VOL.10 NO.3 PAGES 68
www.expresshealthcare.in MARCH 2016, `50
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CONTENTS MARKET Vol 10. No 3, MARCH 2016
Chairman of the Board Viveck Goenka Sr Vice President-BPD
Neil Viegas Editor Viveka Roychowdhury* Chief of Product Harit Mohanty BUREAUS
DRIVING APUBLIC HEALTH REVOLUTION
Mumbai Sachin Jagdale, Usha Sharma, Raelene Kambli, Lakshmipriya Nair, Sanjiv Das Bengaluru Assistant Editor Neelam M Kachhap DESIGN National Art Director Bivash Barua Asst. Art Director Pravin Temble Senior Graphic Designer Rushikesh Konka Senior Designer Rekha Bisht Artists
The Indian Express Group and Express Healthcare, are organising Healthcare Sabha 2016 – The National Thought Leadership Forum on Public Healthcare.As a curtain-raiser to the event which will be held from March 4-6, 2016, we feature the vision of some key stakeholders to enhance public health in India| P26
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IOT HEALTHCARE MARKET TO GROW AT 43 PER CENT CAGR DURING 2016-2022: INFOHOLIC RESEARCH
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EXPRESS HEALTHCARE TO HOST FIRST EDITION OF HEALTHCARE SABHA AT HYDERABAD
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DY PATIL UNIVERSITY HOSTS CONFERENCE ON HEALTH AND HOSPITAL MANAGEMENT
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SIR HN RELIANCE FOUNDATION HOSPITAL CONDUCTS SYMPOSIUM ON UROLOGY
Vivek Chitrakar, Rakesh Sharma Photo Editor Sandeep Patil MARKETING Regional Heads Prabhas Jha - North
28 32
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‘WE HAVE 176 HOSPITALS WHERE WE GIVE TREATMENT FREE OF COST’ COMBATING NCDS: NEED OF THE HOUR
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‘KERALA IS THE THIRD STATE IN INDIA TO HAVE A SEPARATE DEPARTMENT FOR AYUSH’
REVITALISING PUBLIC HEALTH: A SHARED VALUE
Dr Raghu Pillai - South Harit Mohanty - East & West Marketing Team
INTERVIEWS
STRATEGY
KNOWLEDGE
Douglas Menezes Ambuj Kumar E.Mujahid Arun J Debnarayan Dutta
P12:DR ARAVIND R SOSALE Founder Director, Diacon Hospital, Bangalore
Ajanta Sengupta PRODUCTION General Manager B R Tipnis
P44: DR VICTOR D ROSENTHAL
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PERKINELMER REVS UP INDIA DIAGNOSTICS OPS
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MANAGEMENT OF TUBERCULOSIS: 10 COMMON PITFALLS TO AVOID
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TB AND INFERTILITY: AN UNHOLY NEXUS
IT@HEALTHCARE
Founder and Chairman
Manager Bhadresh Valia
P45:DR (PROF) SANTANU
Scheduling & Coordination
CHAUDHURI
Ashish Anchan CIRCULATION Circulation Team Mohan Varadkar
Chairman - Radiation Oncology, Nayati Healthcare
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HELPING HEALTHCARE DEVELOP A CURE FOR BIG DATA
Express Healthcare® Regd.with RNI no. MAHENG/2007/22045,Postal Regd. No. MCS/162/2016 – 18,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 © 2016 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
Debating public health priorities
A
recent release from the Department of Personnel and Training, Government of India stirred up a hornet's nest. The DoPT release had a worrisome line: "In the times to come, the DoPT will also chalk out a possible plan for exit of government sectors from hospitals, air services, etc and a sunset clause will also be attached to every new scheme." The release, which was a summary of points discussed at an internal meeting, was couched as an extension to the ruling BJP party's poll manifesto promise of "minimum government, maximum governance." In line with the clamour to privatise public sector units (PSUs), this was seen as the government's plan to do the same to the healthcare sector by selling off their interests in various public-run hospitals across the country. Fortunately, a clarification followed, with Jitendra Singh, Minister of State in the Prime Minister's Office drawing a distinction between 'rationalisation of government participation', which is being considered in certain sectors, and 'full privatisation.' In the final days before Healthcare Sabha, Express Healthcare's public health focused summit, planned for March 4-6, it is indeed reassuring to know that the government does not plan to wash its hands of the responsibility towards assuring that the public health needs of India's population are met. A certain distance may be a good thing, so that the government gets in healthcare professionals to do what they do best, i.e. treat patients. But ensuring equity and access to affordable healthcare should be the remit of elected representatives of any country. Be it India or for that matter, Australia whose Health Minister recently had to issue a similar clarification when it was reported that her government was in the process of privatising Medicare, the publicly
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Ensuring equityand access to affordable healthcare should be the remit of elected representatives of anycountry
funded universal healthcare scheme. She had to clarify that while there was a proposal to outsource the payment of benefits, her government would still be the deciding authority when it came to laying down doctor payments and patient rebates. Australia’s opposition party has vowed to "never accept the Americanisation of our health system," underlining the deep distrust of the private sector, at least when it comes to healthcare. So, what is the way forward? Governments have to cherry pick initiatives in order to ensure optimal distribution of limited funds. And bureaucrats may not be the best judge of healthcare outcomes. Will this year's Union Budget again prove to be a damp squib for the healthcare sector? And what are the innovative ways in which the public health sector can partner with private healthcare players? Will the public sector be brave enough to pull the plug on unsuccessful partnerships, like Karnataka's Health Minister's move to stop the Arogya Bandhu scheme? (See interview: pages 28-30) We hope that we will be closer to at least a few of the solutions at Healthcare Sabha. To get a peek into the some of the topics up for discussion, read our March 2016 issue and do not miss all the post event coverage in the April issue. This issue also has an in-depth analysis of the Startup India policy and its implications for healthcare startups. While analysts are still worried whether accessing the benefits of the policy hinge on the approval of a deserving startup by an inter-ministerial board, it will be a huge unnecessary road block. (See story: Startup India: Will it lead to Stand up India?, pages: 20-25)
VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com
QUOTE UNQUOTE
FEBRUARY 2016
Check out the online version of our magazine at www.expresshealthcare.in
HEAD OFFICE Express Healthcare® MUMBAI Douglas Menezes The Indian Express (P) Ltd. Business Publication Division 2nd Floor, Express Tower, Nariman Point Mumbai- 400 021 Board line: 022- 67440000 Ext. 502 Mobile: +91 9821580403 Email Id: douglas.menezes@expressindia.com Branch Offices NEW DELHI Ambuj Kumar The Indian Express (P) Ltd. Business Publication Division Express Building, B-1/B Sector 10 Noida 201 301 Dist.Gautam Budh nagar (U.P.) India. Board line: 0120-6651500. Mobile: +91 9999070900 Fax: 0120-4367933 Email id: ambuj.kumar@expressindia.com Our Associate: Dinesh Sharma Mobile: 09810264368 E-mail: 4pdesigno@gmail.com
‘Indian Railways will tie up with the Ministry of Health for ensuring an exchange between railway hospitals and government hospitals. Indian Railways will introduce ‘AYUSH’ systems in five railway hospitals. ’
‘Government committed to provide adequate facilities to secondary and tertiary healthcare in order to reduce the out of pocket burden on the citizens’ JP Nadda
Suresh Prabhu Union Railway Minister, Government of India
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Union Minister for Health and Family Welfare. Government of India
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Important: Whilst care is taken prior to acceptance of advertising copy, it is not possible to verify its contents. The Indian Express (P) Ltd., cannot be held responsible for such contents, nor for any loss or damages incurred as a result of transactions with companies, associations or individuals advertising in its newspapers or publications. We therefore recommend that readers make necessary inquiries before sending any monies or entering into any agreements with advertisers or otherwise acting on an advertisement in any manner whatsoever.
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MARKET
IoT healthcare market to grow at 43 per cent CAGR during 2016-2022: Infoholic Research Investment by government in IoT will impact healthcare services by improving its quality and in turn lead to further development of products and solutions INFOHOLIC RESEARCH, a global ICT market research and consulting organisation, recently published a study titled 'IoT Healthcare MarketGlobal Trends and Forecast – 2016-2022'. Infoholic Research predicts that the IoT solutions will have a positive impact on healthcare services, and with the government spending the healthcare delivery will improve. The research pre-
Driving the robust CAGR growth of 43.01 per cent is the foreseeable wide adoption of IoT solutions. There has been the emergence of self-care where people want to care for their health via devices such as Nike Fuel band, Google Glass, and Fitbit, and with proper integration of technologies, the healthcare system will become incredibly connected
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: Express Towers, 2nd Floor Nariman Point,Mumbai-400 021 : MONTHLY : Ms. Vaidehi Thakar : Yes : Express Towers, 2nd Floor Nariman Point,Mumbai-400 021 : Ms. Vaidehi Thakar : Yes : Express Towers, 2nd Floor Nariman Point,Mumbai-400 021 : Ms.Viveka Roychowdhury : Yes : Express Towers, 1st Floor Nariman Point,Mumbai-400 021 : The Indian Express (P) Ltd 2nd floor, Express Towers, Nariman Point, Mumbai 400021 : Indian Express Holdings & Entp Private Limited 2nd Floor, Express Towers,Nariman Point, Mumbai 400021 : Mr. Viveck Goenka & Mr. Anant Goenka 2nd Floor, Express Towers, Nariman Point Mumbai 400021 : Mr. Shekhar Gupta & Mrs. Neelam Jolly C-6/53, Safdarjung Development Area New Delhi 110 016
I, VAIDEHI THAKAR., hereby declare that the particulars given above are true and to the best of my knowledge and belief.
Date : 1/3/2016
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sd/VAIDEHI THAKAR Publisher
dicts the IoT healthcare market is expected to grow at CAGR of 43.01 per cent for the period of 2016-2022. “IoT healthcare market has huge potential in developing regions. Asia Pacific is one of the largest and a high growth market, and it becomes important how healthcare organisations adopt technologies and applications to improve healthcare outcomes and reduce the overall cost of healthcare,” said Biswo Ranjan Bal, Research Analyst at Infoholic Research. Driving the robust CAGR growth of 43.01 per cent is the foreseeable wide adoption of IoT solutions across regions. Most of the world’s regions are facing a formidable challenge to manage the rapidly increasing cost of healthcare. Despite an overall focus on cost containment, some markets are projected to experience rapid spending growth as public and private healthcare systems develop. There has been the emergence of self-care where people want to care for their health via devices such as Nike Fuel band, Google Glass, and Fitbit, and with proper integration of technologies, the healthcare system will become incredibly connected in the next few years. Tariq Shaik from Research
Operations of Infoholic Research said, “Integration of wellness devices-consumer and regulated medical devices with the existing healthcare ecosystem will change the way healthcare business is done.” The IoT healthcare market is divided into technologies and services. The technologies segment is again analysed by network technologies and applications technologies. The network technologies are further segmented to short range technologies and longrange technologies, which are equally vital top form a connected ecosystem of healthcare. The service market is analysed by consulting, integration and maintenance. The solution segment contributes to the majority of the market. The IoT Healthcare market is analysed by providers, payers, bio-pharma and medical devices. The medical devices segment is further segmented to wellness devices-consumer and regulatory medical devices. The wellness devices – consumer holds the key to a major disruption in the healthcare industry. The IoT Healthcare market is divided into North America, Western Europe, Asia-Pacific (excluding Japan), Central Eastern Europe (CEE), Middle East and Africa (MEA) and Latin America. North America has the largest share of the market and these countries are the early adopters of these information systems. AsiaPacific is one of the high growth markets which has immense potential for the market. The regions are further analysed by countries in the region which influences major spending on healthcare in the particular region.
MARKET I N T E R V I E W
‘We have the first universityrecognised centre for study of diabetology in India’ Dr Aravind R Sosale, Founder Director, Diacon Hospital, Bangalore speaks to M Neelam Kachhap about his diabetes speciality hospital as well as research and training in diabetes care How long have you been working in the field of diabetology? Diabetology is my passion and I have been working in this field for the last 27 years. Diacon Hospital was started on April 8, 1990. Why did you set-up a diabetes speciality hospital? Unlike other states/cities of India, Karnataka/Bengaluru never had a dedicated hospital for diabetes in the late 80s. In those days, starting a hospital for only a single disease was considered as unimportant; as a result of this neglect in the mindset, this critical necessity remained unaddressed. With changing times, things have evolved and more people are now coming forward to start dedicated centres for diabetes. I had started with a vision to ‘help people with diabetes’, and the mission is ongoing! What kind of investment is required to set-up a diabetes specialty hospital? Apart from the infrastructure, a good biochemistry lab, foot care department, radiology, cardiac testing equipment like TMT/ECHO and a full-fledged ophthalmology department are a must. Facilities for PG teaching should always be thought of, to teach young doctors to take up this speciality. We have the first university recognised centre for study of diabetology in India. Diabetes management is a shared approach model and involves nutritionists, diabetes educators, nurse educators,
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podiatric nurses and other staff, apart from the diabetes specialist doctor. More than the money, a lot of investment goes in terms of your time in training the staff to care for the patients.
succumb to cardiovascular death. In fact, the presence of diabetes multiplies the risk of cardiovascular disease by nearly two-fold, as compared to healthy adults.
What is the latest in diabetes management? In India, adults younger than 40 years of age are increasingly being diagnosed with diabetes. Even in such younger patients of diabetes, cardiovascular complications like diseases of the heart, kidneys, eyes or the nervous system may occur commonly, as highlighted in a recent study. This evidence underscores the ever understated need of continual adherence to diabetes care, and a sustainable adoption of healthy lifestyle. Newer medications are now also available, which may reduce the risk of cardiovascular death and heart failure in diabetes. Diabetes may take a toll on neuropsychiatric health! Long standing diabetes may influence the development of not only depression, but also conditions like Alzheimer’s and dementia which may impair the cognitive ability of the patient. Evidence hints towards the benefits of regular aerobic exercise, on improving cognition as well. Good use of technology simplifies many aspects in life, and diabetes management is no different. Multiple means are now available like apps and social media, which facilitate navigation through the journey of diabetes. Many new apps will help change
What are your plans for Diacon Hospital in the next five years? We started the hospital with the promise of ‘Affordable, Accessible and Accountable’ treatment to all our patients. We will continue to keep our promise as we expand the hospital from the existing 25 beds to 50 beds. The Department of Nephrology will start with affordable plans for patients on dialysis. We will continue our efforts with the state and central government to recognise the hospital for all their employees. We are planning ‘budget’ models to include patients of ESI and Arogyabhagya card holders. Over 100 patients with Type I diabetes are getting free treatment including insulin. These numbers will be increased. Young consultant doctors and those in training will be encouraged to do research on a regular basis along with teaching. We will ensure that 40 per cent of their time in the hospital is dedicated to research and teaching, which is the need of the hour. Success is for others to see and we have never chased it. Our motto is to make the ‘life of a diabetic patient sweet without sugar’ has been the motto!
