Lactation consultants also provide much-needed assistance to the family members of first-time mothers. They provide assistance to the fam-
ily members with information such as: ◗ The ‘hows’ and ‘whys’ of breastfeeding ◗ The ‘ins’ and ‘outs’ of positioning and latch ◗ Preventing and managing breastfeeding difficulties that may arise ◗ Breastfeeding twins or triplets ◗ Breastfeeding a premature baby or a baby with special needs ◗ Breastfeeding when medical issues arise with mother or baby ◗ Breastfeeding and returning to work or school Currently, there are a handful of lactation consultants across the country, but there’s a need for more. Mothers need cheerleaders, people who can advocate for them and support them emotionally as they try to fulfil this responsibility to the infants. It can be a long journey from pumping for a fragile infant to direct breastfeeding. Breastfeeding is too important to let it slip away for lack of help or good information. Mothers need support at every step on their way. Women who wants to breastfeed and are unsuccessful in achieving their goals can be reminded of their loss each time they give their baby formula, experience an infant illness, or see other women breastfeeding. A family with breastfeeding issues needs access to lactation support locally and quickly with minimal effort. A small investment in lactation care and services early in a child’s life reaps long term positive return on investment.
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SPECIAL: WORLD BREASTFEEDING WEEK INSIGHT
MOBILISING TECHNOLOGY TO ENHANCE MATERNAL AND CHILD HEALTH 32
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Dr Priya Balasubramaniam, Senior Public Health Specialist & Director, PHFI-RNE Universal Health Initiative, Public Health Foundation of India and Akshya Patil, Project Associate, Public Health Foundation of India deliberate on how technology can be mobilised to reduce the gaps in maternal and child health “Quality means doing it right when no one is looking.” Henry Ford (Industrialist and pioneer)
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ndia’s healthcare sector has evolved in a manner that presents a curious paradox. While an increasing proportion of the country’s mixed healthcare delivery is borne by a competitive, unregulated and expanding private sector, its complex yet comprehensive public health system struggles to keep pace with rapid demographic and epidemiological transitions. More than 80 per cent of healthcare expenditures in the country are out-of-pocket driving 4.2 per cent of India’s GDP towards private healthcare services. As India grapples to achieve global maternal and child health goals such as the Millennium Development Goals (MDG) and bridge ever widening gaps of inequality faced by vulnerable populations, there has been increased emphasis on improving access to healthcare and in the process we seem to have lost out on delivering consistent good quality healthcare. Unfortunately, merely giving populations access to health services without equal stress on the quality of care they are getting defeats the very provision of equitable healthcare. The uneasy relationship between the public and private health sectors is especially stark around quality of care issues. While the public sector considers increasingly dominant private health providers as profit-making entities focussing on higher levels of care, the private sector perceives the public health sector to be lacking in infrastructure and hampered by poor manage-
ment, thereby affecting quality and creating the very market that makes people opt for privately run health services. While the public sector plagued with poorly run primary health centres, overcrowded hospitals, outmoded health camps and lack of accountability of those entrusted with the responsibility of delivering services, is often seen as a major culprit in the erosion of and low quality maternal and child health services, the private sector is no less culpable. The general lack of healthcare regulation has fostered a slew of providers who have, in numerous instances, compromised on care quality in their attempt to cut costs, resulting in the hapless patient often paying the price with their lives or chronic injury. Yet, why should we prioritise quality in healthcare in a country that is barely able to provide clean water and sanitation for its populations and the spectre of undernutrition still looms large. Well largely because providing water and sanitation are invariably measures of effective governance while assuring good healthcare quality for individual patients and populations is intrinsic to the wellbeing of a society at largeand is neither expensive nor difficult to achieve. At the end of the day, an individual citizen walking into any health facility needs to be assured that she or he will be looked after in a clean and hygienic environment, treated with dignity and respect and delivered basic healthcare services in a considerate and error free manner. Neglecting to pay attention to quality in healthcare delivery and wide variations in standards of care has forced our health systems to incur even higher costs related to
unnecessary deaths and wasted resources. The World Health Organization states that for low and middle income countries which especially need to optimise limited resources and expand population coverage, the process of quality assurance and improvement needs to be based on sound local strategies to achieve the best possible results for investments in health. Let us look at some of the data in Reproductive Maternal and Child Health (RMNCH) that is influenced by quality: every year more than half a million women die of causes related to pregnancy and childbirth, and almost four million new-borns die within 28 days of birth. In 2010, India accounted for 19 per cent of all global maternal deaths despite an annual decline of 5.7 per cent in maternal mortality between the years 2005 and 2010. India has the largest number. Neonatal sepsis is one of the common causes of neonatal mortality contributing to 23 per cent of all neonatal deaths. Quality of care is an increasingly significant predictor of service utilisation in maternal
Merely giving access to health services without equal stress on the quality of care defeats the very provision of equitable healthcare
AKSHYA PATIL, Project Associate, Public Health Foundation of India
DR PRIYA BALASUBRAMANIAM, Senior Public Health Specialist & Director, PHFI-RNE Universal Health Initiative, Public Health Foundation of India
health, even more than access. Despite the improvement in the quality of maternal health services over the last ten years, India still fairs poorly in comparison to most emerging economies. The National Health Rural Mission launched in 2005 has contributed immensely to strengthening rural primary healthcare and enhancing access to health services for poor women and children in rural India. Yet, quality continues to remain a concern, with innumerable stories of negligence, deaths and infections being highlighted in the media on a regular basis. While schemes like the Janani Suraksha Yojana promote institutional deliveries (driven by compensation package for the delivering woman and ASHA worker) they have resulted in side-lining other important areas like immediate post-partum contraception that ensures sustained maternal health. In addition, the inadequate staff and lack of space in many facilities frequently lead to most women being discharged from the hospitals within four to six hours of delivery with little follow-up on infection rates. Emergency obstetric care (EmOC) thus continues to be a challenge in public and private facilities in rural India, especially at the field level. The government has recently amended policy to allow staff nurses and ANMs to initiate treatment of pregnancy-related complications, including intravenous fluids and injectable oxytocics, antibiotics, and magnesium sulphate—that were earlier restricted to administration by physicians. Post-natal care is a critical component of maternal and new-born health that has huge implications for standardised quality of care. Immediately af-
ter birth, bleeding and infection pose grave risk to the mother’s life; preterm birth, asphyxia and severe infections threaten the life of a new-born contributing to two-thirds of the neonatal deaths. Appropriate postnatal care critical to reducing maternal and neonatal problems is unfortunately one of the most neglected components of maternal care in India. Data from NFHS-3 shows that only 42 per cent of women surveyed received postnatal care after their most recent delivery. Another quality control red flag in the field of RMNCH is related to efficient implementation of family planning methods. While it is estimated that about 140,000 to 150,000 maternal deaths can be prevented worldwide through efficient family planning (FP) measures, current practices for family planning continue to remain outmoded. About eight per cent of maternal deaths are attributed to unsafe abortions in India and the practice of incentivising health workers to encourage mostly vulnerable women to accepting invasive sterilisation methods has led to the neglect of spacing, use of contraceptive pills and other contraception methods. Data reveals that spacing methods and use of contraceptive pills are provided mainly by the private sector. The public system, which is still the major provider of family planning services, especially for the poor, must be strengthened to improve the choice and methods for delivering safe good quality services. Standards in maternal health care cannot be raised unless the health system guarantees good quality care that follows a consistent and continuous uptake of maternal health services across the country. As mentioned earlier, im-
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SPECIAL: WORLD BREASTFEEDING WEEK proving standards in quality has to be a driving force in restoring public faith in public health facilities which have a long been associated with poor quality services. Why is this? – A common rationale is that public sector services invariably serve the very poor, uneducated and those that simply have no recourse to pay for their healthcare. Yet, is poverty an excuse for poor quality? Looking at our current public system, it seems that way. Even the recent Planning Commission report acknowledges that fact the government run facilities are characterised by high levels of absenteeism, poor availability of skilled medical and para-medical professionals, callous attitudes, unavailable medicines and inadequate supervision and monitoring. Factors like privacy, waiting time and average time devoted to each patient which influence patients perception of the type of care provided should be considered to improve the quality of RMNCH and primary healthcare services in India. To monitor the impact of primary healthcare and ensure quality of RMNCH services, comprehensive health information systems must be developed. The widespread availability of information technology should be well leveraged by the primary healthcare system in far more innovative ways. Quality measures that systematically evaluate and monitor quality of services provided at the primary healthcare level are fundamental for the success of any programme. So, what are some of the solutions to address quality issues in primary health and RMNCH services in our health system? The first is of course at the policy level: designing interventions based on evidence supported by micro-level planning, consistent monitoring and calibrated evaluation. This of course involves drastically improving bureaucratic inefficiencies and creating accountable management structures, all systems level changes that will invariably take time. The second option is to harness technology to assess quality with robust measurement of processes, outcomes and costs as part of a broader strategy that tracks the