We started the hospital with the promise of ‘Affordable, Accessible and Accountable’ treatment to all our patients.We will continue to keep our promise as we expand the hospital from the existing 25 beds to 50 beds ‘behavioural pattern’ in days to come for patients who lack support system. At the same time, it is imperative to differentiate good technological assistance from abuse of technology. Overreliance on Dr Google may have its own negative aspects. Among all the complications related to diabetes which ones are life-threatening and
can these complications be avoided or treated? Vascular complications like heart/brain/kidney diseases, as well as non-vascular complications like infections, are essential considerations in diabetes management, and can be life-threatening. However, cardiovascular disease is the leading cause of death in patients of diabetes. A half to three-quarter of patients,
mneelam.kachhap@expressindia.com
MARKET PRE EVENT
Express Healthcare to host first edition of Healthcare Sabha at Hyderabad Central and state-level policymakers would congregate at the event to deliberate on cohesive, unified and innovative ways to achieve the vision of the National Health Mission IN KEEPING with the objectives of the National Health Mission pertaining to ‘Universal Access to Equitable, Affordable and Quality Healthcare Services’, The Indian Express Group and Express Healthcare are organising Healthcare Sabha 2016 – The National Thought Leadership Forum on Public Healthcare. The first edition of Healthcare Sabha will be held from March 4-6, 2016 at Hyderabad Marriott Hotel and Convention Center. The forum will deliberate on cohesive, unified and innovative ways to achieve the vision of the National Health Mission. Key subjects at the forum would include ◗ Models of financing public healthcare to aid the masses ◗ Usage of ICT in the public healthcare delivery model ◗ The role of frugal innovations in medical technology ◗ Skill enhancement programmes to bridge the workforce deficit ◗ The expanding role of NGOs’, Foundations’ and corporate hospitals’ outreach programmes The event will also host the Express Public Health Awards honouring the visionaries, innovators, and game changers from public healthcare. Public Health Foundation of India (PHFI) will be the Knowledge Partner to the Awards. Dr K Srinath Reddy, Founder and President, PHFI, is the Chairperson of the jury. The categories for the Express Public Health Awards 2016 will
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■ Innovation in increasing affordable access to medicines, vaccines, medical products and technology ■ Innovations in health information systems for population health assessment/quality improvement/increasing transparency and accountability ■ Innovations in human resource for health ■ Excellence in leadership, stewardship and governance at the state level
◗ Express Public Health Award to the Most Effective Public Private Partnership in: This award celebrates state governments which have managed successful, sustained partnerships with the private sector ■ Healthcare infrastructure ■ Diagnostics ■ Human resource for health
be as follows: ◗ Express Public Health Award to the Most Efficient State/Institution in management of: This category aims to recognise and acknowledge state governments which have been the most proactive and efficient in initiating public health programmes and utilising public funds to meet the population’s health needs. The jury would take into account the scope and impact of the project in terms of size of popu-
lation covered, etc., defined measurable outcomes. The subcategories in this segment are: ■ Infectious diseases ■ Non-communicable diseases ■ Reproductive, Maternal, Neonatal, Child and Adolescent Health ■ Excellence in Public Health Service Delivery (in terms of covering greater population and increased range of services through the health system) ■ Innovation in Financing for Health
◗ Express Public Health Award to the Most Effective Healthcare NGO: This category aims to recognise and celebrate the work of registered NGOs which have contributed to identifying and solving healthcare challenges on a local, regional or national level for a minimum of five years. Nominations will be evaluated on the outcomes and scope of their work. The sub categories will comprise: ■ Healthcare for rural poor/urban poor/migrant population ■ Tribal health issues ■ Social empowerment models ■ Women and Child Health ■ Healthcare for elderly and differently abled people
◗ Express Public Health Award for Most Effective Health Technology Systems: This category aims to recognise and celebrate the work of states and institutions which have deployed technology to improve efficiency and access to quality, affordable healthcare services The sub-categories in this segment are: ■ Health Information Management and Systems (HIMS) ■ Telemedicine/teleradiology ■ Health helpline ■ Affordable lifesaving technology ■ Wearable health devices ◗ Lifetime Achievement Award for Contribution in Public Health: It would recognise and celebrate yeoman service in public health, either through their NGOs or through their efforts to support public health causes. Nominations for this category can be made by individuals other than the nominee. ◗ Express Public Health Award for Contribution by a Private Healthcare Practitioner towards Public Health: This award aims to recognise and appreciate outstanding contribution of a private healthcare practitioner towards public health causes and initiatives, bridging the private-public divide. For more information on the event log on to www.healthcaresabha.in
MARKET POST EVENTS
DY Patil University hosts conference on health and hospital management DY Patil University, School of Management recently hosted th ‘India 2020 – 7 National Conference on Health & Hospital Management and the rd 3 National Conference on Banking & Insurance’. The conference was attended by more than 780 people consisting of healthcare professionals, medical and non- medical students across different colleges in Mumbai. It focussed on the opportunities and challenges in the healthcare and banking industries. The conference was inaugurated by Dr Gustad Daver, Medical Director, HN Reliance Hospital; Joy Chakraborty, COO, Hinduja Hospital; Pravin Bhansal, President-Project Finance, DHFL; Dr Sanjay Oak, Vice Chancellor; Dr DY Patil University; Dr R Gopal, Director, DY Patil University School of Management; Dr Nitin Sippy, Associate Professor - Health and Hospital Management and Mangesh Jadhav, Assistant Professor Banking and Insurance. Dr Oak said, “Today, hospitals not only need medical professionals, but also managers and leaders to maintain the equilibrium that the healthcare system requires.” He also mentioned that the legal challenges faced by the healthcare industry that hinders access to good healthcare services. In the inaugural address, Dr Daver said, “We need leaders in our industry who can
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The concurrent theme for the conference was banking and insurance
MARKET come up with innovative ways, with a passion and agility, to bridge the gap between people and the healthcare system.” He also gave insights to aspiring medical attendees on the various aspects of cadaver donation and its importance. Chakraborty emphasised on the required skilled sets of the healthcare industry and stated that with a growth rate of 12 per cent annually, the healthcare industry requires managers who are well accomplished, with knowledge of the hospital business. Dr Gopal said, “India is shining on the global map and progressing fast. Healthcare and banking are the two strong pillars for any nation to grow. Both these management sectors will create huge job opportunities by the year 2020. Thus, as a School of Management, we decided to educate the young Indians about the career opportunities and challenges in both these areas.” Bhansal said, “Today, technology has opened several doors for the aspiring students like you, to make a fruitful career in banking and insurance industry.” The panel discussion on
Delegates at the event
banking and insurance was moderated by Dr Gopal. The participants were Deepak Pande, Former Sr VP, Axis Bank; Apeksha M, VP; SBI Capital, Akshay Kakde, Asst VP, Credit Suisse and Vikas Patil, Asst VP, Axis Bank. The vari-
ants in the banking and insurance sector were the key highlights of the panel discussion. The healthcare panelists included Dr Rajendra Patankar, COO, Nanavati Hospital, Dr Sameer Khan, CEO, Suasth Healthcare, Dr Anupam Kar-
makar, COO, Guru Nanak Hospital and it was moderated by Dr Sippy. The panelists addressed the opportunities and challenges in the healthcare industry. The conference had a intercollegiate debate in which students from TML Nursing and
Dental, Fortis Nursing, Bharti Nursing and Dental, Khalsa College and 20 other colleges took part. After around three rounds of debate, Khalsa College emerged as the winner. The event was well received by all the attendees.
Sir HN Reliance Foundation Hospital conducts symposium on Urology Hosts world renowned urologists from USC Institute of Urology, USA SIR HN RELIANCE Foundation Hospital and Research Centre (RFH) recently conducted its first International Urology Symposium. The symposium, organised at the RFH convention centre, saw specialists from the field of robotics demonstrating their expertise through live surgical workshops, which was attended by more than 150 urologists from across the country. The specialists were invited from ‘USC Institute to Urology, University of Southern California (USC), Los Angeles, US. RFH has a relationship with USC for knowl-
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Dr Inderbir Gill, Chairman & Professor, Dept of Urology, USC Institute of Urology, US delivering lecture on ‘Advances in Robotic Surgery in Urology’
The symposium saw specialists from the field of robotics demonstrating their expertise through live surgical workshops
edge sharing. The conference was chaired by Dr Inderbir S Gill, Chairman & Professor, USC Institute of Urology. He was accompanied by Dr Shlomo Raz, Professor & Director, Female Pelvic Medicine and Reconstructive Surgery, and Dr Monish Aron, Vice Chairman and Professor, at the USC Institute of Urology. A total of 20 national and international faculty members spoke at the seminar. The symposium had lectures, video presentations, live robotic surgeries and case presentations.
MARKET
Dept of Biotechnology organises Global Biotechnology Summit Discusses action plan for $100 billion targets in two-day plenary sessions attended by more than 1500 eminent scientists, entrepreneurs, policymakers and civil society DEPARTMENT OF Biotechnology, Ministry of Science & Technology, Government of India organised a two-day ‘Global Biotechnology Summit’ to discuss opportunities, collaborate and prepare a joint action plan for achieving the target for its biotech sector of $100 billion by 2020. The Summit, organised on the occasion the 30th Foundation Day of the Department of Biotechnology, was reportedly attended by more than 1500 participants including eminent scientists from national and international public and private sector organisations, universities, delegations from state governments, representatives and delegations from other countries with which DBT partners, students, research fellows, biotech start-up entrepreneurs, policy-makers, civil society and so on. Also present on the occasion were Former Secretaries of DBT. Dr Harsh Vardhan, Minister of Science & Technology & Environmental Sciences was the Chief Guest for the occasion. Guests of Honour were Radha Mohan Singh, Minister of Agriculture and
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MARKET Farmers Welfare; Nirmala Sitharaman, Minister of State (Independent Charge), Ministry of Commerce & Industry and YS Chowdary, Minister of State, Ministry of Science & Technology and ES. Congratulating the DBT, its staff and the scientific community, Dr Vardhan in his inaugural address said, “Over 30 years, DBT has achieved several heights and connected research to the needs of the people. Biotechnology has become a crucial arm of the Make in India campaign. The message of the Summit is very clear. India is ready to be a global biotech destination.” The event showcased India’s biotechnology strength and capacity to attract investors and other key partners to invest in the biotech sector in India. The summit was a follow-up to the Prime Minister’s call for Make in India to encourage the start-up ecosys-
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More than 1500 participants including eminent scientists, entrepreneurs and state delegations attended the event
tem which has a potential for scale-up. There were key plenary talks by Prof Ada E Yonath, Nobel Laureate, Weizmann Institute of Science, Israel and Prof Maria Leptin, EMBOExcellence in Life Sciences,
Heidelberg, Germany. “Through its wonderful work the DBT has been actively contributing to some of the key initiatives of the government of India and contributed to multifarious areas like healthcare, agricul-
tural, environmental and industrial. We are ready to launch the start-up ecosystem which will contribute immensely to achieving our target of $100 billion by 2025,” said YS Chowdhury, Minister of State for Science and Technology.
The Summit focused on themes such as Make in India, Start-up India – Nurturing Bio Entrepreneurship, Skill India, Biotech Opportunities and Action for Swachh Bharat and Swasth Bharat, Biotechnology Cooperation, Biotechnology Innovation for Inclusive Development, Biotechnology and Society etc. “Steered under the leadership of brilliant minds over the years, biotechnology in India has crossed significant milestones. With the experience of 30 years, DBT’s endeavour will be to further improve our processes and culture so that we expand our reach and depth effectively,” said Professor Vijay Raghavan, Secretary DBT. Plenary talks and panel discussions helped align the goals of the biotech strategy with the policies of the state governments and prepare a joint action plan.
EVENT BRIEF MARCH 2016 04
HEALTHCARE SABHA 2016
Website: www.healthcaresabha.in
MEDICAL FAIR INDIA 2016
11
MEDICAL FAIR INDIA 2016
HEALTHCARE SABHA 2016 Date: March 4-6, 2016 Venue: Marriott Hotel and Convention Center, Hyderabad Summary: In keeping with the objectives of the National Health Mission pertaining to ‘Universal Access to Equitable, Affordable and Quality Healthcare Services’, the Indian Express Group and Express Healthcare are organising Healthcare Sabha 2016 – The National Thought Leadership Forum on Public Healthcare. The Forum will deliberate on cohesive, unified and innovative ways to achieve the vision of the National Health Mission. The event will also host the Express Public Health Awards honouring the visionaries, innovators, and game changers from public healthcare. Contact For Healthcare Sabha 2016 registrations: Shilpa Chaurasia The Indian Express (P) Ltd 1st Floor, Express Towers, Nariman Point, Mumbai 400 021 Ph: 08879137185 Email: shilpaindianexpress@gmail.com Website: www.healthcaresabha.in For Express Public Health Awards: Raelene Kambli The Indian Express (P) Ltd 1st Floor, Express Towers, Nariman Point, Mumbai 400 021 Ph: 09819614430 Email: raelene.kambli@ expressindia.com
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Date: March 11-13, 2016 Venue: Bombay Convention & Exhibition Centre (BCEC),
Mumbai Summary: MEDICAL FAIR INDIA seeks to serve as a perfect platform and offers a plethora of business opportunities for healthcare
professionals to meet, engage and network with participating companies, delegates and speakers. Organiser: Messe Düsseldorf GmbH
Contact Messe Düsseldorf GmbH Ph: +91 (0) 11 4855 0061 E-mail: BhardwajL@mdindia.com Website: www.messe-duesseldorf.com
cover )
The blueprint for government's Startup India policy has several points which has found favour among the business community, yet some grey areas give them cause for concern BY RAELENE KAMBLI
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(
FOCUS:POLICY
T
he buzz about India's fledgling startup ecosystem has not only encouraged the Indian government to create a better business environment for budding entrepreneurs but also generated curiosity among the common masses. To give an example of the same, I would like to share a recent incident. Travelling in a Mumbai local train, a conversation among five women commuters (all in the age group of 35-50 years) caught my attention. The discussion revolved around the merits and demerits of the government's recently launched startup policy. This made me realise that the government has taken massive efforts to galvanise India’s current start-up ecosystem through its glittering Startup India event held in January this year. Also, with increased awareness created by the media, Indians are closely watching the developments within this space; be it the escalating number of startups across sectors such as IT, healthcare, retail services or the amount of funds being raised. Express Healthcare in this article aims to understand the relevance of the startup policy in the healthcare space and the impact it would create.
In a nutshell PM Narendra Modi, on January 16, 2016, launched the eagerly awaited startup policy. It aims to boost innovation and entrepreneurship in the country and plug the gaps that hinder the growth and development of start-ups. The policy was launched as part of the ‘Start-up India, Stand up India’ campaign - an initiative which led to a first-of itskind dialogue between India’s start-
up community and the government. The event attracted around 40 top CEOs, startup founders and investors from the Silicon Valley as well as star entrepreneurs from India. During this event the Prime Minister, as part of an Action Plan, also announced a slew of measures that are touted to give an impetus to the fast burgeoning startup culture within the country.
Key highlights of the policy ◗ Defining startups: the policy defines a startup as “an entity, incorporated or registered in India not prior to five years, with annual turnover not exceeding Rs 25 crores in any preceding financial year, working towards innovation, development, deployment or commercialisation of new products, processes or services driven by technology or intellectual property (IP).” ◗ Introduction of self-certification: To reduce regulatory burden, startups can self-certify themselves, complying with the labour and environment laws. In case of labour laws, no inspections will be conducted for a period of three years. However, startups may be inspected on receipt of credible and verifiable complaint of violation, filed in writing and approved by at least one level senior to the inspecting officer. In case of environment laws, startups which fall under the ‘white category’ (as defined by the Central Pollution Control Board) would be able to self-certify compliance and only random checks would be carried out. This move will be beneficial to healthcare startups per se. ◗ Establishing a startup hub: This will be a single point of contact for the startup community which will help ensure ease of use and provide guidance.