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To monitor the impact of primary healthcare and ensure quality of RMNCH services, comprehensive health information systems must be developed health of a population. Health quality outcome measures will allow state government policy makers to decide when additional resources need to be spent on direct healthcare (i.e. improving access) and when they need to be spent ensuring that the care is good (i.e. quality). Making quality-related data subsequently publicly available will reduce the risk of extra spending being wasted by corrupt systems. At the primary healthcare level, management practices and provider effort are impor-
tant determinants of quality of services provided. However, healthcare quality is not a single product, it is made up of unusually diverse components that could range from cervical cancer screening, dispensing a medication or performing a minor surgical procedure. Making matters even more complex, the steps in the process to achieve a good outcome are frequently not well specified or mutually agreed upon. In order to measure health care quality, it is necessary to balance the competing viewpoints of many
players in the healthcare system. This challenge can be broken down by using technology to measure quality across three dimensions: ◗ Structure ◗ Process and ◗ Outcomes Structure refers to the infrastructure elements of a healthcare delivery system that promote or prevent access to and provision of services. Process refers to what occurs during the patient-provider interaction, and consists of both technical (the appropriateness of an intervention) and interpersonal excellence (the humane and responsive nature of the care provided to a healthcare seeker). Outcome, the third dimension of quality, refers to the effect of the care on the health status of both patients and populations; it includes efforts to prevent, diagnose, and treat health problems, and is often viewed as the ‘bottom-line’ of healthcare quality assessment. Embedding technologies like telemedicine within existing primary health and RMNCH infrastructure can be applied to evaluate and standardise quality of care functions like patient safety, sterilisation and infection control, procedural checklists and provider accountability in especially in more remote rural areas that have fewer healthcare facilities. Telehealth tools are ideal to address quality of care issues associated with health facility condition and access, administration, health data storage and exchange as well as patient and provider training and education. The scope of decision support technologies should also be explored in assessing the impact of quality metrics on consumer choices in RMNCH. These technologies are being used to screen patient referrals, examine laboratory investigations and develop procedural guide-lists that can be monitored across various levels of care, counselling or treatment based on the patient history and serve as triage and increasing patient-provider contact time. The real strength of technology for quality assessment lies in its potential for use among the non-physician providers and allied health professionals who
form a large part of RMNCH care in the country today. Mobile device technology can also part of low-cost solutions towards enhancing transparency in healthcare facilities and in improving reporting mechanisms where none exist. The Swasthya Slate developed at Public Health Foundation of India is a successful example of harnessing the potential of mobile devices to build capacities of front line health workers in provision of care and simultaneously addressing quality of care issues at the frontline, empowering policy makers who have access to real time data collected by health workers. The slate has applications that cover key aspects of RMNCH care that includes antenatal care, intra-natal care, post-natal care, immunisation and adolescent health. Finally, technology is only one aspect of the solution to enhancing quality of care in the country. No technological innovation can be a standalone. What we need is a mix of sound health policy that emphasises on quality of care and programmes that ensure it is complemented by validated technological innovations. By not choosing to consciously invest resources to measure and ensure health care quality India is creating huge risk for the future of its health sector. If the country is to travel the road to achieving Universal Health Coverage and access without concurrently focusing on quality, it may likely waste an immense amount of resources and lives. References ◗ National Sample Survey Organization (NSSO). NSS 60th Round, NSSO, New Delhi: NSSO, Govt. of India; 2006. Available from: mospi.nic.in/nspb_m.htm. ◗ UNFPA.(1994): The State of World Population. UNFPA, New York. ◗ UNFPA.(1995): The State of World Population. UNFPA, New York. ◗ Nair H, & Panda R. Quality of maternal healthcare in India: Has the National Rural Health Mission made a difference? Journal of Global Health. 2011; 1(1), 79–86. Available from: http://www.ncbi.nlm.nih.gov/pm c/articles/PMC3484741/#
STRATEGY I N T E R V I E W
‘There is an immediate need to improve services at blood banks’ Dr Bhupendra Kumar Rana, Joint Director-NABH, Quality Council of India; and ChairmanISQua Accreditation Council details the measures needed to get NABH accreditation for blood banks and elaborates on the best practices to be implemented for enhancing blood banks standards in the country, in an interaction with Lakshmipriya Nair
What measures should be implemented to get blood bank accreditation? NABH accreditation standards for blood banks/centres and transfusion services are divided into eleven clauses and each clause has been further divided into several sub-clauses. They are as follows: ◗ Organisation and management: The blood bank/blood centre should be a legal identity and must have a valid license from the Central Drugs Standard Control Organization (CDSCO) and approval by the Drug Controller General (India). The blood bank is required to define its organisational structure in terms of various positions and their functions. ◗ Accommodation and environment: The premises, used for the operation of a blood bank/blood centre and/or preparation of blood components should be constructed in such a manner so as to permit the operation of the blood bank/blood centre and preparation of blood components under hygienic conditions and should avoid entry of insects, rodents and flies. It should be well-lighted and ventilated. The blood bank/blood centre should be designed for the efficiency of its operation, to optimise the comfort of its occupants and to minimise the risk of injury and occupational illness. ◗ Personnel: The blood bank/blood centre is required to employ an adequate number
of individuals qualified by education, training and experience. Its operation should be conducted under the active direction and personal supervision of competent technical staff. Qualification and experience for Director/incharge/medical officer/incharge, supervisors, technicians and nurses must be at the minimum as required by the licensing authority. ◗ Equipment: The blood centre must be in the possession of all the equipment required for blood collection, component preparation, processing, examination and storage, appropriate as per the scope of licence. It is a must that equipment are properly calibrated, maintained, and monitored for their functioning and kept in a clean and proper manner and so placed as to facilitate regular cleaning and maintenance. To protect the equipment from damage and improper use, only authorised personnel should operate them. ◗ External services and supplies: There must be documented policies and procedures for the selection and use of purchased external services, equipment and consumable supplies that affect the quality of its services. There should be procedures and criteria for inspection and acceptance/rejection of consumable materials. All supplies and reagents used in the collection, processing, compatibility testing, storage and distribution of blood and blood components should be
Accreditation can play an important role in ensuring high quality and safety in blood bank practices stored at a proper temperature in a safe and hygienic place. A proper inventory control system should be in place. ◗ Process control: The blood bank/blood centre is required to have policies, processes and procedures to ensure the quality of the blood, component, derivatives and services, and ensure that these policies, processes and procedures are carried out under controlled conditions. There should be a mechanism to identify who performed each critical step in collection, processing, compatibility testing and transportation of
blood, component and derivatives issued, and when it was performed. ◗ Identification of deviations and adverse events: The blood bank/blood centre is required to implement a defined policy and procedure when any aspect of its test analysis or function does not conform to laid down procedure. It allows blood bank to identify deviation, if any, caused in its operations and take necessary measures. ◗ Performance improvement: The blood bank/blood centre must put a policy and procedure in place for addressing complaints, or other feed backs received from donors, clinicians, blood camp organisers or other parties. These can be used as improvement tools. ◗ Document control: Blood bank/blood centre must define document and maintain procedures to control all documents and information (from internal and external sources) that form its quality documentation. ◗ Records: All records relevant to the quality management system are uniquely identified and appropriately labelled. Policies, processes and procedures to ensure that records are identified, reviewed, retained and that records are created, stored, and archived in accordance with record retention policies ◗ Internal audit and management review: Management review and internal audits of all elements of the system, both managerial
and technical, is to be conducted at regular intervals but not less than once in twelve months in order to verify that operations continue to comply with the requirements of the quality management system. How can quality standards be maintained postaccreditation? Accreditation is usually based on self-governance and improvement. It should not be subjected to policing, however to ensure that accredited blood bank continuously comply with the accreditation requirements, regular surveillance at mid cycle i.e. between 15-18 months of accreditation is conducted. Further, there is a provision of surprise checks conducted on randomly selected accredited organisations including blood banks. Each month, one facility is selected for such checks. Special visits may be conducted based on complaints or reports. NABH has recently defined following ten quality indicators for blood banks to monitor. Of these, first five are mandatory to monitor and report to NABH every six months. It will help NABH and blood banks to keep an eye on improvement being demonstrated and compliance to standards. ◗ TTI rate ◗ Adverse transfusion reaction rate ◗Wastage rates ◗ Turnaround time (TAT) of blood issues Continued on page 38
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STRATEGY REPORT
Support Elders launch innovative tech-support to aid geriatric population Launched the unique initiative to serve during medical emergencies Joy Roy Choudhury Kolkata
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ecent estimates suggest that people in the 60-plus age group in India will increase to touch 198 million in 2030. The geriatric population will increase to 12 per cent of the total population by 2025, 10 per cent of whom would be bedridden, requiring utmost care. Hence, providing geriatric care to these senior citizens would be a major challenge. “Nowadays, we have often noticed that aged people are left alone in their houses as their children had to shift their base due to their professional commitments. These hapless people are left at lurch when they need urgent medical attention. So we decided to set up this organistion,” said Apratim Chattopadhyay, Co-founder, MD & CEO of Support Elders, a one-of-its
kind social entrepreneurship initiative launched recently in Kolkata for providing customerdirected-at-home support for elderly population. "The biggest fear that the elderly have is the fear of an emergency which inhibits their day-to-day life," said Chattopadhyay. He, along with two other founder members, launched this initiative to serve the city's elderly by leveraging technology and a promise for speedy removal to a partner hospital in case of a medical emergency. Chattopadhyay said, “Each subscriber registering with us is provided an imported smartwatch for continuous wear. The smart watch has three pushbuttons, by pressing any one of it, one can send an alert to the company's National Alarm Centre located at Salt Lake's IT hub, along with his/her GPS location and the unique code number of the smart watch. The built-in
loudspeaker and microphone in the smart watch, also allows the subscriber to speak directly to the alarm centre executive for any assistance – the number of which is preset. If someone presses the button but is unable to speak to the operator, then the operator will call him/her back. If the operator does not get any response she will trigger the Member Care Associate who will be pressed into the service'. “We have divided and sub-divided the entire city into 21 zones/beats which are handled by different member care associates (MCAs) who will reach the emergency site using the latest GPS tools at the least possible time, intervene and arrange for the ambulance and admit the member to the nearest partner hospital in case of any medical emergency. We are in the process of tying up with leading hospitals in each zone of the city. We also have a protocol in place about whom to reach for spare keys in case the member is unable to open the door,” explained Brig Satyesh Nath
Bhaduri, COO, Support Elders. “Our protocols are designed in such a way so that the entire process is completed with an hour (the 'Golden Hour' as per medical parlance). But we are conducting drills on a regular basis to cut down on the time taken,” said Brig Bhaduri. Besides the Medical Emergency Alert Solutions (MEAS), Support Elders also offers 'Care Management Services', which allows remote medical monitoring as well as monitoring of pre-defined virtual boundaries for Alzheimer's patients, task reminders and notification receiver; and a fall and movement sensor. In addition to this, the MCAs visit the member once a week for health monitoring and helping him/her with day-to-day, out-of-home chores to help the member function independently in society. Through the 'Companionship Services', it aims to be in regular touch through one-to-one sessions to assist members to be mentally and physically active and stay connected. Professionally qualified
caregivers with elderly care orientation are provided. Support Elders has also devised attractive subscription packages for the members. It charges a nominal security deposit for the smart watch and promises to pay it back in case any subscriber intends to leave. “Our team consists of retired military personnel, mostly from Army Medical Corps, who are very compassionate to the cause of the elders and visit the member every week to check on the device. These people are pressed into action during medical emergencies. While on their weekly visits, these personnel also offer other support services like buying groceries, medicines or depositing a cheque in the bank of the member,” said Chattopadhyay. Commenting on future plans, Chattopadhyay said, “As we are only few months old and would now like to concentrate more on the quality aspect. After we capture a sizeable market share in Kolkata, we shall branch out to other parts of the East and the country.”
tested for essential parameters e.g. HIV, HCV, malaria etc. and if transmitted to a patient, results may be deadly. The commitment of the management to provide safe blood and adopting safe transfusion practices is critical and essential area to give importance to improve standards.
very difficult to rope in blood banks. However, NABH has drawn a strategy to bring more and more blood banks under its accreditation programme. This includes conducting awareness programmes, organising three days programme on implementation and liaising with National AIDS Control Organisation (NACO), Ministry of Health, Government of India. In addition, we try to encourage blood banks through our experts/assessors who communicate with blood banks on the benefits of accreditation.
Continued from page 37
Policy makers make... ◗ Component QC failures (for each component) ◗ Adverse donor reaction rate ◗ Donor deferral rate ◗ Percentage of components ◗ TTI outliers percentage ◗ Delays in transfusion beyond 30 minutes after issue- sample audit by BB every month. How can policy makers better blood bank practices? Blood banks needs to be licensed before starting its operations, therefore, strong regulatory regime i.e. licensing is important to ensure compliance to minimum
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requirements in terms of structures and some processes as laid out in D and C Act. Accreditation can play an important role in ensuring high quality and safety in blood bank practices. Policy makers should make use of accreditation to ensure high quality and safety in blood bank practices. Policy makers can make it happen by promoting importance of safe blood amongst blood banks. What is the need of the hour for Indian blood banks? There is an immediate need to improve services at blood
banks. Despite many claims, there are reports regarding lack of availability of required blood, wrong transfusion of blood to patient as well as infected blood. It is important that efforts are taken to increase the availability of blood by promoting voluntary donations. Proper use of blood is essential as one unit of blood may be used for more than one patient if its components are prepared. It is also seen that at times wrong blood group is transfused, leading to catastrophic incidents. Some times the blood is not properly
How can NABH encourage blood banks to get accreditated? There are 69 blood banks accredited by NABH in India. Being a voluntary process, it is
lakshmipriya.nair@expressindia.com
KNOWLEDGE I N T E R V I E W
‘We want to advocate for at least one concrete policy change with respect to people affected by leprosy’ The Government of India claims that the country has been able to eliminate leprosy as a public health threat in 2005. However, the Disabled People’s International (DPI) has a different story to tell. Javed Abidi, Chairperson, Disabled People’s International reveals that India is one of the high endemic countries of leprosy and people affected by it are often ignored when it comes to disability rights in India, in an interview with Raelene Kambli. Excerpts:
What are the statistics on leprosy in India? What are the disability rate related to India? India declared elimination of leprosy as a public health problem in December 2005 indicating that at a national level there were less than one per 10,000 cases on treatment (as per the government statistics). WHO defines elimination of leprosy as a prevalence rate of less than one case per 10,000 persons. Yet, official figures from 115 countries show the global registered prevalence of leprosy at 189,018 at the end of 2012 and during the same year, 232,857 new cases were reported. As per the Weekly Epidemiological Record – September 5, 2014, WHO and NLEP‘Progress Report for the year 2013-14 ending on March 31, 2014’, Central Leprosy Division, Directorate General of Health Services, New Delhi, following are some statistics: ◗ 58.85 per cent of new leprosy cases in the world are in India ◗ 1.27 lakh new cases of leprosy were reported in India during 2013-14 ◗ 12,043 new cases of leprosy during 2013-14 were children. In 13 states/UTs, more than 10 per cent of new cases detected
were children ◗ 46,845 new cases of leprosy during 2013-14 were women. ◗ A total of 86,000 (0.86 lakh) cases are on record as on April 1, 2014, giving a prevalence rate (PR) of 0.68 per 10,000 population. What is the condition of people effected by leprosy in India? What about laws for their rights? I feel it is pertinent to mention that despite the World Health Assembly’s enthusiastic adoption in 1991 of a resolution to ‘eliminate leprosy as a public health problem by the year 2000,’ it remains an important cause of global chronic neurological disability. ◗ In India, a strong stigma is attached to leprosy and people affected by leprosy are often discriminated against. People affected by leprosy are prevented from accessing community resources (e.g. water) or marrying individuals who do not have leprosy and are excluded from festivals, religious areas, employment, education and even healthcare facilities. ◗ People still believe that leprosy is a divine punishment for past sins and immoral behaviour.