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cover ) Implementation of the startup India policy will drive further innovation Amit Mookim Country Principal, IMS Consulting Group
It is important for the government to understand is that not even a handful of startups become profitable in the very first three years Saurabh Arora Founder & CEO, Lybrate
Given the new focus on funding innovation and expanding infrastructure, Indian startups have never had a more nurturing environment to thrive in Jagruti Bhatia Senior Advisor-Healthcare, KPMG Advisory Services
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◗ Simplifying the startup process: The mobile app and portal will allow startups to get registered within one day. It will also act as a platform for information sharing between startups. ◗ Providing legal support and accelerating patent applications: Patents filed by startups will get priority. They will also get a rebate of 80 per cent in filing patents. This will ensure IPR protection for startups, one of their major concerns. ◗ Simplifying exit norms: The exit norms and policies have been modified for startups with simple debt structures which can be fast tracked to 90 days. ◗ Tax exemption from capital gains: Investors will be exempted from tax on capital gains. ◗ Tax holiday on profits: Startups will get an exemption of three years. ◗ Introduction of ‘funds of funds’: With a corpus of Rs 10,000 crores over four years, the governmentsponsored fund will support startups. ◗ Credit guarantee fund for startups: Government aims to catalyse entrepreneurship by providing credit to innovators across all sections of the society. ◗ Relaxed public procurement norms: Eased norms on experience and turnover whilst maintaining quality and technical requirements. This is specially for the manufacturing sector, they get a level playing field with experienced companies. ◗ Setting up of 35 new incubators: These will be set-up at existing institutions across the country for which 80 per cent funding by central and state governments each and 20 per cent by private sector has already been committed. ◗ Organising startup fests: For promotion, visibility. ◗ Setting up of seven new research parks: These will be modelled on the lines of the research park at IIT, Madras. ◗ Promoting biotech entreprenuership: Plans to set up
five new bioclusters, 50 new bioincubators, 150 technology transfer offices and 20 biotech offices will heavily help the sector. Thus, the government’s action plan seeks to revitalise the startup ecosystem in the country. It has found appreciation among many national and international business leaders. During the startup event, Masayoshi Son, Chairman and CEO, Softbank called this move as the beginning of a Big Bang for India! He further said that India has the potential to surpass the US in next 25 years. Travis Kalanick, Founder of Uber applauded the government's initiative and urged the many Indian startups present at the event to keep innovating as creativity is the only way to success. Likewise, Onno Ruhl, Country Director, World Bank said, “India needs to create jobs in a big way and innovation is the key. We will support the government in every possible way." Some leading economists have called this move a revolution in the Indian entrepreneurial sector. Ease of registering a business, shutting it down, a three-year tax holiday on profits and discounts on registering intellectual property (IP) are some of the incentives that have been lauded by economists. All this and more has enthused startups in India. But, does the startup policy fit the bill for healthcare? Let’s examine.
Fostering a healthy startup culture Backed by innovation and the growing need for healthcare services, several startups have come up with an aim to change the face of healthcare as we know it. According to Amit Mookim, Country Principal, IMS Consulting Group, the Indian healthcare market today is pegged at $100 billion and is expected to grow to $280 billion by 2020. Hence, Mookim believes that there are enough white spaces to explore, providing an enormous opportunity for the entrepreneurs. Healthcare
INDIA NEEDS TO CREATE JOBS IN A BIG WAY AND INNOVATION IS THE KEY. WE WILL SUPPORT THE GOVERNMENT IN EVERY POSSIBLE WAY ONNO RUHL, Country Director, World Bank
start-ups can tap into these prospects where the big players have not been able to penetrate. “Implementation of the Startup India policy will drive further innovation among the startups. With numerous global and domestic players – big and small – across healthcare products and services offerings, the market has increasingly become globally competitive. In such a scenario, the new age players can take a lead in breaking the archaic mode of providing services to the end customers. There has already been a surge in the last two years with the entry of numerous healthcare startups that have efficiently tried to bridge the gap between the service providers and the end-users. It is really commendable to see how these new entrants are trying to reach out to the end customers with innovative services, making the entire healthcare experience to be easy and simple,” he explains. Jagruti Bhatia, Senior Advisor-Healthcare, KPMG Advisory Services, chips in, “Given the new focus on funding innovation and expanding infrastructure, Indian startups have never had a more nurturing environment to experiment and thrive in. The factors paving the way for digital health startups in India have been in play for almost a decade now – a rapid growth in GDP, smart phone penetration and half a billion citizens under the age of 25 will add impetus to the
burgeoning startup culture.” She further mentions that some of the top scoring healthcare startups such as Physioconnect, Arooj Home Healthcare, Avitas, Aajicare, Practo, NetMeds, Portea Medical, MedGenome, Lybrate, Attune, Relisys, 1mg, WelcomeCure, DocEngage, LiveHealth etc., could be game changers in the healthcare space. Bhatia also feels that the newly launched startup policy will dynamise the sector and propel it towards accelerated growth. She opines, “It is designed in a way that it addresses a lot of pain points that the startup entrepreneurs faced in India. The government's 'Startup India, Stand up India' programme intends to build a strong ecosystem for nurturing innovation with a view to driving sustainable economic growth and generating largescale employment opportunity. The Indian diaspora of entrepreneurship will be greatly enthused by the policy though we have to wait and watch for its effective implementation. But it’s a great start and in my opinion, this will open up many doors for building a ground for innovations, entrepreneurship and interventions in healthcare to make a big difference and change the way healthcare maybe delivered over the next deacade.” While analysts see the startup policy opening new avenues for healthcare startups, entrepreneurs are also optimistic as they see some interesting incentives lined up as part of the policy's action plan. “For long, Indian entrepreneurs have depended on foreign capital for seed funding. This policy will create the momentum for the formation of seed capital in the country. Ideas themselves are incapable of doing much without adequate application of capital. Hence, this policy is a step in the right direction,” opines Srinivasan HR, Vice Chairman & MD, TAKE Solutions. Anurav Rane, Founder & CEO of PlanMyMedicalTrip.
( a catch to this situation?
THIS MOVE IS THE BEGINNING OF A BIG BANG FOR INDIA! INDIA HAS THE POTENTIAL TO SURPASS THE US IN THE NEXT 25 YEARS MASAYOSHI SON, Chairman and CEO Softbank
com, conveys, “In India, the biggest reason for not establishing a new organisation was the fact that they would receive no support from any experienced agencies nor would the bureaucracy support their cause. But we believe that this initiative by the government will do good to the startup culture in India.” Harpreet Singh, Director, Oxyent Group, also calls it a well-timed policy and says, “To maintain the economic growth of India at eight per cent, it is important that India produces more jobs. Since the outsourcing industry has reached to a good size, more organic growth of the country via entrepreneurship and SMEs will promote manufacturing and innovation in India. It is a fairly young country and hence it will definitely see more attempts to convert ideas into reality. Since government has eased income tax and IP registration, it will definitely provide a platform for more initiatives to be tried.” On the same lines, Saurabh Arora, Founder & CEO, Lybrate adds, “The policy that the government has come up with shows its steely resolve to encourage and catalyse the startup ecosystem, in letter and spirit. No ecosystem can establish itself fully and flourish in the absence of government and local support. Startups are doing extremely well in India, apparent from the fact that we are today ranked third when it comes to the most number of start-ups worldwide. The government has grasped the reality as to how greatly they can contribute to economic growth and this is very timely.” With so much fervour in the air, can we say that government's startup policy has brought a new lease of life for healthcare players? Or is there
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The flip side and corrective measures As the old saying goes 'There are two sides to every coin,' Likewise, the startup policy too has its share of areas that need better clarity and loop-
FOCUS:POLICY
holes that need to be plugged. Let’s delve into understanding them. The definition of a startup mentioned in the policy is ‘as an entity with an annual turnover not exceeding Rs 25 crores, working towards innovation, driven by technology or
intellectual property.’ However, the question that arises is how will the government decide whether a startup is driven by innovation? Within the healthcare space, there are many startups who are working towards resolving a healthcare need, but are not heavily
TRAVIS KALANICK Founder, Uber
This initiative by the government will do good to the startup culture in India Anurav Rane Founder & CEO PlanMyMedicalTrip.com
We need to establish a systematic platform to ensure that innovative ideas are grouped in different categories and SMEs for each category are picked based on proven industry track record Harpreet Singh Director Oxyent Group
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driven by technology and IP. Will the government consider them as startups? Arora also raises this point. He feels that this definition will create confusion in the minds of many. He further says that if the government decides whether a business is driven by innovation or not, it will only give rise to bureaucracy. Additionally, to encourage seed capital investment, the government exempted tax above fair market value (FMV) for incubators in startups, which is currently only available to venture capital (VC) funds. Experts are of the opinion that this move has a drawback and the government should reconsider this provision. Gupta explains, “The whole concept of FMV is a big pain point for a startup. In most of the cases, startups try to get FMV as close as possible to the share issue price, which is an unhealthy practice. Then, we still have the issue of how we treat foreign investment. The FDI rules are still unclear and I am not sure how much this policy will prevent startups from moving to Singapore.” Another valid concern was raised by Gupta. Will this policy stem the exodus of healthcare startups to other preferred business destinations? Difficulty in doing business is often cited as the key reason for the exodus of startups from India. The startup policy primarily aims to resolve this issue. In fact, the government has introduced capital gains exemption on startups to prevent them from moving
100 $ 280 $
Expected to grow to by 2020
billion
KEEP INNOVATING AS CREATIVITY IS THE ONLY WAY TO SUCCESS. INDIA, ALWAYS BE JUGAADING AND CREATE MAGIC
billion
Indian healthcare market today
out of India, which is certainly a welcome move. However, some startups feel that this provision remains ambigous. “Government has not eased out on capital gains, moreover the investor funding aggregators and exit liabilities are still ill-defined in India. I feel that most entrepreneurs will still prefer Dubai and Singapore to monetise on mature ideas based on capital gains,” Singh states. Most startups also complain about the provision of tax holidays being limited to three years. Raising concerns on this provision and suggesting corrections for the same, Arora points out, “What is important for the government to understand is that how many startups become profitable in the very first three years. Perhaps, not even a handful. It takes good time for startups to establish themselves and to let users become accustomed to their models, a time-consuming process. When users begin to understand the innovation and taste the benefits, only then will they shell out money to use the platforms. If the aim of the government is to cut the cash outflow of startups and make them financially viable, I would recommend giving tax break for the first year of profitability within six years of inception. This is likely to ensure that more companies become eligible to avail the tax benefit while at the same time the total amount of benefit remains almost the same.” Moreover, some experts also feel that the government has ignored taxes such as service
Highlighs of Startup India
cover ) 3
years tax holiday
`
10,000 crores
Corpus fund for startups
35 20 New incubators
Biotechnologyoffices
tax and custom duty which are very crucial to businesses that are built in the B2B space and who are also dealing in the medical equipment space. They are of the opinion that if the government really intends to boost healthcare startups, then it should also consider providing custom duty exemptions for the initial two to three years. This would be beneficial to startups in the medical equipment space who regularly import components to design their products. Another point of worry is the establishment of the ‘funds of funds’ to finance startups. Under this provision the government will take taxpayer funds to invest in other VC funds, which in turn will fund startups. However, what is the rationale for the government to risk taxpayer funds in this? Not just the experts, but even the common masses raise this query. Agreeing with this point, Arora elucidates, “This is debatable as it involves taxpayers’ money and investing in startups is a risky bet. Government wants to stay away from directly funding the startups and thus it has found the way of doing so via VC funds. Funding is an initial roadblock that many entrepreneurs are unable to get through and many innovative ideas are nipped in the bud for that reason. To encourage budding entrepreneurs, the step is meaningful. But, against the backdrop of the thriving VC industry, the best the government can do is to make sure that the fund managers put in the money
only in those companies which are actually solving the real problems of the country, like those addressing the problems of healthcare, rural education, financial issues of farmers etc. They should invest only in those startups which if capitalised has the potential to change the face of the nation.” Bhatia chooses to disagree and has a counterview to offer. She says, “We are aware that India is over-reliant on foreign VCs and the government needs to offset this imbalance. So ,this may be an effective way to address it. Although there are mixed opinions about this as some find it to be irrational, the government is looking into these and plans to take all viewpoints into consideration. An advisory panel set up by SEBI and led by Infosys Founder NR Narayana Murthy has just submitted a report suggesting reforms to make the fundraising environment for VC funds more conducive.” “The biggest challenge is ensuring that the funds reach the deserving entrepreneurs. It should not happen that we have a sudden splurge in new companies being created to leverage the income tax period and utilise the IP registration facilities to register non-pragmatic ideas, leveraging the current economic themes i.e. alternate energy and healthcare to all. We need to establish a systematic platform that ensures that innovative ideas are grouped in different categories and SMEs for each category are picked based on
( On January 16,2016,PM Narendra Modi
launched the startup policy that aims to fill gaps in the economy for the growth and development of startups as well as boost innovation and entrepreneurship in the country
proven industry track record. This will ensure that government funding is utilised in improving maturity of the concerned industry and allows India to improve its R&D capability in the concerned industry,� informs Singh. Pradeep Dadha, Founder & CEO, Netmeds.com chips in, “Whenever there is a government programme, by nature, there will be more beauracracy, and of course, the opportunity for mismanagement and corruption. The challenge will be to make the agency agile, efficient and fair.� Bhatia highlights another area for the government to reconsider. She says, “According to the new policy, public procurement norms relaxation maybe applicable only to startups in the manufacturing sector. This leaves technically capable startups in the fields like health IT, healthcare services etc., away from public bidding.�
In times to come.. All said and done, the government, by introducing the startup policy and preparing an action plan, has created a positive environment. Though the action plan is still in its nascent stage, if implemented effectively, we can hope for better outcomes. All that is needed is concerted efforts by all stakeholders including the central government, various state governments, entrepreneurs, investors, mentors etc., to drive this mission to the next level. Kalanick’s advice during the Startup India event was, “India, always be Jugaading and create magic.� Paying heed to this, startups within the healthcare space should make hay while the sun shines. raelene.kambli@expressindia.com
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The event attracted
around 40 top CEOs, startup founders and investors from the Silicon Valley as well as star entrepreneurs from India
FOCUS:POLICY
An event ensured
first-of its-kind dialogue between India’s startup community and the government
The policy has
found appreciation among many national and international business leaders
SPECIAL FOCUS - PUBLIC HEALTH
DRIVING A PUBLIC HEALTH REVOLUTION G
ood public health services are vital to country's development. Yet, the public healthcare system in our country is deficient on various fronts. Hence, there is an urgent need to revitalise the public health systems in our country and this calls for concerted efforts by the policy makers, organisations, public and private healthcare providers and individuals. Hence, The Indian Express Group and Express Healthcare, are organising Healthcare Sabha 2016 – The National Thought Leadership Forum on Public Healthcare. As a curtain-raiser to the event which will be held from March 4-6, 2016, at Mariott, Hyderabad, we feature the vision of some key stakeholders to enhance public health in India.
UTKHADER,Minister for Health and Family Welfare,Government of Karnataka
DR ALKADESHPANDE Ex Professor & HoD of Medicine,JJ Hospital,Grant Medical College
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DR DAMODAR BACHANI,Deputy Commissioner (NCD),MoH&FW,Government of India
DR GIRDHAR J GYANI, Director General,Association of Healthcare Providers (India)
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DR M BEENA,Secretary (AYUSH),Government of Kerala
DR RAMESH BHARMAL, Dean,BYL Nair Hospital and TN Medical College Mumbai
I AKUNDAN,Mission Director, NHM,Maharashtra
DR PRAVIN SHINGARE, Director, DMER,Maharashtra
DR G SRINIVAS RAO,Chief Programme Officer,NHM,Telangana
Healthcare Sabha 2016 will deliberate on cohesive, unified and innovative ways to achieve the Vision of The National Health Mission i.e. Universal Access to Equitable, Affordable and Quality Healthcare Services
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SPECIAL FOCUS - PUBLIC HEALTH I N T E R V I E W
‘We have 176 hospitals where we give treatment free of cost’ Karnataka's Minister for Health and Family Welfare, UT Khader is known for his progressive outlook.The sunny side of his personality is also underlined by his acts of benevolence like lending his car to ferry accident victims. Recently, he put a stop to the Arogya Bandhu scheme, wherein the government had partnered with NGOs, charitable trusts and private medical colleges to run 52 of its primary health centres (PHCs), as he believes the partnership did not yield desired fruits. In a conversation with M Neelam Kachhap, he talks about his people centric schemes and future plans for the state healthcare department
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Why did you decide to do away with the Arogya Bandhu scheme? Karnataka State recognises the immeasurable value of enhancing the health and well being of its people. Our aim is to provide quality healthcare with equity, which is responsive to the needs of the people, and is guided by principles of transparency, accountability and community participation. This was not being followed by many NGOs and hence we decided to stop the scheme.
How has the state of healthcare delivery changed in Karnataka over time? Karnataka has got a rich history of healthcare delivery. In comparison to other states, we have done well as we have achieved the MDG to reduce child mortality to 31 per thousand live births and maternal mortality ratio (MMR) to 133. We have an auxiliary nurse midwife (ANM) centre per 10000 population; a primary care centre per 30,000; and a community
health centre at 110,000 population. Besides every taluka has a taluka hospital and district has a district hospital, some even have medical colleges. But our aim is to have super speciality functions at every district. We are working towards that. Going forward, we would like to focus more on preventive healthcare. We do not want to keep increasing hospitals but want to keep our people healthy so that they do not need more hospitals.