We feel that the voice of people affected by leprosy has been neglected by government and the disability movement for long now
◗ Even educated persons can become victims of misconceptions about leprosy. ◗ Worse still, the rights of those affected by leprosy and their families, continue to be violated even now. ◗ Numerous national and state laws contain discriminatory provisions against people affected by leprosy, including prohibiting people affected by leprosy from contesting elections, obtaining a driving license and travelling in trains. The laws also allow leprosy as grounds for divorce, meaning a person affected by leprosy can lose their home, belongings and access to their children. Many legislators, legal bodies and members of the government are not aware of the existence of discriminatory legislation or its devastating impact on people affected by leprosy, therefore concrete action has not been taken to end these practices. You say that there are 10 to 15 laws in the country which are discriminatory towards people affected with leprosy. People affected with leprosy can be divorced, be denied property, etc., on the basis of these laws. Can you shed some light on this issue?
In India, we still have draconian laws that emerge from the Lepers Act of 1898. There are nine laws that have direct discriminatory provisions: 1. Hindu Marriage Act, 1955 [Section 13(1)(IV)] gives grounds for divorce if a partner has been suffering from leprosy for at least three years. 2. Dissolution of Muslim Marriage Act, 1939 [Section 2(VI)] grants divorce if the spouse is suffering from leprosy. 3. Indian Divorce Act, 1869 [Section 10] states that a marriage can be dissolved on the grounds that a partner has been suffering from leprosy for at least the previous two years. 4. Indian Christian Marriage Act, 1872 states that a marriage can be dissolved on the grounds that a partner has been suffering from leprosy. 5. Hindu Special Marriage Act, 1954 [Section 27(g)] states that divorce can be granted if a partner has been suffering from leprosy. 6. Special Marriage Act 1954, [Section 27 (1)(g)] states that divorce can be granted if a partner has been suffering from leprosy for at least three years, the disease not having been Continued on page 41
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KNOWLEDGE INSIGHT
Transcatheter therapies: Improving cardiac care
DR UDAY KHANOLKAR Senior Consultant Cardiologist, Narayana Health City
Dr Uday Khanolkar, Senior Consultant Cardiologist, Narayana Health City gives insights on the evolution of novel transcatheter therapies for cardiac care
N
ovel transcatheter therapies for valvular heart disease have developed tremendously over the past decade. These innovative interventional methods are largely modeled from established surgical heart valve procedures, which have started to evolve to less-invasive approaches. Until a decade ago, interventional valve procedures included only balloon pulmonary, aortic, or mitral valvuloplasty, serving highly selected patients. In 2002, percutaneous valve therapy advanced greatly with the first catheter-based aortic valve replacement (AVR) procedure. Since then more than 55000 high-risk patients have had percutaneous aortic valve replacement worldwide. Symptomatic aortic stenosis (AS) carries a poor prognosis. Medically treated patients with symptomatic AS have a one and five-year survival of 60 per cent and 32 per cent, respectively. Conventional open heart surgery is the first-line therapy for symptomatic aortic stenosis. In the ideal candidate, surgical AVR has an estimated operative mortality of four per cent. However, the mortality rate associated with AVR increases substantially with increasing age, the presence of left ventricular dysfunction, or other comorbidities. These factors are considered one of the main reason for which one-third of patients with valve disease are not referred for surgery. Percutaneous transcatheter
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aortic valve implantation (TAVI) opened the possibility of treating patients who until now had been left untreated because it was believed that their operative mortality outweighed the benefits offered by traditional AVR. Percutaneous heart valves are stent-based xenografts that are collapsed onto a catheter and are expanded at the time of implantation. Procedure is performed in a catheterisation laboratory, usually by placing a sheath in the femoral artery. The prosthetic stent valve is mechanically crimped onto a balloon catheter immediately before implantation. With a steerable guiding catheter, the balloon-mounted valve is passed retrograde through the aorta and positioned within the native aortic annulus. Positioning is confirmed by fluoroscopy, aortography, and trans-
esophageal echocardiographic imaging. The delivery balloon is then inflated to expand the valved stent, thereby excluding and compressing the native aortic valve. The transapical approach is the most recently developed form of transcatheter AVR. The procedure involves a small left lateral thoracotomy and is performed in a hybrid operative suite. It requires a direct puncture and sheath insertion into the left ventricle. Patients who require AVR but have a ‘porcelain aorta’ or have peripheral vascular disease should be considered for the transapical approach. None of the procedure requires cardiopulmonary bypass or a sternotomy, and the femoral approach may not require general anesthesia. Because they are delivered via a catheter, percutaneous heart valves have the potential advantage of lower perioperative mor-
bidity; mortality and lesser hospital stay (three to four days) than valves implanted using conventional surgical approaches. The procedure is reserved for those people for whom an open heart procedure is too risky. For that reason, most people who have this procedure are in their 70s or 80s and often have other medical conditions that make them a better candidate for this type of surgery. Although a variety of mitral valve (MV) transcatheter therapies grew in parallel with aortic valve therapies, the MV therapies have had a slower development path. Challenges arising from the complex anatomy of the MV and mitral apparatus and the interplay of the MV with the left ventricle (LV) contribute to the greater difficulty in conceiving of and evaluating mitral devices. A
number of transcatheter MV therapies have been adapted from surgical techniques and are being applied in patients at high-risk for surgery as a result of coexisting comorbidities. Among all catheter-based mitral therapies, the leaflet repair MitraClip system to date has the largest clinical experience worldwide, with established and reproducible safety profile and effective reduction of MR with amelioration of symptoms and improved quality of life in high-risk surgical patients. The MitraClip is a mechanical clip that permanently opposes the middle of the anterior and posterior mitral leaflets. The procedure is performed in the cardiac catheterisation laboratory in the beating heart, under general anesthesia, and with fluoroscopic and transesophageal echocardiographic guidance. Globally, the MitraClip has been used in more than 10,000 patients to mechanically reduce MR without the incisions and cardiopulmonary bypass needed for MV surgery. Although initial MV trials included patients with low to medium surgical risk, current usage and evidence suggest that a primary role for the MV device may be to treat symptomatic MR in patients who are either unsuitable or at high risk for MV surgery. The development of percutaneous MV replacement devices is in its early stages. The challenges for mitral replacement are more
KNOWLEDGE complex than for the aortic valve, and it is clear that the development and testing of these devices will take more time than with transcatheter aortic valve replacement. Device delivery and anchoring and the large size and eccentric geometry of the mitral orifice are the main complexities. It is important to emphasise that these novel percutaneous techniques are not meant to replace surgical techniques in low-risk patients who are good candidates for surgery. They can be an effective option to improve quality of life in patients who otherwise have limited choices for repair of their valve. Coronary angioplasty with stenting has revolutionised the treatment of coronary artery
Coronary angioplasty with stenting has revolutionised the treatment of coronary artery disease.The coronary stents have substantially evolved since their first use in 1980s and there are on-going studies to refine their design, structure and material disease. The coronary stents have substantially evolved since their first use in 1980s and there are on-going studies to refine their design, structure and material. Drug-eluting stents were a breakthrough in the development of stents, with their ability to significantly reduce restenosis rates and the need for repeat revascularisation.
Nevertheless, they are still associated with subacute and late thrombosis mostly associated with the polymer and necessitate prolonged antiplatelet therapy for atleast 12 months. Latest revolution in the field of interventional cardiology is the introduction of biodegradable stents, a stent that does its job and disappears. The rationale for a fully biore-
sorbable scaffold is to provide the vascular scaffold (similar to a stent) for a defined period after Angioplasty; but these scaffolds are then gradually resorbed, so that the vessel will be free of any caging and can regain its normal function. The absence of any residual foreign material and restoration of endothelial coverage would also reduce the risk of stent thrombosis and
the requirement for long-term anti-platelet therapy. Bioabsorbable implant stents can be used as a delivery device for agents such as drugs and genes, and will perhaps play a role in the treatment of vulnerable plaque. Also, bioabsorbable stents are compatible with MRI and MSCT imaging. Finally, it can help eliminate the concerns that a minority of patients have at the thought of having ‘an implant in their bodies for the rest of their lives.’ A number of different materials ranging from magnesium to a variety of polymers have been used to construct stents of different designs. Results from various trials show that bioabsorbable stents are the future of coronary artery disease treatment
Continued from page 39
We want to advocate .... contracted from the petitioner. 7. Hindu Adoption and Maintenance Act, 1956 [Section 18(2)(c)] states that a Hindu wife is entitled to live separately from her husband without forfeiting her claim to maintenance if he is suffering from Leprosy. 8. Prevention of Begging Act, 1959 allows detention of ‘lunatics and lepers’. 9.Life Insurance Corporation Act, 1987 [Section 12] specifies a higher premium for people with leprosy. There are seven laws that can be used against people affected by leprosy: 1. Indian Railways Act, 1989 [Section 56] gives railway authorities the power to refuse carriage to people affected by leprosy. 2. Motor Vehicle Act, 1988 [Section 8(4)] considers people affected by leprosy ineligible for a driving licence. 3. Maharashtra State Road Transport Corporation Act, 1980 prohibits people affected by leprosy in getting a driving licence in Maharashtra. 4. Bombay Municipal Corporation Act, 1888 [Section 421] 3 Every medical practitioner who
treats or becomes cognizant of the existence of any dangerous disease [or any case of continuous pyrexia of unknown origin of more than four days’ duration] in any private or public dwelling, other than a public hospital, shall give information of the same with the least practicable delay to the executive health officer. The said information shall be communicated in such form and with such details as the executive health officer, with the consent of the commissioner, may from time to time require. 5. Industrial Disputes Act, 1947 [Section 2] provides for termination of service of workmen on the grounds of continued ill-health, including people affected by leprosy. 6.Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 [Section 2] includes ‘leprosy cured’ under the term ‘Disability’, but not persons affected by leprosy who have not yet been cured. 7. Rehabilitation of Council of India Act, 1992 [Section 29©] does not cover all the disabilities associated with leprosy under its definition of ‘handi-
capped’. Your organisation has also started a campaign on this. Can you share the objective of this campaign and give an update on the efforts taken so far? We strongly feel that the voice of people affected by leprosy has been neglected by government and the disability movement for long now. There’s a direct connection between leprosy and disability and I am amazed that for so many decades, people affected by leprosy have not been integrated with the disability movement. Disabled People’s International (DPI) in collaboration with The Nippon Foundation and National Centre for Promotion of Employment for Disabled People (NCPEDP) has undertaken an initiative to include the voice of people affected by leprosy in the global disability movement, with a particular focus on India, and to advocate for a significant policy change vis-a-vis the rights concerning people affected by leprosy. Being the first global crossdisability DPO with an unparal-
lel reach in more than 150 countries, DPI in collaboration with The Nippon Foundation are making conscious efforts to bring greater visibility to issues concerning the rights of persons affected by leprosy. Our project is expected to have a two way impact. On one hand, DPI and the overall cross disability movement in the world would be strengthened by the participation of persons affected by leprosy in the larger global disability movement. On the other hand, the voices of persons affected by leprosy against discrimination and for equal rights would be strengthened with the support of larger disability community. The longterm effect would be reduced discrimination and increased awareness on the rights of persons affected by leprosy. In the long run, people affected by leprosy would be able to lead their life with dignity and as equal citizens. How do you wish to reach out to the government to fight for the rights of people affected by leprosy? We want to advocate for at least one concrete policy
change with respect to people affected by leprosy. ◗ We have formed a Core Group and a baseline report has been prepared. ◗ We are working towards creating a larger movement that will advocate against repealing of all the discriminatory laws. What kind of help do you wish from the healthcare industry? Leprosy is primarily a disease of the poor. Hence the steps needed are: ◗ Health education for self care and MDT compliance. ◗ Decrease health inequity due to poverty, especially in rural areas with limited access to healthcare. ◗ Address cultural myths and beliefs. Cultural aspects of leprosy affecting its control include traditional medicine and stigma. ◗ Sensitisation is required in all aspects, even in hospitals leaving no room for stigma that can lead to discrimination. The healthcare industry should play an important role in dispelling the social evils of the disease. raelene.kambli@expressindia.com
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DIAGNOSTIC SPECIAL
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NO RULES TO THE GAME The Indian diagnostic sector's poised for growth; however lack of regulations is a major deterrent BY RAELENE KAMBLI
I
n the last two decades, the Indian healthcare sector has taken several strides towards innovation and progress. With its innovative competencies and immense business opportunities, the healthcare sector in India leads the priority list of several global players. According to the India Brand Equity Foundation, the sector is expected to grow at a CAGR of 17 per cent during 2011–2020 to reach $280 billion. In India, private healthcare accounts for almost 72 per cent of the country’s total healthcare expenditure. The per capita healthcare expenditure is estimated to grow at a CAGR of 15.4 per cent during 2008–2015 to reach $88.7 by end of this year. Moreover, between 2012–2022, the diagnostic market is expected to grow at CAGR 20 per cent to $32 billion from $five billion in 2012. There are over 1,00,000 diagnostic laboratories across the country, of which 70 per cent offer pathology services and 30 per cent offer radiology and imaging services. Although corporate players such as Dr
Lal Pathlabs, Metropolis, SRL Diagnostics and Quest Laboratories are gaining a reasonable market share, major bulk of the industry is still fragmented and unorganised. This acts as a major detriment to the progress of the sector as it creates an uncertain business environment. Moreover, there are no specific laws regulating the industry, which is the root cause of this issue. While corporate players depend on accreditation from organisations like the National Accreditation Board for Testing and Calibration Laboratories (NABL) which is an autonomous body under the Department of Sci-
ence and Technology, and the College of American Pathologists (CAP), smaller players operate more like mom-and-pop shops in the absence of any binding regulatory norms. Only about one per cent of diagnostic labs functioning within the country have received accreditation.