I will give you a simple example. We have free BP and sugar check-up facilities at all PHCs but people do not make use of it. They would rather spend an hour at a restaurant eating food that may end up giving them heart problems but people do not want to spare five minutes for preventive check-ups. We would like to create awareness about a healthy lifestyle. Focus more on preventive measures than curative measures to build a healthier society. What measures are you taking in this regard? Creating awareness is a difficult task. It is not as easy as it looks to convince people to change their lifestyle. However, we have partnered with NGOs to help us in this task. We also use our ANM network to spread awareness to mothers so that they can inculcate healthy habits in the family. We give importance to both allopathy and traditional medicine like ayurveda. It’s the patients' choice, our job is to make these treatments available. What measures have you taken to make treatment available and affordable? We have 176 hospitals in the state where we give treatment free of cost. Karnataka is the only state that provides universal health coverage (UHC) for its people. We have the Vajpayee Arogyasri scheme for below poverty line (BPL) families and Rajiv Arogyasri scheme for the above poverty level (APL) families. The patients are provided free admission, food and travel allowances, medicine, investigation, treatment and other expenses at the hospital. Under the scheme, patients can avail treatment for 449 surgical procedures for polytrauma, cardiac, cancer, renal, burns, neonatal and neurological problems. For BPL families it is completely free of cost and for APL families 70 per cent of the
Bike ambulance launched by the Karnataka government to provide timely care to its populace cost is taken care of by the government. And we have also partnered with private hospitals to ensure that the full state is covered. We have provided an Arogya Mitra at all hospitals to help the patients. Are you facing problems in implementing schemes due to reluctance on the side of private players to partner with the government ? Yes. Initially we faced some problems as the private providers were not ready to give treatment at our cost. But, we have streamlined the process and there is no third party involved. The hospital has to send the bill to us within one month of the treatment given and we release the payment within a week of receiving the bill. Any delay, either on our part or the hospitals’ part, invites penalty. So, now we hope that there will be no complaints from private providers. What happened to the scheme of opening a dialysis unit in at least one taluka
per district ? We are focussed on providing dialysis facility to our people and we will take this scheme forward. However, we have received a setback in terms of shortage of trained manpower. We are speaking to other healthcare providers and will partner with them through the PPP model to help us tide over this shortage. At present, dialysis centres have been set up in 16 district hospitals and two taluk hospitals. During 2013-14, 46315 dialysis cycles were received by the patients whereas during 2014-15, 7831 patients received 54740 dialysis cycles in the dialysis centres set up at government hospitals. How did the government respond when the emergency medical services under the 108 Arogya Kavacha scheme in the state were disrupted due to emergency medical technicians and drivers going on strike? The ambulance services under the 108 Arogya Kavacha scheme is run by GVK Emergency
Management and Research Institute (GVK EMRI) in Karnataka. We instituted this scheme for the people and not for the drivers. We want discipline and performance but the leaders of the drivers are frequently disrupting services. At present, 153 members of the association who were disrupting services were sacked. We have put KSRTC drivers and even our department drivers on duty so that people do not suffer. Ambulances are running with better performance levels. Earlier the performance level was 86 per cent, now with our drivers it is 96 per cent. At any cost ambulance should reach a patient within 20 minutes. You had also launched the bike ambulance scheme. Tell us about it. For the first time in India we launched ‘Platinum 10 minutes’ trauma care initiative with 30 two-wheeler ambulances. Today, we order pizza and it reaches us in 10 minutes, why not medical care. However,
some urban areas in Karnataka are so congested that even if an ambulance was available it would get delayed in traffic. Our two wheeler ambulances were launched in April 2015 to resolve this issue and since then they receive almost 12 calls each day. The bike ambulance rider is a trained paramedic who reaches the accident spot in 10 minutes, gives first aid and starts resuscitation measures to save the victim till the fourwheeler ambulance arrives. We have spent around Rs 2 lakh on each of the bike ambulances. Each bike ambulance is equipped with 40 medical items including the stethoscope, pulse oxymeter, bandages and IV normal saline, apart from 53 basic drugs. This facility is not available in other parts of India or even Asia. What about utilising Karnataka's core strength in IT? How many government hospitals have patient management and record software?
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SPECIAL FOCUS - PUBLIC HEALTH We have invested heavily on health IT infrastructure. Last year, we announced a project for massive digitisation of patient information with the help of the National Informatics Centre (NIC). The NIC will execute the e-hospital software in all the hospitals of the state to document and utilise the health information of every patient visiting the government hospitals. Along with this, we have also introduced a system of grant-based supply of medicines that exists hitherto in all government hospitals of the state. Henceforth, supply of essential medicines will be made to all hospitals as per the requirements. For some big primary health centres a set amount may be too little and for a small PHC it may be too much so there is a lot of wastage. This is the reason why we implemented a need-based supply of medicines. What about the shortage of doctors in government hospitals of Karnataka? I agree that when I joined office there was shortage of doctors. In fact, in the last 10 years no new appointment had been made. During this time, some doctors left their job while some retired. These vacant posts also added to our problems. Hence, we appointed new doctors on contract basis and are in the process of hiring new doctors through the Karnataka Public Service Commission. Almost 80 per cent of our doctor problem has been resolved. What is the status of The Karnataka Compulsory Service Training Act? The Karnataka Compulsory Service Training by Candidates Completed Medical Course Act, 2012, and the Karnataka Compulsory Service Training by Candidates Completed Medical Courses (Counselling, Allotment and Certification) Rules, 2015 will come into force soon. At least, we hope that it does. It’s not like we are asking the candidates to work in the rural area for free. Every MBBS candidate gets a monthly pay of
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Rs 39,000 and postgraduates (PGs) or senior residents get Rs 45,000. We have budgeted for this around Rs 280 crores per year. We have notified this, making one-year rural service mandatory for medical students. Besides a penalty ranging between Rs 15 lakhs and Rs 30 lakhs for violation of the rule, it will also cost students their medical degree. If the stay vacates there will be no doctor shortage in Karnataka. We will be able to provide doctors to not only our state but also other parts of India. Tell us about the low cost diagnostics initiative. We have launched a medical imaging and special diagnostic laboratory in Bengaluru and we want to take it to 14 districts across Karnataka. Traditionally, MRI and CT scans are among the most costly diagnostic services. We decided to have our own MRI and CT machines so that we could provide these facilities at a lesser cost to our people. At our centre these are 60 per cent cheaper than the market rate. And this facility is not only for the inpatients. Any outpatient who requires these services could also avail them. The first of these labs was inaugurated by Governor Vajubhai R Vala at KC General Hospital, Bengaluru in January this year. Apart from CT scan, haematology, biochemistry, microbiology and pathology services will also be available. We are able to do this by implementing a PPP model. Why did you start a free denture scheme? We are the first in the country to have an oral health policy. Good oral hygiene is key to good health and wellness. With our Dantha Bhagya scheme we hope to distribute free dentures to those below the poverty line who are more than 60 years old and have lost their teeth. We are also in the process of recruiting dentists and buying equipment for all government hospitals as part of a major push to improve oral hygiene. We will also work on creating
We are the first in the country to have an oral health policy awareness about oral health and have oral health check-ups for all school-going children. Tell us about the accidental insurance scheme? Karnataka will be the first state in India to provide all its people with a government accidental insurance scheme. The Chief Minister’s Comprehensive Health Insurance Scheme will pay Rs 25,000 for treatment in the first 48 hours of the accident at the empaneled hospital. We have observed that many people do not help accident victims because they are the ones who are asked to pay various fees once they take the victim to the hospital. Sometimes people just leave the victim at the hospital's door and run away. With this scheme people will be able to avail cashless services at hospitals for trauma injuries and hospitals will not turn their back on patients or refuse to treat patients. This will be available to any one who meets with an accident in Karnataka. It could be a tourist, a student from another
state, a labourer or a worker. No accident victim will be rejected treatment. Due to some technicalities we have not been able to formally launch the scheme. However, all work has been done in this regards and will launch this soon. We have set aside Rs 73 crores for this and Rs 10 crores have already been released. We presented this in a meeting at Delhi and the scheme was appreciated by Prime Minister Narendra Modi, who mentioned it in his Mann Ki Baat programme. We have also launched cashless treatment facility (Jyothi Sanjeevini) for all state government employees. Earlier, the state employees would spend out-of-pocket on treatment which would be later reimbursed by the department. This was a very inconvenient and tiresome process. We have streamlined everything and now it is much easier for state employees to seek treatment. What are you working on next? We are working on having our own medical equipment maintenance system. We are also planning to have a separate department for this. Keeping equipment functional with minimal 'down-time' has been a challenge especially in remote locations. Available evidence indicates that 30-35 per cent of medical equipment is non-functional in different hospitals across the state. For example; if an X-ray machine breaks down there would be a toll free number to call for maintenance and repair. As soon as that call is placed, a timer will start and only stop after the person who placed the call verifies and certifies that the machine is again functional. Shortage of ventilators is a big problem and we are working on combating this situation by making more ventilators and ICUs available for the people. In the coming months, ICUs with 6-10 beds would be set-up in all district hospitals and ICUs with four to six beds in 25 taluka hospital will be set-up soon. To decongest patient load in
government hospital in Bengaluru ICUs will be set-up at the outskirts like Yeshvantpur, Yelahanka and Madiwala. An outlay of Rs 22.37 crores has already been approved. We have opened Jansanjeevani stores (generic medicines) across all district hospitals. This will be launched officially soon. In Phase-1, 30 stores will be opened with an objective of having at least one such store in each district. Jansanjeevani will have over 1,200 generic drugs and branded medicines including life saving drugs. Only drugs manufactured by well-known companies will be sold here to ensure quality. While 361 generic drugs can be procured under Jan Aushadhi, as many as 748 drugs are available under Jansanjeevani. We did not find the Centre’s model feasible, as drugs for critical illnesses including cancer, aren’t available at a lower cost, so we have partnered with HLL for this. We are also considering the introduction of an insurance scheme offering free medical treatment for secondary care or optional procedures. Anything else you would like to add? Although we are doing a lot in healthcare there are a lot of problem areas which need attention. One such area is second opinion. This is an important function in healthcare and we are thinking of having an ombudsman committee to address this. Also, we would like to bring about a change in some norms regarding cadaver organ donation and transplantation to bring in certain amount of flexibility to offer organs of the deceased person/ brain-dead person. This needs to be accompanied by a massive awareness programme. The health department is also looking for innovative ideas to solve healthcare problems and people with such ideas should come forward and partner with us. mneelam.kachhap@expressindia.com
Core India Institute of Legal Medicine,Pune,Maharashtra
SHAPING THE FUTURE OFLEGALMEDICINE IN INDIABYCREATING CENTRE OFEXCELLENCE Brief about Core India Institute of Legal Medicine, Pune It gives us pleasure to introduce, Core India Institute of Legal Medicine, the organization in the medico legal field. In addition to medico legal consultancy, it will contribute to the field of legal medicine of India by organizing a number of academic programs and publications for doctors, advocates and hospital employees. The modus operendi of the CIILM is as follows ■ Medico legal consultancyProfessionally helping the doctors, hospitals and advocates in court proceedings, Pleading
and representing doctors and hospitals in the Courts. ■ Medico legal skills development- various academic programs and courses for doctors and advocates, also for judges ■ Mediation, Conciliation and Arbitration- Though India does not have this system at present, it is best alternative to resolve disputes and it should be offered to all medico legal disputes as first solution. ■ Crisis Prevention and Intervention- Mainly training hospital employees with the techniques of prevention and intervention of crisis in the hospitals. Organizing programs and courses.
■ Risk management- Offering insurance based solutions to the doctors and hospitals for dealing with medico legal risks. “Doctor Patient Synergy: A way towards medical legal partnership for patient safety” The Core India Institute of Legal Medicine is organizing a medico legal conference for doctors, advocates, medical and law students with the above theme on 26th 27th March 2016. The associate for the conference is the Indian Medical Association, Pune Branch. Eminent speakers for this conference include Senior members from Judiciary, Senior Police officials, Senior
medical professionals and advocates, Media Experts and Actors. The venue will be Smt.Shakuntala Shetty Auditorium, Kannada Sangha, Erandavana, Pune.
Schedule of Program ◗ Session 1 Violence Against Hospitals and Medical Professionals ◗ Session 2 Release of IMA Medico legal Diary ◗ Session 3 Evolution of Law governing Medical Negligence ◗ Session 4 Dispute Resolut ion in Healthcare Role of Mediation, Conciliation and Arbitration ◗ Session 5 Healthcare Risk
DR.SANTOSH KAKADE, MS (Surgery), D.Ortho, FICS, LL.M., PhD in LAW, FCLM. , MBA Hospital Management, Executive MBA Finance MD & CEO
Management ◗ Session 6 Social Aspects of Doctor Patient Relationship Felicitations and speeches Contact for Participation Conference Secretariat, Indian Medical Association, Dr.Nitu Mandke Building, Tilak Road, Pune Phone numbers: 020-24464771, 24430042 Email: info@ciilm.com, imaofpune@gmail.com
“DOCTOR PATIENT SYNERGY: A way towards medical legal partnership for patient safety” Medico legal Conference organized jointly by Core India Institute of Legal Medicine and Indian Medical Association, Pune
26-27 March 2016 Venue: Smt.Shakuntala Jagannath Shetty Auditorium, Kannada Sangha, Kaveri Group of Institutes Educational Complex, Near CDSS, Ganeshnagar, Erandwane, Pune. ORGANISING COMMITTEE Dr.Avinash Bhutkar
Dr.Sanjay Gupte
Dr.Jayant Navarange
Dr.Santosh Kakade
Organizing Chairman President, IMA, Pune
Executive Organizing Chairman
Organizing Co Chairman
Organizing Secretary
Dr.Sanjay Patil
Dr. Padma Iyer
Dr.Bhagyashri Kakade
Organizing Co Secretary Hon. Secretary, IMA, Pune
Treasurer
Co Treasurer
Regd. Office : Flat No. 9 + 16, Damodar Prasad Apt., Hingne Khurd, Sinhagad Road, Pune – 411051, India Email: info@ciilm.com, drsantoshkakade@ciilm.com Web: www.ciilm.com Phone: +91 020 24347585 Mobile: 09422071490
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SPECIAL FOCUS - PUBLIC HEALTH EXPERT SPEAK
Combating NCDs: Need of the hour Dr Damodar Bachani, Deputy Commissioner (NCD), Ministry of Health & Family Welfare, Government of India elucidates on the emerging threat of non-communicable diseases (NCDs) in India and outlines the way forward to deal with them as a public health priority
G
lobally, 14.2 million people die prematurely every year from noncommunicable diseases (NCDs) between 30 and 69 years of age. 86 per cent of these premature deaths from NCDs occur in developing countries. Deaths due to communicable diseases, maternal, perinatal conditions and nutritional deficiencies were 15.98 million which means 27.2 per cent of all deaths in 2008. It is projected that in the year 2030, this number would shrink to 9.37 million, and in proportionate terms, just 13.8 per cent. NCDs, on the other hand, would rise from 37.12 (63.2 per cent) million to 51.62 million (76.1 per cent) in the same year. While deaths due to cancer, heart diseases and stroke will increase, deaths due to communicable diseases, perinatal conditions and injuries will reduce during the next 15 years India is also going through a time bomb of chronic NCDs epidemic at present, with over 60 per cent of the deaths in the country already attributable to non-communicable diseases, particularly the four biggest killers, namely cardiovascular diseases, diabetes, cancers and chronic obstructive lung diseases. While the nation’s priorities in terms of other longstanding health problems such as maternal and child health as well as various communicable diseases, have shown significant decline over the last two decades, there still seems to be a long way to go and the government has been consistently focusing on the challenges posing them. How-
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ever, it also realises that India is running against time in combating large epidemics of various chronic illnesses in the coming years due to an increasing lifespan besides, rapid changes in lifestyle and the physical environment owing to economic progress and urbanisation. A WHO report has suggested that India is projected to spend $ 237 billion (1.5 per cent of the GDP) as a result of heart disease, strokes and diabetes from 2005 to 2015. A World Economic Forum report (2014) reported that India is expected to lose $4.58 trillion before 2030 from expenses in care for NCDs and mental health conditions. Of this, $2.17 trillion is expected to be consumed by cardiovascular diseases alone. Increase in life expectancy and unhealthy lifestyle behaviour are two main reasons for this epidemiological transition. Tobacco use, both smoking and smokeless forms, unhealthy diet rich in salt, sugar and saturated/trans-fats, physical inactivity and alcohol use are key risk factors associated with this trend. Increasing levels of air pollution and mental stress have also been attributable to this trend. National response to the NCD epidemic has been praiseworthy in recent times, though far from adequate, given the magnitude of the burden and the challenges in its control. A National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) was launched by MoH&FW in 100
THE MINISTRY OF HEALTH & FAMILY WELFARE HAS ALSO PREPARED A MONITORING FRAMEWORK TO PREVENT AND CONTROL NCDS AND THEIR RISK FACTORS BY THE YEAR 2025 WITH THE FOLLOWING GOALS Indicator
Year 2025
Relative reduction in premature mortality from NCDs
25 per cent
Obesity & Diabetes Prevalence:
Halt the rise
Relative reduction in prevalence of insufficient physical activity Relative reduction in the prevalence of raised blood pressure
10 per cent 25 per cent
Relative reduction in mean intake of salt/sodium intake
30 per cent
Relative reduction in alcohol use
10 per cent
Relative reduction in prevalence of current tobacco use
30 per cent
Eligible people receive drug therapy and counselling to prevent heart attacks and strokes Availability of essential NCD medicines and basic technologies to treat major NCDs public/private facilities Relative reduction in household use of solid fuel
50 per cent 80 per cent 50 per cent
Investment on health promotion and prevention and capacity building to manage NCDs will be cost-effective in the long run to avert premature deaths and disability in the productive age group and reduce out-of-pocket expenditure select districts within 21 states in 2010-11 and has expanded to all the districts in a phased manner. Key strategies of the programme include health
promotion for healthy life styles to reduce exposure to risk factors, early diagnosis through periodic/opportunistic screening of population and
DR DAMODAR BACHANI, Deputy Commissioner (NCD), Ministry of Health& Family Welfare, Government of India
better diagnostic facilities, infrastructure development for management of NCDs, capacity building of human resources in public health facilities, facilitating rapid referral in medical emergencies (e.g. in heart attack and stroke) to reduce mortality and providing treatment to persons with NCDs including rehabilitation and palliative care. The government is also planning to introduce population-based interventions wherever applicable through multi-sectoral approach (See table). To achieve these targets, it would be necessary to introduce healthy public policies, involve the government, rope in NGOs and the private health sector and have massive campaign to make people realise to imbibe healthy lifestyle consisting of healthy and balanced diet, being physically active and abstain from use of alcohol and tobacco. Populationbased intervention would require subsidies for healthy option, raising taxes on unhealthy food, tobacco and alcohol, controlling air pollution, providing clean energy in rural areas and upbringing children and adolescents in healthy lifestyles. The government should also realise that investment on health promotion, prevention and capacity building to manage NCDs will be cost-effective in long run by means of averting premature deaths and disability in productive age group and reducing out-of-pocket expenditure on these chronic diseases.