Lack of regulation: A major issue Although the Government did pass the Clinical Establishment Act in 2011 to bring the diagnostic industry in its purview, the law is yet to be implemented. Again, the implementation of this Act rests with indi-
vidual state governments. Says Sanjeev Vashishta, CEO, SRL Diagnostics, “According to a study that SRL conducted this year, the size of the diagnostic industry including pathologies and imaging centres in India is worth $ eight billion. Nine per cent of this is run by SRL, which means we have 600 labs across India. But the biggest challenge we face is lack of regulations which allows the unorganised sector to mushroom freely.” Neeraj Raghuvanshi, Business Director-Preanalytical Systems- BD Diagnostics, BD India opines, “Diagnostic results play a very critical role in
healthcare delivery and almost 70 per cent of the treatment decisions are based on the test results. Timely and reliable diagnosis has a great positive effect in not just ensuring the correct treatment but also in bringing down the overall cost of healthcare. However, for such a crucial element of the healthcare delivery process, there is no specific regulatory framework that governs the diagnostic industry in India. Very limited entry barriers, with registration under the Shops and Establishment Act as the only criteria to start a lab has led to the proliferation of a large number of small labs with varying standards and practices. There is no established guideline that mandates minimum standards in terms of quality, technology, infrastructure and qualification of personnel for setting up and running a diagnostic lab. Accreditation is voluntary and the patient largely depends on the doctor or physician’s referral while making the choice of laboratory. So, the regulations that would drive quality, reliability and standardisation in pathology services in India need to be upgraded and
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DIAGNOSTIC SPECIAL updated.” Adding to this, Ameera Shah, MD and CEO, Metropolis Healthcare informs, “The Central Government has recently put in place a voluntary accreditation programme but no measures are taken to spread awareness on its importance. There are no inspections or quality checks that are mandatory.” This means that the industry is left to function on its own whims and fancies. What kind of harm can this situation cause to the industry and the people at large? No regulation leaves a lot of room for malpractices and over-pricing. “This is the most alarming part of the healthcare industry. In India, all it takes to open and run a medical laboratory is a 'Shops and Establishment license.' It can be operated without any permissions and quality control mechanism. Unqualified professionals, proxy signatories, sub-standard equipment and reagents combine to yield diagnostic results which may be a dangerous basis to initiate a treatment,” replies Abhimanyu Kumar, Co-Founder, Director and CEO, Preventine. “It took us several years to prove ourselves about the sophistry of the work we do, and today we test the samples coming from 11 countries, a few of them being developed nations in Europe. Had the baggage of being operative in a low regulated environment not been there, we could have reached these markets long before and moving faster than we are. The collective reputation of the country builds only on the correctness of the regulatory environment and more importantly, the implementation of the same. India has to work hard towards this. One doesn’t need to be a global player to face the bottlenecks; the lack of regulations affects you in several other small and big ways also. For example; one of the ways is that since the quality mechanism is not so strict for laboratories, even the vendors and suppliers of reagents and consumables adjust to the cozy environment. The sub-standard supplies
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make it to the laboratory system, thereby affecting the diagnostic results; and hence the treatments,” he adds. On the same lines, Shah says, “In India, laboratories are required to be registered with the respective health departments before setting up. There are no other checks. Quality of the personnel, equipment, systems and processes remain unchecked. The Indian Medical Council did issue an advisory that pathology reports need to be signed by a doctor. While that does add some amount of accountability and credibility, it would still not guarantee precision in results. Right from sample collection, to sample transport and registration, there are a variety of things that could go wrong with a sample even before it is tested. These are called preanalytical errors. From sample collection to report delivery, it is important to uphold highest quality standard in each step to ensure that the final report is error free. It is important to eliminate any human or machine made error because with each report, it is a person’s health and wellbeing at stake.” “Lack of regulations and low entry barrier has led to the proliferation of a large number of laboratories offering various degrees of quality and reliability with no specific minimum standard that the patient can expect. Huge fragmentation in the industry with only 10-15 per cent of the labs being ‘organised’ creates another big challenge of scalability of practice and process standardisation. Training and education efforts are also largely concentrated within the ‘organised’ segment of the industry. A large number of small laboratories in tier II and III towns are untouched by advancements in technology and practice,” adds Raghuvanshi. Lack of regulations not only taints the image of the industry but has an adverse effect on consumers too. Consumers, on the other hand, are circumspect about the rising and differing pric-
In India, all it takes to open and run a medical laboratory is a 'Shops and Establishment license.' It can be operated without any permissions and quality control mechanism
There are no rewards for voluntarily adhering to quality standards and no penalty for flouting these standards
Abhimanyu Kumar
MD and CEO, Metropolis Healthcare
Co-Founder, Director and CEO, Preventine
Lack of regulations and low entry barrier has led to the proliferation of a large number of laboratories offering various degrees of quality and reliability Neeraj Raghuvanshi Business DirectorPreanalytical Systems- BD Diagnostics, BD India
Ameera Shah
The biggest challenge we face is lack of regulations which allows the unorganised sector to mushroom freely Sanjeev Vashishta CEO, SRL Diagnostics
Lack of regulations not only taints the image of the industry but has an adverse effect on consumers too. Consumers also are circumspect about the rising and differing pricing policies applied for similar services by players
ing policies applied for similar services by players. Anoop Mehra (name changed to protect identity), a resident from Mumbai to whom this Express Healthcare correspondent spoke to, reveals that there is a huge difference of price when he gets a routine blood test done at a corporate diagnostic centre and a local centre owned by a pathologist. “The difference is as huge as Rs 2000-3000. This makes it difficult for me to make a choice as to which diagnostic centre I should get my test done,” he discloses. Like Mehra, there are many such consumers who are unable to evaluate the quality vis-a-vis the price. Shah agrees that differing price is an issue, but she justifies the industry as well. “The biggest challenge faced by the industry is the disparity in price and quality. Accredited laboratories invest more in giving a report that is accurate, which also comes at a cost. Most of these accredited laboratories are national reference laboratories, and owing to the huge volume and work load, it makes it possible for us to provide tests at an affordable price to the patients,” she explains. “There are no rewards for voluntarily adhering to quality standards and no penalty for flouting these standards,” she further highlights. “Cost of several high-end tests is a function of volume. With the fragmented nature of this market, the small and mid-size laboratories are either not able to provide the entire range of tests, or offer low-cost proxy tests which do not yield concrete findings. Quality control steps have a cost irrespective of the volumes. With low volumes, the cost of maintaining quality goes substantially up, which is why the smaller laboratories choose not to invest in the quality maintenance. The circle remains unbroken because the medical fraternity as well as consumers continue to remain fine with the results coming without an integral quality control process; either due to lack of
India vs global Some industry experts feel that that there are certain disparities between the Indian diagnostic sector and the other global markets. “Laboratories in most of the developed countries need to get licensed by fulfilling all criteria before going operational. In addition, since the markets are mostly organised, the players voluntarily go for more accreditations from independent bodies like CAP and ISO15189. Their entire ecosystem, which also comprises the consumer, has evolved such that the sub-standard laboratories can anyway not exist,” Kumar informs. Comparing our Indian ecosystem to another emerging economy i.e. Brazil, he analyses, “I feel that there are over concentrations in certain geographies and under servicing in others. If analogy is picked from one of the similar economies then even Brazil has got about 85-90 per cent of the industry well organised.” Kumar also cites the instance of Germany which has built up a brand for itself to the
extent that service takers across the world swear by their quality. “If the government actively works through a process of developing the brand for India by way of bringing a few, simple and sensible reforms, I am confident that we have very large opportunities to cater to,” he feels. So, what are the efforts taken by the industry? Is the industry joining hands to urge the government to enact laws to regulate testing labs?
Efforts taken so far Certainly! Even if the government has been overlooking the important issue of introducing regulations within the sector, industry experts have not turned a blind eye. SRL informs that industry bodies like FICCI and NATHEALTH have got together to frame some guidelines to regulate the diagnostic sector. They are already speaking with the government to review and introduce guidelines for establishing and running diagnostic labs in India. Further on, Raghuvanshi speaks about how BD, along with Dr Lal's Laboratories, have initiated an education programme for doctors, patients and technicians to enhance laboratory skills. “Regulations or conformance to standards creates a mindset change and builds a sense of urgency to improve on the current state. Within the industry, efforts are being made through outreach programmes to educate the prescribing doctors on the quality and reliability aspects of the laboratory and raise criticality of the diagnostic results in their eyes. While it is still limited, some large laboratories have also started communicating with the most important stakeholder i.e. the patient through mainstream media. Organisations like BD have been working with laboratories and industry associations to drive practice change, paramedical curriculum building and skill enhancement of laboratory personnel to help ensure better patient outcomes. Recently, BD India and Dr Lal’s Path Labs launched best practices in phlebotomy in Gurgaon to reduce lab errors and improve patient outcomes.
DIAGNOSTIC INDUSTRY INCLUDING PATHOLOGIES AND IMAGING CENTRES IN INDIA IS WORTH
$
8
billion
knowledge of laboratory quality management or for a fact that better results means higher costs. It is also the continuing rapport with the small laboratory next door that relationship comfort makes up for the uncertainty with the quality they have,” Kumar reckons. Certainly, Shah and Kumar have a point in saying that diagnostic centres that abide by quality control norms would invest huge sums in maintaining standards and using highend equipment. It also means that the cost of test would be high at such labs. However, in India, accredited high- end labs stand for only one per cent of the overall number. What about the rest? And does high quality always mean high prices? Then, the industry also keeps talking about affordable healthcare. How can one provide cost-effective services if there will be no efforts taken to bring down diagnostic service cost to economical rates? How do diagnostic laboratories abroad function? Do they have a similar issue?