SPECIAL FOCUS - PUBLIC HEALTH I N T E R V I E W
‘Kerala is the third state in India to have a separate department for AYUSH’ Kerala’s health indicators are among the best in the country. Over the years, how has AYUSH contributed to the state’s healthcare achievements? AYUSH systems of treatment, especially ayurveda has been the traditional treatment modality followed by the people of Kerala over the years. The infant mortality rate (IMR) and maternal mortality rate (MMR) in Kerala are at par with the international standards. AYUSH systems of treatment have played a key role in bringing Kerala to this level. Women in Kerala have a tradition of availing ayurvedic treatment for pre-maternal, maternal and post-maternal care. This helps the mother to deliver a healthy child and to maintain their health by avoiding complications before, during and after delivery. The prasuthi tantra of ayurveda describes all aspects related to pregnancy, labour and post maternal management. The health management principles of ayurveda (swasthavirtha) deals with all aspects related to healthy living. Ayurveda is gaining momentum as an effective alternative to the conventional system of medicine by virtue of its systematic approach to prevention and cure of ailments using natural resources. Homoeopathy, as a system of medicine, has played a key role in developing immunity among the children in Kerala. This helps in reducing the infant mortality rate. As the AYUSH systems of treatment have less side
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AYUSH recently got renewed focus on the central government level in India. Yet, Kerala, the southernmost state of the country has always had a rich heritage of ayurveda and homeopathy. M Beena, Secretary (AYUSH), Government of Kerala, speaks on the contribution of AYUSH to Kerala's good health indicators, steps to streamline the sector to improve health access, challenges hindering its growth and more, in an interaction with Lakshmipriya Nair
effects, more and more people are opting for them over the years. Siddha, yoga, naturopathy and unani the other components of AYUSH are also playing significant roles. Kerala is one among the few states in India which offers ayurvedic and homoeopathic treatment facilities in almost all the panchayats. It has several primary, secondary and tertiary care facilities across the state. The state also boasts of several good and reputed government/aided/self financed medical colleges for ayurveda, homoeopathy and siddha. Kerala is the third state in India to have a separate department for AYUSH in the government with a dedicated Secretary for the sector. What role can AYUSH play in the coming years to improve healthcare access across the country? AYUSH professionals can be deployed across the country in primary, secondary and tertiary healthcare institutions for effective implementation of national programmes. Starting AYUSH healthcare centres across the country will also help improve healthcare access. What are the challenges in the growth of the AYUSH sector? How can they be tackled? Infrastructure facilities in AYUSH healthcare institutions have to be improved. All AYUSH hospitals do not have clinical investigation facilities. This
SPECIAL FOCUS - PUBLIC HEALTH
has to be addressed. The state has formulated Kerala Accreditation Standards for Hospitals (KASH) guidelines for the AYUSH Department with an aim to improve the quality of AYUSH healthcare delivery system. All the AYUSH hospitals in the state have to brought up to KASH. Lack of research studies, proper documentation and publication in national/international journals, limitation in conducting information, education, and communication/behaviour change communication (IEC/BCC) activities, nonavailability of quality drugs, non availability of sufficient medicinal plants, fund shortage as compared to other streams etc. are the main challenges faced by the department. The budgetary provision forAYUSH has to be increased. People have to be made aware about the strength and efficacy of AYUSH systems of treatment through print/audio and visual media.
The budgetary provision forAYUSH has to be increased. People have to be made aware about the strength and efficacy of AYUSH systems of treatment through print/audio and visual media. AYUSH educational systems also need to be improved AYUSH educational systems also need to be improved. Healthcare facilities need to be standardied. Spurious drugs are a serious concern in India, What are the regulatory measures/amendments being considered to ensure quality in the AYUSH industry? The state desires to strengthen the regulatory framework of ASU&H Drugs by appointing a Drug Controller for ASU&H Drugs. There should be one drug inspector for every 30 manufacturing units. The
existing drug testing laboratories will be strengthened by appointing adequate staff and providing sufficient infrastructure facilities. Periodic site inspections and quality checks should be conducted for the samples collected. Steps will be taken to control misleading advertisements of ASU&H Drugs. The penalty imposed for the violation of DMR (OA) Act will be increased for single and repeated offences. What are the three major steps needed to propel the
communicable diseases.
sector towards further progress? ◗Establishing AYUSH systems of medicine as the first choice of treatment in primary healthcare ◗Making Kerala a 100 per cent ayurvedic state and 100 per cent homoeopathic state by providing ayurvedic treatment facility and homoeopathic treatment facility in the remaining local self-government institutions (LSGIs) ◗Creating more public health initiatives for AYUSH in the state to effectively tackle communicable and non-
What are the lessons that Kerala can offer in this sphere, given its rich tradition in Ayurveda medicine? The ayurvedic system followed in Kerala has its own cardinal principles. Its Keraleeya panchakarma treatment modality has also found global acceptance. By following the swasthvirtha principles, people will be able to maintain health as prescribed by the WHO. The lifestyle diseases can be prevented and managed by following the dietary and seasonal regime prescribed by ayurveda. By using ayurvedic medicines for acute and chronic ailments, drug-induced ailments can be reduced. Morbidity and mortality rates are increasing day-by-day in both rural and urban areas. The incidence can be reduced by adopting Keraleeya panchakarma treatment modalities. lakshmipriya.nair@expressindia.com
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SPECIAL FOCUS - PUBLIC HEALTH
Revitalising public health:
ASHARED VALUE Public health experts share their views on the challenges in India’s public health sector and recommend measures for improvements, with Express Healthcare
Dr Pravin Shingare
Dr G Srinivas Rao
Director, Directorate for Medical Education and Research (DMER), Maharashtra
Chief Programme Officer, NHM,Telangana
‘Addressing challenges in the implementation of the health policies is most important’
‘There is a need to revitalise the public healthcare system with sufficient manpower and funds’
P
P
ublic health refers to all organised measures to prevent disease, promote health and prolong life among the population as a whole (WHO). Public health also includes assessing, monitoring and prioritising the health needs of the community and the population at risk. Public health policies should resolve the identified local and national health problems and secondly, ensure that the population has easy access to appropriate and cost-effective care in order to prevent diseases and promote health. These core values of public health should be shared between all the stakeholders of the public health. Public health is a social responsibility, hence it is the role of the stakeholders to respond timely to the community’s health needs along with the primary healthcare providers, as they themselves are the beneficiaries of these health policies. In order to make public health a shared value between all stakeholders, it is important to consider making the public health concerns a top priority. Not only policy makers and public health professionals but also the rest of the stakeholders should join in implementation of educational programmes, recommending health policies, administering services and conducting research
in contrast to clinical professionals who primarily focus on treatment rather than prevention. Accordingly, addressing the challenges in the implementation of the health policies is an important initiative for the better health of the society. The most common challenges that need to be addressed include: lack of skilled personnel, inadequate funding, inadequate resources, limited buy-in form leadership, decentralised local and state public health services. Hence it’s high time that each stakeholder and every individual worked towards a healthier nation.
IT’S TIME EACH STAKEHOLDER AND EVERYINDIVIDUAL WORKED TOWARDS AHEALTHIER NATION
ublic services are vital for country's development, yet they face problems like shortage of manpower and shortage of funds. Forcing the doctors obtaining the degree from Government Medical Colleges to enter in the public health services arena will not improve the quality of the services. Doctors can't be forced to examine the patients and treat them. Hence, manpower shortage needs to be tackled by offering various incentives like facilities for postgraduate study, additional remuneration, early promotion etc. There are many public health activities where sufficient fund is available but they do not reach the target population due to insufficient manpower. Apart from the National Health Programme (NHP), health is also a state subject. Most of the activities are carried out with the funds from the state government. Yet, only 1-1.5 per cent of the state budget is being allocated to the health department. Unless this percentage is increased the goals of achieving universal health cannot be achieved. Several private organisations offer funds for specific health activities with an intention to make profits. These pri-
vate organisations provide funds one time and then burden of carrying out these activities fall on the government machinery. Private healthcare providers are nowadays participating in public health activities through PPP models, but many are in the pursuit of mere profits. Hence, there is a need to revitalise the public healthcare system by providing sufficient manpower and sufficient funds.
IN MANYPUBLIC HEALTH ACTIVITIES, SUFFICIENTFUND IS AVAILABLE BUT THEYDO NOT REACH THE NEEDY DUE TO MAN POWER SHORTAGE EXPRESS HEALTHCARE
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March 2016
SPECIAL FOCUS - PUBLIC HEALTH
I A Kundan
Dr Girdhar J Gyani,
Mission Director, National Health Mission, Maharashtra
Director General, Association of Healthcare Providers (India)
‘Information for transaction intensive discretionary healthcare is a concern needing a remedy’
‘We need to implement an Infection Control Surveillance programme in all public health institutes’
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B
ublic health is a cross-cutting subject wherein all stakeholders and various government departments are required to address the issue of healthcare in the state and the nation. The community members or the users of health facilities are the end major stakeholders of public health. Further moving up, any intervention can never be implemented successfully without the help of frontline health functionaries who are a part of their respective community and are directly involved in the public health programme implementation at the village level. Then, other primary stakeholders of public health are service providers at the health facilities including the district hospitals, rural hospitals, sub-district hospitals, primary health centres and sub-centres. The managers at facility level or district level or state level also have a role in ensuring uninterrupted logistic supply and operation maintenance to make the service encounter meaningful. Therefore, at state headquarters, the policy makers can design policies for the benefit of general public. But these policies can never be
successful without the effective and efficient implementation by various stakeholders and the frontline workers as they are the backbone of the entire system. The information among various stakeholders, particularly for transaction intensive discretionary healthcare, is a concern needing a remedy. In lieu of this, Maharashtra has introduced two programmes through which information is being exchanged by various stakeholders like community members, doctors and healthcare providers, front line workers etc., at the same time i.e. Health Advice Call Center (HACC) which is a 104 call center to provide health advice free of cost and on 24X7 basis. Another programme that runs on the same concept is the RGJAY helpdesk which gathers grievances and suggestions from network hospitals, users and potential users. Here, various stakeholders including the general public can access the information about the treatments provided, coverage amount, eligibility and nearest empaneled hospitals on 24X7 basis.
HOR Committee report in 1946 had estimated that bulk of healthcare was being delivered from government hospitals and only eight per cent services were with private (trust) hospitals. The report strongly recommended that healthcare services should continue to be with the government. With the time and with growth of population, government however could not keep pace in terms of opening of new hospitals and that paved the entry of private/corporate sector in to healthcare. Today, the government investment in the health systems is limited to 1.1 per cent whereas the private sector was incurring 3.8 per cent of GDP. As of now more than 70 per cent of OPD and 60 per cent of IPD services are with private sector. Government is committed to provide health for all (UHC). But, it does not have adequate capacity of its own to provide UHC. Setting up of new hospitals at this stage would call for huge expenditure and government was not in position to do that. The only option available with government is that it procures health services from the private sector and delivers to the community. Such an arrangement has been
proved successful by government health insurance schemes in Andhra Pradesh, Tamil Nadu, Karnataka, Telangana, Gujarat and Maharashtra and more recently in Rajasthan. These services are made available to BPL families through cashless options from empanelled private hospitals and therefore are largely confined in urban settings. The rural population however continues to depend on a network of PHCs/ CHCs and district hospitals. These institutes suffer with inherent problems associated with government establishments. For e.g., we do not have specialists posted at CHCs. We need to strengthen the systems by improving efficiency and safety. We need to implement ‘Infection Control Surveillance programme’ in all public health institutes and monitor the key clinical outcomes. We need to train clinicians for undertaking clinical audits. We need to train nurses on infection control. This will make the public health system robust, safe and efficient, besides it will introduce an element of accountability within the system.
‘A realistic national policy for medical education is needed’
T Dr Alka Deshpande, Director General, Association of Healthcare Providers (India)
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he health sector revolves around human life. The right to health is upheld as a basic human right by the UN. But do we have adequate doctors, nurses and paramedical health workers to ensure this right to our populace? Medical education and health policies discuss doctor to population ratio. However, the ratio considers only allopathic doctors for the purpose of calculations while in reality along with allopathic doctors, AYUSH doctors are also catering to the healthcare needs, which is approved by GOI too. (Maharashtra has 80,000 allopathy doctors and 120,000 AYUSH practitioners) If so, why are they excluded from the
ratio? Yet, AYUSH doctors are permitted to prescribe modern medicines which results in unwarranted treatment and antibiotic abuse. Therefore, we need to develop a realistic approach while developing rational policies. Medical education is also divided between the goverment and the private sector. Both sectors are riddled with certain drawbacks. The government sector has a large number of patients who are unaware about their rights (Drug Trials!). Lack of trained teachers, advanced amenities for diagnosis are some of the other challenges. On the other hand, private medical colleges charge capitation fees alongwith exorbitant tuition fees. Hence, there is
a need to streamline medical education with better policies. The bottom line of drug procurement is low price. However, due to doubtful efficacy of these drugs, the patients end up spending double on drugs. Stringent regulations on pharma is the solution, but the industry itself can lower the prices by cutting down on promotional activities and favours to doctors! Self discipline, coupled with a code of conduct for the industry will change the scenario. Long term planning for procurement of equipment in government set ups is also essential. Better treatment protocols also need to be developed to improve healthcare delivery in India.
Dr Ramesh Bharmal, Dean , BYL Nair Hospital and TN Medical College Mumbai
‘Good population health is essential for developments in the economy and community’
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ublic health has traditionally been perceived as the responsibility of the government, by way of providing infrastructure facilities, personnel and materials for the population. The new concept of shared value recognises the common benefit derived by individuals, communities, groups, local bodies, businesses and governments when there is active participation of all the concerned stakeholders in public health efforts and initiatives. This improves the quality of life of the population while simultaneously reducing the healthcare costs. The most important stakeholders are those most dramatically affected. In order to gain stakeholder participation and support, it’s important to understand not only who potential stakeholders are, but the nature of their interest in the effort. With that understanding, it should be possible to invite their involvement, address their concerns, and demonstrate how the effort will benefit them. Stakeholder analysis is used to identify and assess the influence and importance of key people, groups of people, or organisations that may significantly impact the success of an initiative. As public participation becomes increasingly embedded in national and international public health policy, it becomes ever more crucial for decision-makers to understand who is affected by the decisions and actions they take, and who has the power to influence their outcome. The motivations for degree and depth of involvement of any stakeholders in the public health efforts vary widely. Some may have a truly altruistic outlook and volunteer because they feel it’s the right thing to do. In the case of governments this may well be improvements in public health, the creation of a healthy society etc. Poor health is both a symptom and a creator of inequality. Preventable disease reduces people’s ability to work, removes valuable resources from society and reduces economic perform-
ance at both country and organisational level. Good population health is essential for developments in the economy and community. Employment opportunities and inward investment are facilitated by a labour market that is characterised by high levels of fitness and health. Funding relevant research to understand what can be done to improve health, and equity in health outcomes, is a priority as is making the best use of that research as part of government objectives But, this will not be a legitimate reason for other stakeholders to become involved. Businesses, companies and trade unions may see benefits in terms of reducing loss of productivity due to sickness, reducing healthcare expenditure because of effective prevention and also as a part of their corporate social responsibility. At times businesses may participate just because their competitors are doing it, thus they must do the same to maintain their market position. The government can create opportunities for employers to participate in health promotion initiatives through national and local health campaigns, accreditation/ award schemes and capacity building. For a few stakeholders it’s a matter of compulsion e.g. doctors serving in rural areas as a compulsory part of their curriculum and bonds with the government. The significant risk with this approach is that stakeholders might not willingly participate in the activities and will do the absolute minimum expected from them. Promoting and supporting the development of a healthy society must include disease prevention and health promotion and through their legitimate roles NGOs are ideally placed to facilitate this process. NGOs can hold government and employers to account on issues relating to the public health, the provision of information and access to facilities/products relating to diet and physical activity and the prevention of lifestyle related diseases.
THE CONCEPTOF SHARED VALUE RECOGNISES THE BENEFITDERIVED BY THE PARTICIPATION OFALLTHE STAKEHOLDERS IN PUBLIC HEALTH. THIS IMPROVES THE QUALITYOFLIFE OF THE POPULATION AND REDUCES HEALTHCARE COSTS Research associated bodies are sources of evidence, expertise and innovation. They include academia, respected expert national and international entities, and research and development corporations. Media has a powerful role in influencing culture and opinion and is a key partner in strategic communications. It has a formal role in educating and creating interest and readiness for change through strategic communications. The media is also able to draw attention to issues from the public’s perspective. As with any community building activity, work with stakeholders has to continue for the long term in order to attain the level of participation and support needed for a successful effort. New stakeholders may need to be
brought in as time goes on. Stakeholder engagement is not about giving the public a list of options to choose from – it’s about drawing them in right from the start, so that their views, needs and ideas shape those options and the services that flow from them. There are three levels of stakeholder engagement. The lower levels, (manipulation, therapy, informing) relate to situations in which the organisation is merely informing stakeholders about decisions that have already taken place, although these levels represent bad practice if done in isolation. They are often among those most affected by an effort, and thus have good reason to work hard for or against it, depending on how it affects them. Often, the stories of those who have or will benefit from the effort can be effective motivators for people who might otherwise be indifferent. At middle levels, (explaining, placation, consultation, negotiation) stakeholders have the opportunity to voice their concerns prior to a decision being made, but with no assurance that their concerns will impact on the end result. Providing whatever information, training, mentoring, and/or other support they need to stay involved is always helpful. Maintaining their enthusiasm with praise, celebrations, small tokens of appreciation, and continual reminders of the effort’s accomplishments goes a long way in achieving full participation. The highest levels, (involvement, collaboration, partnership, delegated power, stakeholder control) are characterised by active or responsive attempts at empowering stakeholders in decision-making. Employing them in the conception, planning, implementation, and evaluation of the effort from its beginning usually assures full participation. Coordinated and committed participation of the stakeholders is key to impact and success of a public health initiative.
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STRATEGY SPOTLIGHT
PerkinElmer revs up India diagnostics ops With one of the highest birth rates in the world, India is one of the most obvious strategic growth markets for the prenatal and neonatal diagnostics business of PerkinElmer. Dr Prahlad Singh, President, Diagnostics, PerkinElmer and Jayashree Thacker, President, PerkinElmer India explain the company's strategy for the country By Viveka Roychowdhury
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he US-based PerkinElmer recently launched a 13440 sq feet diagnostics facility in Chennai's TICEL Bio Park. Approximately 10400 sq feet will be devoted to lab operations for prenatal and newborn screening (NBS), and will extend the company's capabilities in India with a widened set of assays related to cytogenetics and molecular diagnostics. PerkinElmer will also provide customer service and support, along with product training and demonstrations at this facility. (See story: http://www.financialexpress.com/a rticle/healthcare/happeningnow/perkinelmer-opens-diagnostics-facility-in-chennai/212687/) Besides diagnostics, the parent company straddles several markets such as pharmaceuticals, biotech, food, agriculture, chemicals, plastics, automobile, academia and research labs with its portfolio of instrumentation and services. PerkinElmer has had a presence in India since 1981 through distributors. It established direct operations in India in 2004. Today, the company is reportedly a market leader in the space of diagnostic screening services in India, with the majority of tests being performed in the prenatal and NBS space. This includes PerkinElmer’s recently launched Bacs-on-Beads (BoBs), a highthroughput molecular karyotyping platform, which does not require culturing of samples and delivers result in 24 hours compared to conventional karyotyping techniques which deliver results in about three weeks. But even as a market leader, PerkinElmer India and other
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Lamp lighting ceremeony by Dr Prahlad Singh
labs in the country currently screen just a tiny fraction of the nearly 29 million pregnancies and 26 million newborns in India. Clearly, the growth potential is huge and this explains the Waltham, Massachusetts-based parent company's renewed focus on its India operations. In a chat on the sidelines of the launch, Dr Prahlad Singh, President, Diagnostics, PerkinElmer who formally inaugurated the facility, is very clear that a major focus of their investment will be in emerging markets such as China and India. "These countries are clearly our two strategic markets and resources will be disproportionately allocated here. I expect market growth in India to be in the high double digits and we are actively looking for inorganic growth opportunities and partnerships to achieve this growth." After India and China, other Emerging Markets, including Brazil, Mexico, ASEAN coun-
tries as well as the Middle East would be the next areas of focus. Giving an overview of the company's headcount in India, Jayashree Thacker, President, PerkinElmer India says that of the approximately 350 staff in India, around one-fifth would be in the Diagnostics division. Globally, the parent company reported revenue of approximately $2.3 billion in 2015, has approximately 8,000 employees serving customers in more than 150 countries, and is a component of the S&P 500 Index. In its home market of the US, where NBS is part of the public healthcare system, PerkinElmer provides NBS services to almost all of the states, a majority of which have their own public health laboratories, according to Dr Singh. But emerging markets have been slow to make NBS part of the public, for a variety of reasons; primarily lack of financing, infrastructure and awareness. Singh says it takes several years
of partnering with the government to make NBS a part of the public healthcare system, for example in China where newborns are now tested for atleast a couple of disorders. NBS first made its appearance in 1963. The Health Ministry's plans for universal NBS in India were made public in 2012. And momentum seems to be picking up, with the National Neonatology Forum hosting a day-long Newborn Screening Policy and Consultative Meeting in September last year. Numerous research papers have shown that in India congenital hypothyroidism, congenital adrenal hyperplasia, and glucose 6phosphate-dehydrogenase deficiency are the most prevalent inborn metabolic disorders present in significant numbers to be designated as public health problems. The goal of any NBS programme is to catch the disorder early enough to treat the condition before it can escalate. In order to screen a
majority of newborns it requires setting up the appropriate infrastructure which involves the logistics of transporting and storing the sample kits at public hospitals, training the staff to administer them, consenting and counseling parents and family members, and then transporting the samples themselves to the test centres. The follow up with positive and borderline positive samples is also fraught with challenges. But there is no doubt that treatment and disorder management costs at the early stages would be a fraction of what it would cost were these disorders detected at later stages. In a country where most of healthcare spend is out of pocket, it is no wonder that an increasing number of would-be parents are opting for these tests. Thacker confirms that “the company has seen a steady rise in demand for maternal foetal health and NBS solutions in India as hospitals, clinicians and expectant parents strive to ensure healthier outcomes through early detection, diagnosis and proper management of prenatal and neonatal conditions. This state-of-the art laboratory underscores our commitment to our continued expansion plans in India. By increasing our capacity to accommodate higher testing volumes, offer a comprehensive and growing menu of diagnostic assays, and provide a hands-on experience with our innovative technologies, we are further supporting India’s healthcare requirements.” viveka.r@expressindia.com
STRATEGY INSIGHT
Management of tuberculosis: 10 common pitfalls to avoid Dr Srinath Satyanarayana and Dr Madhukar Pai, TB researchers at McGill International TB Center, McGill University, Montreal, Canada share valuable insights on the most common mistakes made healthcare practitioners in diabetes management
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ndian TB patients get diagnosed after a delay of nearly two months, and are seen by three different providers before a diagnosis is made. At the primary care level, patients rarely get investigated for TB, even when they approach a practitioner with classic TB symptoms. Instead, providers give broad-spectrum antibiotics (e.g. fluoroquinolones) and remedies such as cough syrups and steroids. Even when TB is considered likely, private physicians tend to order tests that are non-specific, such as complete blood count, ESR, Mantoux test, and chest X-rays. They rarely seek microbiological confirmation via sputum smear microscopy, culture or polymerase chain reaction tests. Even if the diagnostic hurdle is overcome, TB treatment in the private sector is far from standard. When private practitioners initiate anti-TB treatment, they tend to use drug regimens that are not recommended by WHO or the International Standards of TB Care. Furthermore, private practitioners often fail to ensure treatment completion, and provide adherence support to their patients. This article, discusses the 10 most common pitfalls that doctors should avoid. Addressing these pitfalls should greatly improve the quality of TB care in India.
PITFALL 1: Not recognising and suspecting TB
PITFALL 3: Use of inappropriate diagnostic tests
Doctors in India often miss TB, because they do not suspect TB in patients presenting with cough for two weeks or longer.1 Multiple rounds of broad-spectrum antibiotics are tried, but tests for TB are rarely ordered at the primary care level.2 Even when TB is suspected, history taking is often incomplete – family history of TB is rarely elicited, and previous treatment for TB is also missed.2
PITFALL 2: Inadequate diagnostic work-up When doctors in India think of TB, they often order non-specific tests such as total and dif-
ferential blood counts (TC/DC), erythrocyte sedimentation rate (ESR), and chest X-ray.1, 2 While these tests can be helpful, they do not confirm tuberculosis. Abnormal X-rays, for example, do suggest TB, but other lung conditions can also produce abnormalities on radiography. So, only relying on chest X-ray can result in over-diagnosis. Tuberculosis can only be confirmed by microbiological tests such as sputum smear microscopy, GeneXpert, and cultures. So, it is very important to order sputum tests that can directly detect mycobacterium tuberculosis.
Active tuberculosis is a microbiological diagnosis. Serological, antibody-based tests (e.g. TB ELISA) are inaccurate and banned by the Indian government.3 They should not be used for TB diagnosis. In India, there is growing concern that tests such as Mantoux (tuberculin skin test) and IGRAs (e.g. TB Gold, TB Platinum) are being misused for active TB diagnosis. These tests were designed to detect latent infection, and cannot separate latency from active disease. The Standards for TB Care in India (STCI) clearly states that both TST and IGRAs should not be used for the diagnosis of active TB in high endemic settings like India.3 If Mantoux and IGRAs are used for active TB diagnosis, this will result in significant overdiagnosis of TB, because of the high background prevalence of latent TB infection in India. In children, STCI suggests that the Mantoux test may have some value as a test for infection, in addition to chest Xrays, symptoms, history of contact, and other microbiological investigations (e.g. gastric juice acid fast bacilli and Xpert MTB/RIF).3
PITFALL 4: Not considering the possibility of drug-resistant TB (DR-TB) DR-TB occurs when patients
DR SRINATH SATYANARAYANA TB researchers at McGill International TB Center, McGill University, Montreal, Canada
DR MADHUKAR PAI TB researchers at McGill International TB Center, McGill University, Montreal, Canada
fail to complete first-line drug therapy, have relapse, or newly acquire it from another person with DR-TB. All persons who have previously received TB therapy must be considered to have suspected DR-TB. If patients have any risk factors for drug-resistance, or live in a high MDR-TB prevalence area (e.g. Mumbai city), or do not respond to standard drug therapy, they must be investigated for MDR-TB using drugsusceptibility tests (DST) like GeneXpert, line probe assays, and liquid cultures. Indian physicians under-use DST and this can result in mismanagement.
PITFALL 5: Empirical management of suspected TB with quinolones and steroids When doctors suspect TB or other lower respiratory tract infections, they frequently use broad-spectrum fluoroquinolones (e.g. levofloxacin, moxifloxacin) for short periods. However, such empirical management with fluoroquinolones will mask and delay the diagnosis of TB. Fluoroquinolones, in particular, are bactericidal for M. tuberculosis complex. Empiric fluoroquinolone monotherapy for respiratory tract infections has been associated with delays in initiation of appropriate antituberculosis therapy and acquired resistance to the fluoroquinolones.4 Doctors also tend to use steroids in individuals
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STRATEGY with history of chronic cough. Steroids, again, can result in temporary clinical improvement, but delay the diagnosis and treatment of underlying tuberculosis.
PITFALL 6: Once TB is diagnosed, not addressing co-morbidities and contacts Once TB is diagnosed, it is important to make sure the patient is not suffering from comorbid conditions such as HIV and diabetes. It is also important to check if the patient is a smoker/alcoholic and provide them advice on smoking/alcohol cessation. It is also necessary to ask about TB symptoms among family members. In particular, small children living in the same family as the adult case must be tested for TB.
PITFALL 7: Use of irrational TB drug regimens Even if the diagnostic hurdle is overcomed, TB treatment in the private sector is far from standard.1 When private practitioners initiate anti-TB treatment (ATT), they tend to use drug regimens that are not recommended by WHO or the Standards of TB Care in India (STCI). All patients who have not been treated previously and do not have other risk factors for drug resistance should receive a WHO-approved firstline treatment regimen for a total of six months.4 The initial phase should consist of two months of isoniazid, rifampicin, pyrazinamide and ethambutol.
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Adherence to the full course of Anti Tuberculosis Treatment is important to ensure high cure rates and to prevent drug-resistance The continuation phase should consist of isoniazid and rifampicin given for four months. There is no need to add additional drugs such as quinolones to the standard drug regimen.4 Also, there is no need to extend the duration of treatment beyond six months, unless there is evidence of treatment failure, or there are complications (e.g. bone & joint TB, spinal TB with neurological involvement and neuro-tuberculosis). Drug dosages should be based on body weight, and daily dosing is preferable.4 Some physicians have the mistaken perception that second-line medication are more potent than first-line medication. In fact they are less effective (and more toxic) medications, and should be reserved only for patients with drug-resistant TB, or first-line drug intolerance.