1,00,000 DIAGNOSTICS LABORATORIES ACROSS THE COUNTRY,
70 36 PER CENT OFFER PATHOLOGY SERVICES AND...
PER CENT OFFER RADIOLOG YAND IMAGING SERVICES
Lack of regulations puts the industry on the brink of a crisis situation. Hence, corrective measures should be taken on an urgent basis This landmark initiative will provide certified phlebotomy courses to healthcare professionals, laboratory technicians, assistants and nurses, and support them in driving best practices in pre-analytical processes for accurate and reliable diagnosis,” he says.
For better times ahead Efforts like these are indeed appreciated. However, much more is needed from the government and industry as well. Lack of regulations puts the industry on the brink of a crisis situation and gives rise to malpractices. Hence, corrective measures should be taken on an urgent basis. Industry experts recommend measures for better times. “While there are many initiatives that the industry is driving, one of the big gamechangers would be the implementation of the Clinical Establishment Act in letter and
spirit. It is really important to have a census of what can be classified as a pathology laboratory – some basic guidelines around staffing, infrastructure, personnel, quality that gives the patient some assurance on the reliability of test results. Diagnostic tests are largely out of the scope of insurance. As the government moves towards giving universal health coverage, there should be recognised focus on preventive cover in addition to curative cover,” suggests Raghuvanshi. “A strict, well-regulated environment, well-monitored and most importantly, a forum where the decisions against faulty quality can be addressed in minimal time,” chips in Kumar. Shah sums up saying, “Organised laboratories and laboratory professionals have voiced their opinion time and again to bring in minimum quality standards to effect for
diagnostic industry. There is an urgent need for legislation. The NABL has done a commendable job in formulating a rigorous quality protocol in place. Health departments of all states need to work with NABL to bring more laboratories in the ambit of accreditation. Unless this is mandated, it is difficult to raise the overall quality standard of diagnosis in India.” All in all, there is no doubt about the potential of the Indian diagnostic sector to prosper in future. However, lack of regulations is a major deterrent. It adds to the cost, gives rise to malpractices and medical complications due to wrong diagnosis and even leads to high mortality. It is necessary for the government to intervene for added impetus to the burgeoning sector. A legislation is the need of the hour. raelene.kambli@expressindia.com
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LIFE
Results of India StartHealth Competition declared OmiX Labs is the winner with a hand-held portable device for vector-borne infection diagnosis and prognosis, and xBiTS is the runner-up with a table-top diagnostic device for faster and accurate detection of UTIs
U
nitus Seed Fund announced the results of its India StartHealth Competition. OmiX Labs emerged the winner for the invention of a hand-held portable device for vectorborne infection diagnosis and prognosis that is targeting to reduce the time and cost to detect infectious disease pathogens. Reportedly, the device could be deployed to the more than one lakh (100,000) diagnostics labs across India. “OmiX Labs has a great team and collaborators needed for the success of the project. Early stage disease detection in India is still at a very nascent stage and this product has the potential to be a new standard of care for infectious disease detection,” said A
Vijarajan, Founder and CTO, InnAccel and a StartHealth jury member. Omix will receive a prize of Rs 10 lakhs and an opportunity to pitch for participating in Unitus’ StartHealth investment Program that includes up to Rs 50 lakhs of additional non-dilutive funding, an investment of up to Rs one crore from Unitus Seed Fund and go-to-market support from StartHealth partners Narayana Health, Manipal Hospitals, PATH, Pfizer and Unitus Seed Fund. xBiTS was declared the runner-up for developing a table-top diagnostic device for faster and accurate detection of urinary tract infections (UTIs). The device can provide results as accurate as the high-
end microbiology devices and do so in under four hours. Similar to OmiX, the xBITS’s team is also working on solving the drug resistance problem by separating out and detecting specific pathogen species. “Very impressed to see a near commercial solution coming out of a university,” said one of the jury members, K Chandrasekhar, Founder and CEO at Forus Health. xBiTS will soon be pitching for entry to Unitus’ StartHealth investment Program with potential for additional funding and support from the StartHealth partner network. The competition received 130 applications, of which 10 health-tech start-ups participated in the final online pitches to an industry jury. The compa-
nies were assessed on several factors including the depth of innovation, business model, market feasibilty, leadership and impact. StartHealth Competition’s other finalists included: ◗ Nayam Innovations: Developing a Novel Intra Ocular Lens (IOL) implant for spectacle-free vision after cataract surgery ◗ Aindra Systems: Building an Affordable and portable, ‘point-of-sample-collection’ cervical cancer screening system that utilises pap testing ◗ Chikitsak: Building a bluetooth-enabled device that screens the vitals of subjects in remote area ◗ Cooey Tech: Connected smart devices that logs the medical records of the pa-
tients and helps connect to doctors ◗ Excocan Healthcare: Creating oncotechnology platform to deliver cancer diagnosis and imaging ◗ Matrikas Inc: Sensor-based kit for diagnosis of cervical cancer, HIV/AIDS and infections affecting women’s reproductive tract ◗ Pravarthan Technologies: Providing high-quality healthcare for the masses including micro-wireless ECG devices and cloud platform for remote specialist consultancy services ◗ Lifesense Medical Systems: Indigenously developed ECG monitoring device that can be installed at zero cost and charged on a per-patient basis.
PEOPLE
Dr Suniti Solomon, pioneer in HIV research and treatment in India, passes away She set up the first voluntary testing and counselling centre and an AIDS Research Group in Chennai while serving at the Madras Medical College DR SUNITI SOLOMON, whose team was the first to document evidence of HIV infection in India in 1986, recently died at her residence in Chen-
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nai. A pioneer in treating HIV patients since the 80s at a time when many physicians were reluctant, she founded the first voluntary HIV testing and
counselling centre, YR Gaitonde Center for AIDS Research and Education (YRG CARE), a premier HIV/AIDS care and support centre, in
Chennai. She was also the Professor of Microbiology at the Madras Medical College. At a time when the international journals had been writ-
ing a lot about the HIV outbreaks in the world in 1980s, it was the six blood samples she collected from female sexworkers sheltered at a govern-
LIFE
Dell Healthcare & Life Sciences appoints Dr Nick van Terheyden as CMO Dr van Terheyden will be responsible for providing strategic insight to help Dell advance its support of healthcare organisations, medical professionals and patients through information-enabled healthcare
ment home in Mylapore that sent first shockwaves of the deadly virus in India. Samples initially tested positive were sent to Christian Medical College (CMC) in Vellore as the facility for ELISA test was only available there in mid-80s. Later, samples were sent to the Johns Hopkins University in Maryland, US for further confirmation. The first findings of the deadly virus, in Tamil Nadu, was even read out in the state legislative assembly. She set up the first voluntary testing and counselling centre and an AIDS Research Group in Chennai while serving at the Madras Medical College and Government General Hospital as a Professor of Microbiology. She was also a member of the National Technical Team on women and AIDS and a member of the advisory board of International AIDS Vaccine InitiativeIndia, member of the Scientific Committee of the National AIDS Research Institute, Pune, Government of India, a permanent member on the Microbicides Committee of the Indian Council for Medical Research (ICMR) and member of the Asia Data Safety
A pioneer in public health and HIV related studies, she was part of several pioneering HIV research studies. She will be remembered as a doctor who dared to deal with HIV at a time when many physicians were reluctant to enter that field Monitoring Board of the Division of AIDS, NIH, USA. A pioneer in public health and HIV related studies, she was part of several pioneering HIV research studies including the US National Institute of Mental Health’s multi-country HIV/STD Prevention Trial, the US National Institute of Allergy and Infectious Diseases’ HIV Prevention Trial Networks, NIH award that will measure stigma in healthcare settings in Southern India, and a Phase III study of six per cent CS GEL, a candidate mi-
crobicide of CONRAD. She also served as the President of the AIDS Society of India. Among her colleagues and specialists, she is always remembered as a doctor who dared to deal with HIV at a time when many physicians were reluctant to enter that field. She used to recall an unforgettable case in which she treated a pregnant woman tested positive in 1992, who delivered a baby who also tested positive, although he later died at the age of 17.