PITFALL 8: Not ensuring treatment adherence Adherence to the full course of ATT is critically important to ensure high cure rates and to prevent the emergence of drugresistance. But private practitioners struggle to ensure adherence. Most do not maintain any medical records, and this
makes it very difficult to followup patients. Patients often do not receive sufficient counselling about the importance of completing the full course of ATT. Drug-related side effects (if not adequately counselled on at the outset) is another common reason for non-adherence, and possible treatment default. Every TB patient should receive counselling at the start of TB treatment. By notifying all TB cases to the local health authorities, private practitioners can seek help from the public sector to help follow-up patients who default. Physicians can also work with community-based organisations, and enlist community health workers to supervise treatment.
failing regimen is a big concern. Many physicians add a quinolone to the four first-line drugs (HRZE) when the standard therapy does not result in improvement. This is wrong, and can result in MDR-TB. Sometimes, patients end up moving from one doctor to another, and each time the drug regimen gets modified without adequate drug-susceptibility testing (DST) to guide the choice of drug combinations. This creates a perfect environment for drug-resistance to emerge or worsen.
PITFALL 9: Not monitoring response to therapy and changing regimens without DST
TB treatment is available free of cost to all patients in India via the Revised National TB Control Programme (RNTCP).5 So, private practitioners can refer all TB patients for treatment through the RNTCP, unless patients insist on being treated in the private sector. RNTCP provides a range of services such as contact investigation, linkage to free TB drug programmes, adherence support, and linkage to PMDT services for patients with MDR-TB.5 By availing
Once ATT is started, doctors have the responsibility of monitoring the patients to check whether therapy is working. This requires follow-up smear and culture testing. Negative smears at the end of therapy is important to ensure cure. If a patient is not responding to ATT, it important to investigate for the reason behind the same. Addition of a single drug to a
PITFALL 10: Not notifying all cases and using free public sector services for vulnerable patients
these free services, patients can protect themselves from catastrophic health expenditures. Irrespective of where the patients are diagnosed and treated, it is mandatory for private practitioners to notify all TB cases to their respective District or Corporation TB Officers. References 1.Satyanarayana S, Subbaraman R, Shete P, et al. Quality of tuberculosis care in India: a systematic review. Int J Tuberc Lung Dis 2015; 19(7): 751-63. 2.Das J, Kwan A, Daniels B, et al. Use of standardised patients to assess quality of tuberculosis care: a pilot, cross-sectional study. Lancet Infect Dis 2015 (published ahead of print). 3.World Health Organization Country Office for India. Standards for TB Care in India. URL: http://www.tbcindia.nic. in/pdfs/STCI%20Book_Final% 20%20060514.pdf (date accessed 7 April 2015), 2014. 4.TB CARE I. International Standards for Tuberculosis Care, 3rd Edition. URL: www.istcweb.org (date accessed 7 April 2015)2014. (accessed. 5.Sachdeva KS, Kumar A, Dewan P, Kumar A, Satyanarayana S. New Vision for Revised National Tuberculosis Control Programme (RNTCP): Universal access - "Reaching the un-reached". Indian J Med Res 2012; 135(5): 690-4. This article was originally published in GP Clinics as part of a supplement entitled Let’s Talk TB.
KNOWLEDGE INSIGHT
TB and infertility: An unholy nexus Dr Trupti Mehta, Senior Infertility Consultant,Jaslok Hospital and Research Centre, Mumbai highlights that genital TB can cause infertility and emphasises on early detection and treatment
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B can have particularly severe consequences for women, especially during their reproductive years. Worldwide prevalence of genital TB is estimated to be 8-10 million cases. India is a country with one of the highest burden of the infection, accounting for one fifth of the global incidence annually. While pulmonary TB (of lungs) is the most common form of TB, genital TB impacts the fertility of women and men. The actual incidence of genital TB cannot be determined accurately because it is estimated that at least 11 per cent of the people having TB are asymptomatic and the disease is discovered incidentally during an evaluation for cause of infertility. It’s prevalence varies from 18 per cent in India to less than one per cent in the US. The causative organism which is usually mycobacterium tuberculosis spreads through the air when an infected person coughs, sneezes, spits, laughs or talks. Once in the body it lodges in the lungs and may cause an infection or stay dormant in the body for years defined as a latent infection. The infective focus in the lung often heals, but can spread elsewhere causing an infection or may again lie dormant for years, only to reactivate later like during times of low immunity. Genital TB is almost always secondary to TB elsewhere in the body originating in the lungs and sometimes in kidneys, gastrointestinal tract, bone or joints. Increased circulation, hormone dependence of genital organs after sexual maturity may in part explain why the genital system is vulnerable to this infection during this phase. The most common genital sites of infection in women are the
fallopian tubes (involved in around 90 per cent cases), endometrium (involved in 50–80 per cent cases), ovaries (involved in 20–30 per cent cases), and cervix (involved in five to 15 per cent cases). Among men, the usual sites of infection are the epididymis, prostate, vas deferens, seminal vesicles, ejaculatory ducts and testis in a lower proportion of cases. In women the presenting symptoms are generally varied; infertility being the most frequent (43-74 per cent). There are subtle signs that could indicate a problem, especially if a woman has suffered from pulmonary TB in the past. However, some of the symptoms to watch out for include pelvic pain, back pain, irregular menstrual cycle, vaginal discharge stained with blood, bleeding after intercourse and to say the least infertility. 32-year old Nisha was married for eight years and had already undergone three attempts of intra-uterine insemination (IUI) and two attempts of in-vitro fertilisation (IVF) without any demonstrable cause of their problem. The couple had lost all hopes of a child when they were suggested an evaluation of Nisha’s endometrial lining. To their utter dismay, her tests indicated genital TB and she underwent the anti-tubercular treatment. She was delighted to conceive naturally while on the medication and is now a mother to a chubby baby girl. Thus, genital TB is found to be a causative factor in many couples with unexplained infertility. Even latent genital TB may be a cause of repeated IVF failures if the disease is not diagnosed and treated. Other major presenting complaints are abnormal bleed-
DR TRUPTI MEHTA Senior Infertility Consultant Department of Assisted Reproduction & Genetics Jaslok Hospital and Research Centre, Mumbai
ing, pelvic pain, and amenorrhea. Genital TB can affect the fallopian tubes causing them to get hardened, stiffened (leadpipe like appearance), obstructed (tubal block), retortshaped, swollen(hydrosalpinx) which not only causes infertility but also increases chances of an ectopic (pregnancy in the tube) which can prove life threatening if not detected and managed in time. Apart from the tubes, TB also affects ovarian function. Depending upon the severity and stage of disease, there may be tubercles on the ovary, adhesions, caseation, tubo-ovarian cyst or abscess formation. It can reduce the blood supply to the ovaries resulting in a reduced ovarian reserve. Such women would at times need donor eggs to help them conceive. The endometrium which is the uterine lining can get damaged to various degrees resulting in endometritis (inflammation of the lining), calcification (calcium deposits in lining) or in severe cases adhesions in lining. Depending on the extent of damage the couple may be advised assisted reproductive techniques ranging from IUI to IVF to even surrogacy or adoption in cases where there is irreparable damage to the endometrium. In men it can be present as azoospermia (absence of sperm in semen), aspermia (absence of semen during ejaculation), dysuria (pain while passing urine),
tenderness, swelling or abscess in the scrotal area or rarely, a penile ulcer. The cause of male infertility is usually obstruction of the seminal vesicles or vas deferens. However, the disease poses a great diagnostic challenge. Diagnostic methods include smear and culture of infected tissue. The gold standard for the diagnosis of TB in any site is culture to identify M. tuberculosis. Mycobacteria grow slowly, hence it can take up to six weeks for a culture to be positive. The newer radiometric culture BACTEC has a sensitivity of 80- 90 per cent. PCR test is now commonly employed for the diagnosis of genital TB. Various other methods for detection are Mantoux Test, Interferon y Release assays, histopathology, intravenous urography (IVU), ultrasonography and CT. In addition, PCR can detect the genes that confer resistance to drugs; for example, the rpoB gene, which signifies resistance to rifampicin, and can probe for mutations associated with resistance to isoniazid, quinolones and aminoglycosides which are used as anti-tubercular drugs. This process allows early identification of multi-drug resistant (MDR) or extensively drug resistant (XDR) TB. Continuing research is needed for finding simpler and practicable methods for making definitive diagnosis which can help early detection and timely treatment. Also men and women are usually upset when they learn of the diagnosis to be a cause of their infertility, as the disease carries a social stigma. Many people who have fertility problems feel higher levels of stress. Apart from getting support from family and friends, it can be helpful to see a professional
counsellor who has experience working with people dealing with such issues. They can help manage the emotional stress and decision-making challenges during treatment. Following early diagnosis, multiple regimens of treatment with standard four-drug regimen anti-tubercular drugs are used for a minimum of at least six to nine months. These help restore reproductive function and are favourable for fertility when tissue damage is minimal. Minimally-invasive laparoscopy may be needed to treat/block hydrosalpinx(ges) and hysteroscopic adhesiolysis or metroplasty to repair the uterine cavity damage. Women without tubal or endometrial damage given early anti-tuberculosis treatment have a good chance of early spontaneous conception. In cases where the organs are more severely involved the outcome is compromised even with specialised assisted reproductive techniques like IVF, ICSI. Studies have shown that even if these women conceive there is a higher chance of having a spontaneous abortion or an ectopic pregnancy. Damini and Yogesh were both diagnosed with genital TB. They underwent a couple of failed attempts at IVF following which they were advised surrogacy which helped them have Yash in their lives. Thus in some cases, where the illness has damaged the reproductive organs to a great extent, many have to opt for surrogacy or adoption to enjoy the joys of motherhood. Finally early detection, starting treatment of the core condition soon after it is detected and completion of the course of the treatment are certain ways to help ensure a minimal impact on fertility.
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KNOWLEDGE I N T E R V I E W
‘Number of patients acquiring HAIs is more than those with cardiac problems, cancer and AIDS’ Dr Victor D Rosenthal, Founder and Chairman, International Nosocomial Infection Control Consortium (INICC) talks about the prevalence of HAI infections in India and the measures that healthcare providers can adopt to reduce their incidence, in an interview with Sanjiv Das
What is the incidence of healthcare associated infections (HAIs) in India? How does India as a country compare with global numbers? Mortality rate of HAIs is between 20-40 per cent. The number of patients acquiring HAIs is more than those with cardiac problems, cancer and AIDS. The HAI rate from public sector in India is unknown and higher than the private sector. HAI rates of private sector, as an example for central line associated bloodstream infections (CLABSIs) is around five CLABSIs per 1000 vascular catheter days, meanwhile, in the US the CLABSI rate is one per 1000 vascular catheter days. While India has lower HAI rates than most other developing countries, such infections are on the rise in the country because of various reasons such as limited awareness among health workers. For patients, it will mean longer hospital stay and enduring medical costs. What are the key findings and recommendations of the India-based study conducted by the International Nosocomial Infection Control Consortium (INICC) on CLABSI rates in India? A recent study was conducted in India between April 2012 and August 2014 on 1096 patients. The study was
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carried out in five medical surgical adult ICUs in two tertiary-level hospitals, published in the American Journal of Infection Control (2015) has proved that usage of open connectors and conventional practices such as manual preparation of intravenous fluids – increased CLABSIs (catheter associated blood stream infections). Adoption of advanced technology namely, split septum needle less connectors and single use pre-filled flush helped in reducing CLABSI rates, shorten hospital stay and cost savings. Which parameters did you keep in your mind while conducting the study? INICC receives HAI rates data from 20 cities of India, the most recent published report has a representation of data from the year 2003 – 2014, and the CLABSI rate for this duration was five CLABSIs, which is five times more than in the US. Then we reviewed all interventions to control CLABSI rates and found that the interventions in India are different than in US, and this explains why the rate of CLABSIs is five times of the US. Thus we decided to analyse the impact of two interventions (split septum and single use flush) in India. As a result, we achieved a rate of 2.2 CLABSIs, which is lower than India’s mean CLABSI rate of five CLABSIs
and closer to the US mean rate of one CLABSI.
The most recent published INICC report on HAI has a representation of data from the year 2003 – 2014, and the CLABSI rate for this duration was five CLABSIs, which is five times more than in the US
How can the findings of the study be utilised by hospital managements in India to reduce HAIs? In order to achieve lower CLABSI rates, hospital managements and healthcare professionals should adopt catheter care bundles – defined as a ‘group of best practices that individually improve care, but when applied together result in substantially greater improvement’, these bundles consists of behavioural as well as technology elements. ◗ Hand hygiene ◗ Maximal barrier precautions upon insertion of vascular catheters ◗ Clorhexidine skin antisepsis ◗ Optimal catheter site slection, with avoidance of the femoral vein in adult patients ◗ Daily review of line necessity with prompt removal of unnecessary lines ◗ Sterile dressing care at insertion site ◗ Clorhexidine impregnated dressing at insertion site ◗ Closed IV containers ◗ Split Septum as a connector ◗ Single use pre-filled flushing ◗ Disinfection of catheter hub, connector, and injection port before they are accessed ◗ Bath with chlorhexidine By adopting latest technology, health professionals may prevent much unnecessary medical and financial distress to their
patients. What are some of the biggest barriers to reducing HAIs: cost, mindset of healthcare practitioners or other factors? Awareness of bundles for HAI prevention, compliance to best practices, research and resources. Give us some details of the surveillance tool that you are currently working on which could change the way hospitals manage infections? The INICC surveillance programme includes surveillance of deviceassociated - HAI rates (rates of CLABSI per 1000 vascular catheter days), use of invasive devices, their adverse effects, including length of stay, mortality rates, microorganism profile, and bacterial resistance, and patient characteristics, such as age, sex, average severity illness score (ASIS), and underlying diseases. Investigators are required to complete outcome surveillance forms at their ICUs. CLABSI definitions and surveillance methods were performed applying the definitions for HAI developed by the Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN) programme. sanjiv.das@expressindia.com
KNOWLEDGE I N T E R V I E W
‘ The main challenge that we face is lack of education and knowledge amongst the masses about cancer’ Dr (Prof) Santanu Chaudhuri, Chairman - Radiation Oncology, Nayati Healthcare speaks to M Neelam Kachhap about the challenges in radiation oncology in India What is the most interesting part of being a radiation oncologist? The most interesting part of being a radiation oncologist is being associated with a branch of oncology which deals with technological advancements each day. Advancement of technology has equipped us with techniques which can treat the tumour in a targeted manner without or minimally radiating the surrounding structures or organs which are normal. This is an ever evolving speciality, developing each day. Being a clinical oncologist, I can contribute to the nonsurgical management of cancer patients. Pain and palliation is also an important area of my practice. Nayati Multi super Specialty Hospital, Mathura sits in a belt where we have a very high incidence of cancer. Due to poor awareness and late detection, we get more than 60 per cent of cancer in late stages. Radiation oncology plays an important role in these patients of stage 3 and stage 4, where intent radical and palliative treatment provides a good quality of life improvement. In early stages, radiotherapy alone or in combination with chemotherapy or targeted therapies gives excellent results. In organ preservation radiotherapy can be used radical setting alone, or with combination with other forms of cancer treatment. What challenges do you face in your everyday practice and what do you do to overcome those challenges? Nayati Healthcare operates in tier-II and tier-III cities and towns. The main challenge that we face is lack of education and knowledge amongst the masses about cancer. In order to
◗ Dedicated day care services ◗ Radiosensitisers, radioprotectors and concomittent therapies ◗ Biologically targeted therapies ◗ Multi-disciplinary Tumour Board ◗ Oncological emergency services ◗ Lymphoedema management ◗ Stoma clinic ◗ Counselling support ◗ Onco e-library ◗ Evidence-based treatment following international protocols
address this challenge, Nayati Healthcare recently unveiled ‘Hope for Cancer’. This is a unique initiative to create awareness and engage with the community to educate them on early detection and prevention of cancer. Our practice other than the main treatment includes majorly, educating the patient and the relatives about the disease, its manifestations, the treatments and the side effects. We are spreading the awareness amongst masses that if detected at an early stage and with timely proper treatment, there is hope for all cancer patients and their families. We also educate them about associated myths about cancer and its treatment. What is new in radiation oncology in India? The quality consciousness in our patients who are affording, has educated them enough in today’s electronic world to understand what is best for them. Patients now come to us asking for the most advanced treatments available in the world for their disease like IMRT, VMAT, and IGRT etc. For such advanced treatment techniques, highly specific immobilisation and simulation are needed. 4D CT and PETMR Fusion have become routine in our practice nowadays. Other than this, Stereotaxy has become clinically very useful in certain subgroup of patients. SRS/SRT and SBRT are also being used often in selective cases of brain and body where high conformation of target area is required. Advancement in brachytherapy including image guided (MRI/CT) brachytherapy is also an area of high precision.