DELL SERVICES has announced that Dr Nick van Terheyden, former Chief Medical Information Officer of Nuance Communications, has been named Dell Healthcare & Life Sciences Chief Medical Officer. As CMO, Dr van Terheyden will be responsible for providing strategic insight to help Dell advance its support of healthcare organisations, medical professionals and patients through informationenabled healthcare. He will report to Sid Nair, VP and Global GM of Dell’s Healthcare & Life Sciences (HCLS) Services business. “Dr van Terheyden’s unique combination of medical experience, business strategy and creativity make him the perfect addition to Dell. As Dell’s CMO, Dr van Terheyden will play a key role in providing our customers access to expertise that is crucial in navigating clinical issues and applying innovative solutions in an increasingly complex healthcare industry,” said Nair. Dr van Terheyden is wellregarded for his contributions to the evolution of healthcare technology. Reportedly, Dr van Terheyden will help Dell’s global healthcare customers develop a strategy and apply technology to achieve an IT environment that is interconnected, efficient and patientfocused. Prior to joining Dell, he served as CMO for Nuance, where he drove the company’s
Dr van Terheyden is well-regarded for his contributions to the evolution of healthcare technology healthcare strategy to improve healthcare utilising technology including speech recognition, medical intelligence and clinical language understanding. Dr van Terheyden has international experience in the Middle East, Australia, the UK, Malaysia and New Zealand. His career experiences include collaborations with top healthcare organisations including Philips Healthcare, Mount Sinai Medical Center, KPMG, Healthcare International and Shell. Additionally, he aided in the development of one of the first electronic medical records, served as a business leader in one of the first speech recognition Internet companies. He has several professional memberships including HIMSS, mHealth Executive Committee, AMIA and AMDIS.
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Practo appoints Anshumani Ruddra and Tarun Bhambra as product heads Would lead product teams to expand Practo into professional networking and prescription space respectively PRACTO, A healthcare platform, has announced the appointment of Anshumani Ruddra and Tarun Bhambra to lead new product teams to expand Practo into professional networking and prescription space respectively. Ruddra has a lot of experience in building world class product teams and create fantastic products that consumers love. His most recent role was to head up Tiny Mogul Studios at Hike, and he was also the game design lead on some award winning multi-player online games including Mafia wars and Café World. During his tenure, Tiny Mogul built
games like Shiva: The Time Bender - one of the first Indian made games to be featured on Google Play globally - and Dadi vs Jellies - winner of Game of the Year at NASSCOM Game Developer Conference 2014. Reportedly, as Product Head – Networks, Ruddra will build products that will help the nearly 200,000 healthcare professionals on Practo help connect and communicate amongst themselves. “Practo is on an incredible path to make a real difference to healthcare as it exists today. I am thrilled to join the team and build a game changing dedicated networking platform for
Anshumani Ruddra
Tarun Bhambra
healthcare professionals that allows them to seamlessly exchange ideas as well as gather peer opinion,” said Ruddra. Bhambra brings with him diverse experience across venture capital, consulting and operations with past roles at McKinsey and ITC. In his most
recent role, Tarun was the colead of healthcare investments at Matrix partners, a leading investment houses in India. As Product Head – Prescriptions, Bhambra will lead the product team at Practo to accelerate Practo’s march towards becoming a single health
app for all health and wellness needs of consumers. “I am excited to join the Practo team and help transform healthcare for billions of people around the world. Medication, though highly localised and unstructured today, is an important aspect of healthcare. I look forward to working with the incredible team at Practo to bring better experience to billions of people globally,” said Bhambra. “I am thrilled to welcome Anshumani and Tarun to the Practo team. They bring incredible cross domain expertise along with significant experience in building game changing products. With their leadership, I am confident Practo will further accelerate our march towards being the only healthcare app for consumers,” Shashank ND, Founder and CEO, Practo.
Bhavdeep Singh rejoins Fortis as its CEO He had also served as the Non-Executive Chairman of Fortis Malar Hospitals from March 2010 to January 2011 Fortis Healthcare has appointed Bhavdeep Singh as its new CEO. Welcoming the appointment, Executive Chairman, Malvinder Mohan Singh and Executive Vice Chairman,
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Shivinder Mohan Singh, said, “We are pleased that Bhavdeep will be taking on the mantle as our new CEO. Importantly, he brings continuity to the role and a proven track record with a successful previous innings at Fortis as CEO between 2009 and 2011. He is on familiar ground and has a deep understanding of the healthcare space, firsthand knowledge of Fortis, our culture and strategy. His deep experience in India and overseas in the retail and services sector will be particularly valuable as we relentlessly pursue our vision to create a world-class integrated healthcare delivery system, with a
focus on India.” Prior to his coming to Fortis, Singh was most recently with Ahold, a retailer, for almost five years and served on the company's executive board. While there, he was initially EVP HR and then went on to heading up US operations and new formats. Singh has also served as the NonExecutive Chairman of Fortis Malar Hospitals from March 2010 to January 2011. Speaking on his appointment, Singh said, “I am excited to be back in India and very excited to be back at Fortis. The Indian healthcare market is poised for rapid growth and Fortis, at an in-
flexion point, is strategically placed on its growth trajectory. With renewed vigour and focus on India, I see a substantial opportunity for value creation and our ability to deliver clinical excellence without compromise. I look forward to working with many of my old colleagues and together building an institution known for clinical excellence and distinctive patient care.” Singh is a seasoned professional, with over 30 years of experience and has held senior executive roles in HR, Retail & Healthcare. Prior to joining Fortis in 2009, he held Chief Executive roles with Reliance Retail and Spencer's.
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TRADE & TRENDS
Godrej Appliances tie-up with UK firm Sure Chill for medical refrigerators The refrigerators are designed to provide precise cooling for preserving vaccines used in immunisation programmes and for the storage of blood
GVR 50 AC
GODREJ APPLIANCES, in partnership with The UK-based The Sure Chill Company, has launched the 'Godrej medical refrigerators with Sure Chill technology'. These specialised medical refrigerators have been designed to provide precise cooling for preserving vaccines used worldwide in immunisation programmes and for the storage of blood in blood banks. Reportedly, Sure Chill's technology helps maintain the optimum temperature range of 2-8o C - a necessity for vaccine preservation and blood storage.
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GVR 100 DC
This refrigerator maintains its temperature even in case of power outages for as long as 8-12 days in ambient temperatures of 43°C. In regions without electric supply, the system can be teamed with solar power to deliver the same results, thereby, making it a perfect fit for global immunisation needs. Godrej, making its first foray into the healthcare space, has signed a technology transfer agreement with The Sure Chill Company (UK) to develop and manufacture these refrigerators for sale in India and
Sure Chill's technology helps maintain temperature range of 2-8o C a necessity for vaccine preservation and blood storage
neighbouring markets covering SAARC and MENA countries including Pakistan, Bangladesh, Bhutan, Nepal, Saudi Arabia, UAE among others. Commenting on the launch, Kamal Nandi, Business Head and EVP, Godrej Appliances, said, "Godrej Appliances has built its expertise in refrigeration over the years. The brand is synonymous with trust and is therefore, best placed to enter a category like medical refrigeration, which delivers critical care. In line with our commitment to a greener
planet, we are proud to state that the Godrej medical refrigerators are the world's first and only green ILR’s currently available.� Godrej Sure Chill will be available in two model variants, 100 litres- priced between Rs 1.35 lakhs to Rs 1.5 lakhs, and 50 litres-priced between Rs 65,000 to Rs 75,000. These medical refrigerators meet strict specifications laid down by WHO and are listed as performance, quality and safety standards (PQS) prequalified products on its website.
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.