Radiation oncology is an evolving and developing speciality, mostly due to high dependency on technological advancements
The support services in an oncology set up enumerated below are very important in order to provide a multimodality approach to cancer management. ◗ Dedicated palliative medicine and cancer pain management services. ◗ Preventive oncology services
Is India slow to adopt new technology? Not at all. In my career, I have travelled extensively to many internationally acclaimed cancer management centres, but of late, I see that the technological advancement and the knowledge base in India is as strong as any place in the world. It had been very fast in the last decade in selected pockets as economics plays an important role in a cancer centre setup. You practice in a tier-II city how is that different from tier-I city? Firstly, in a tier-II city most of the patients are those, who due to paucity of facilities used to go to tier-I cities for their treatment. Nayati multi-super specialty has reversed the trend by taking treatment to the patients. The need for cancer care and cure is nowhere greater than in Uttar Pradesh, which is faced with the challenge of highest incidence of cancer in the country and to address this challenge in a comprehensive yet humane manner; we have launched the Nayati Centre of Excellence for Cancer. Since
our hospital has all specialties under one roof, cross referrals will not be a problem, as cancer patients’ issues are normally multi prong. Secondly, in tier II cities, the awareness of the disease is poor. So the practice in addition to the treatment involves counselling and educating the patients about the disease and its management. How do you see the field changing in the coming years? Radiation oncology is an evolving and developing speciality, mostly due to high dependency on technological advancements. In the coming few years, from the Indian context, I think the following areas need to develop for further advancements: ◗ More post graduate trainings for doctors, physicists and technicians ◗ Technological upgradation with even more advanced technologies like Tomotherapy, Cyber-knife and proton therapy. ◗ Advancement in field of cancer research ◗ Due to huge volume of advanced cancer cases, standalone palliative care centre need to come up. ◗ Mobile early detection facilities have to be made available. ◗ Domiciliary care improvement. ◗ Tele networking with other major cancer centres of India and abroad. ◗ Technology transfer and human resource transfer programme between us and other oncology centres of excellence. ◗ Promote medical tourism mneelam.kachhap@expressindia.com
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IT@HEALTHCARE INSIGHT
Helping healthcare develop a cure for Big Data
JOHNNY MA Director, Healthcare & Life Sciences, Asia Pacific, Hitachi Data Systems
Johnny Ma, Director of Healthcare & Life Sciences, Asia Pacific, Hitachi Data Systems gives valuable tips on how healthcare professionals should tackle Big Data effectively to ensure best outcomes
I
f there is anything that doctors understand, it’s how to analyse data!
In fact, the entire profession is built on developing an empirical understanding of the causes of diseases and the efficacy of treatments. And while brilliant inspiration plays a key role – take the discovery of penicillin for example – the majority of medical benefits come from analysing and understanding data sets, from which lifechanging conclusions can be drawn. But things are changing. In the past, the data might have come from a single source, such as a research programme. And even the Human Genome Project, which unlocked the secrets of our DNA, drew data from a very narrow set of sources. Today, the big challenge that healthcare professionals face isn't analysing data. It’s dealing with the so called ‘Big Data’ – the sheer volume of different kinds of information being generated every second of the day. With the right tools, Big Data can be used in an unimaginable number of ways to advance science, benefit patients and, last but not least, enable healthcare institutions – from single surgeries to huge hospitals – to operate as efficiently as possible.
Welcome to the world of Big Data Many hospitals are just em-
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barking on the big data journey and even compiling a full background picture of a patient can prove extremely difficult. This is largely because the necessary data is coming from such a large and constantly increasing variety of sources. For example, a single hospital department often operates several different types of medical equipment, with each one producing data in a different format. They all have to be combined with data from other sources – such as blood work, past and present medication, family history and doctor and nurses notes – before they can tell an accurate story. Although the pace of medical innovation has enabled the industry to overcome many issues, the Big Data explosion has created new challenges. Accordingly, many of the most forwardlooking healthcare providers are now looking for ways to integrate all their data in a single place on a single platform, so they can unlock the value hiding in this constantly growing resource. Thankfully there are solutions coming to market that can address these issues and integrate health applications, data sources and locations. These systems mean all data can be integrated, regardless of whether it is generated by proprietary applications, equipment, social media or new technologies. This enables doctors to easily and quickly
gain access to a patient’s full history, and ultimately leads to better and more efficient care. It’s a small step for technology, but it could mean a giant leap for the future of medicine.
Step 1: Integrating data These solutions are having an impact in the region. One of Hong Kong’s leading private hospitals is using Hitachi Cloud Services Connection (HCSC) – Healthcare to consolidate all patient-relevant radiology images into a single platform, giving Visiting Medical Officers (VMOs) access to patient results in real-time and from any location regardless of origin or data format. We are working together to integrate all Picture Archiving and Communication Systems (PACS) into a single repository and will even enable mobile access to patient records by
VMOs and other healthcare professionals anytime, anywhere. Taking this a step further the hospital then plans to use clinical analytics to create opportunities to establish wellness campaigns and implement evidence-based protocols that will directly impact the delivery of patient care. This seemingly simple step forward in data integration is actually having a huge impact on medical care.
Step 2: Turning data into information Of course, once you have the data you then need to use it. So many healthcare organisations are looking to take the next logical step. And by that I mean, further analyse patient data to accelerate diagnoses, immediately spot warning signs and help to prevent dis-
eases. The latest technologies in preventive care and personalised medicine are able to identify trends, maximise access and improve patient outcomes by leveraging data. Take the research collaboration agreement that Hitachi Data Systems recently signed with one of Malaysia’s most prominent universities – Universiti Teknologi PETRONAS (UTP). Aimed at improving clinical support for traumatic brain injuries, the study brings together our HCSC – Healthcare solution with UTP’s biomedical image analysis and analytics. It will initially be focused on traumatic brain injuries, and will integrate magnetic resonance imaging (MRI) scans, blood panels and intensive care unit (ICU) data. The result will be instant clinical support that can benefit both patients and healthcare professionals. UTP has been involved in the field of neurosciences for some time and has a wealth of patient data. With HCSC – Healthcare, the university will be able to integrate that wealth of information and gain new insights into these kinds of complex injuries. And once the healthcare industry really comes to grips with Big Data, who knows what benefits or medical innovations might eventually arise. Although, the cure for one of my least favourite maladies – the common cold – may still be a long time coming!
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TRADE & TRENDS
Healthcare: Is it geared for the next big wave of information? Dinkar Adlakha, VP - Govt & PSU, EMC India highlights how data analytics will play a vital role in healthcare in the years to come THE HEALTHCARE industry is changing – fast. The 2015 HIMSS Leadership Survey found that while 41 per cent of healthcare leaders think big data analytics is a number one priority for their organisation, a surprising 81 per cent still have basic questions around the quantity and type of data they should be collecting and how to actually turn that data into insight. That’s not especially good news considering healthcare data continues to grow at 48 per cent per year through 2020 from clinical applications, Internet-enabled medical devices, wearables, and remote patient monitoring. With questions on how to manage all of the data being generated today, how will healthcare providers collect, secure, and share the next big wave of infor-
mation to come?
Making a splash with predictive analytics Consider the key role predictive analytics play as hospitals work to reduce their 30-day re-admissions rates for acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN). To meet these requirements, healthcare providers must speed up the continuous feedback process using analytics across the continuum of care, including inputs from patient monitoring located in the home. Healthcare providers that have successfully implemented predictive analytics see measurable results – 54 per cent of health IT leaders who spent 1-5 per cent of their operating budget on analytics reported
success within financial and clinical management. Advanced predictive analytics also provide organisations with clear cost reductions.
Eye on Data Lake Horizon A data lake provides massive scalability and multi-protocol data-in-place analytics, along with the enterprise data protection and security required by healthcare organisations. It provides a powerful data architecture with a unified location to help reduce silos across the healthcare enterprise. Data can also be connected from trusted outside sources including payers, genomic research centers, public health databases, biobanks, and social media feeds. Clinical departments, business analysts, and data sci-
ence teams can conduct effective cross-data analysis as all internal data sources and trusted external sources are incorporated. Healthcare providers can further advance accountable care initiatives, creating a new realm of data science for uncovering trends, patterns, relationships, correlations, and discoveries that can impact integrated patient care.
Making public health a shared value For a holistic approach to the betterment of healthcare industry in the country, it is also imperative for IT sector to develop solutions that curate and integrate all medical records of patients. The applications that are being developed today are more
Dinkar Adlakha, VP - Govt & PSU, EMC India
inclusive and robust storage capabilities in the backend. One such example is LifeCare healthcare solution that is developed by EMC for the Andhra Government deployed in Vishakhapatnam. With time, it is becoming more and more important to take on a stronger app strategy that state governments also have to be an active part of. With that, public health becomes a shared value between all stakeholders.
Carestream wins 2016 North America Frost & Sullivan award for NewProduct innovation Leadership Company focuses on innovation to elevate value of diagnostic imaging that helps facilities enhance patient care and clinical collaboration FROST & SULLIVAN has awarded Carestream Health its 2016 North America Frost & Sullivan Award for New Product Innovation Leadership for innovation focused on value-based imaging that solves real-life problems and addresses unmet customer needs. By empowering numerous new points-of-care and spe-
cialties with advanced, easyto-use and cost effective imaging modalities, Carestream is expanding its value proposition well beyond the centralized imaging departments, through its best-of-breed imaging and informatics solutions, to areas such as orthopedics, intensive care, emergency department, intraoperative and bedside imag-
ing. The award focuses on all aspects of the company’s digital medical imaging portfolio which includes new fluoroscopy and ultrasound systems; new cone-beam CT technology; and a vendor neutral enterprise imaging Clinical Collaboration Platform. “A result of Carestream’s commitment to innovation is
its latest flagship digital radiography (DR) product, developed using proven, in-house detector technology,” said Frost & Sullivan Industry Principal Nadim Michel Daher. “This next-generation product builds off of its predecessor, the first-of-its-kind ‘DR retrofit’ offerings. It supports a higher level of workflow productivity, dose effi-
ciency and image quality, without requiring heavy investments.” Carestream is set to replicate the success of its DR systems in the fluoroscopy department with the launch of the DRX-Excel Plus, its multipurpose fluoroscopy/radiography equipment. Continued On page 61
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TRADE & TRENDS
Sawpalmetto: Natural hormones regulator A CHEMICAL substance produced in the body that controls and regulates the activity of certain cells or organs is called a hormone. Hormones are essential for every activity of life, including the processes of digestion, metabolism, growth, reproduction, and mood control. Many hormones, such as neurotransmitters, are active in more than one physical process. Problems of hair are also related to hormonal imbalance. The general scientific term for hair loss is alopecia. Subtypes of alopecia include: Alopecia Areata: An autoimmune disease that causes the body to form antibodies against some hair follicles. Alopecia Areata causes sudden smooth, circular patches of hair loss. There are no known cures and in many cases the hair grows back on its own. Alopecia Totalis: An autoimmune disease similar to Alopecia Areata but that results in the loss of all hair on the scalp. It may begin as Alopecia Areata and progress into Alopecia Totalis. Alopecia Universalis: An autoimmune disease that results in the complete loss of all hair over the entire body, including eyelashes and eyebrows. Telogen effluvium: Telogen effluvium is an abnormal loss of hair due to alteration of the normal hair cycle. Normally, most of the hairs are in the growth stage and only one hundred hairs per day fall from the scalp. When telogen effluvium occurs, a greater proportion of the hairs enter the resting phase of the cycle and hair shedding is greater than normal. Androgenetic Alopecia: It is the most common cause of hair loss, presenting as loss of hair over the top (vertex) and the anterior mid-scalp area (receding hairline) in affected men. The term androgenetic alopecia denotes that both a genetic predisposition and the presence of androgens are necessary to cause expression. AGA is also referred to as male pattern hair loss and typically begins gradually in men
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and blocked the conversion of testosterone to DHT by inhibiting the activity of 5-alpha-reductase. The berries also inhibit cyclooxygenase and 5-lipoxygenase pathways, thereby preventing the biosynthesis of inflammationproducing prostaglandins and leukotrienes. Hirsutism in women is also related to this enzyme.
in their 20s with incidence increasing 10 per cent per decade. This is the most common form of hair loss and can also affect women. Other terms for this condition include: MPB, male pattern baldness, female pattern baldness, hereditary Alopecia and Androgenic Alopecia. Chronic inflammation of the hair follicle (HF) is considered a contributing factor in the pathogenesis of androgenetic alopecia (AGA). (R. M. Trüeb, Experimental Gerontology, vol. 37, no. 8-9, pp. 981–990, 2002)
Hirsutism Hirsutism is the presence of excess hair in women. This phenomenon is usually an androgen-dependent process. 25 to 35 per cent of young women have terminal hair over the lower abdomen, around the nipples, or over the upper lip. Most women gradually develop more androgen-dependent body hair with age. Nevertheless, normal patterns of female hair growth are unacceptable to many women. At the other extreme, severe hirsutism may rarely be the earliest signs of masculinising diseases. More often, however, severe hirsutism reflects only increased androgen production in women with a non serious underlying disorder. It's often caused by genes, hormones, or medication. Sometimes, hirsutism runs in families. It's also more common in people from the Middle East, South Asia, and the Mediterranean. Many times, the condition is linked to high levels of male hormones (called androgens). It's normal for women's bodies to make these, and low levels don't cause excess hair growth. But when these amounts are too high, they can cause hirsutism and other things, like acne, a deep voice, and small breasts. High levels of male hormones and hirsutism are common in women who have Polycystic ovarian syndrome, Cushing's syndrome etc. Acne and Seborrhoea: There are other diseases associated with 5α reductase activity such
Role of Saw palmetto ARUN NARANG, COO, ROWAN BIOCEUTICALS PVT LTD
as acne and inflammatory skin disorder (seborrhoea) and eczema. The key for treating all of these diseases is the modulation of 5α reductase activity. 5 -Alpha Reductase inhibitors : Drugs in this class work by inhibiting the enzyme 5 alpha reductase, which limits the conversion of testosterone to DHT. Finasteride: The first drug in this class to undergo extensive clinical trials in men. Finasteride has selective activity against 5 alpha reductase. As a result, serum and follicular DHT levels are significantly reduced. Saw palmetto extract: Studies have shown that Saw palmetto is an effective antiandrogen. It acts in a similar way that Finasteride does. Firstly it lowers levels of DHT in the body by blocking 5 alpha-reductase. Secondly, Saw palmetto blocks receptors sites on cell membranes required for cells to absorb DHT. Studies have been performed on the use of Saw palmetto in the treatment of benign prostatic disease, which is similar to androgenetic alopecia in that it also depends on the production of dihydrotestosterone.
What is Saw palmetto? Saw palmetto is an extract derived from the deep purple berries of the saw palmetto fan palm (Serenoa repens), a plant indigenous to the coastal regions of the southern United States and southern California. There is an estimated one million acres of wild saw palmetto palms in
Florida, where the bulk of commercial saw palmetto is grown. Pharmacology of Saw palmetto: Saw palmetto is widely used as a therapeutic remedy for urinary dysfunction due to enlarged prostate or benign prostatic hyperplasia (BPH) in the US and more so in Europe. Based on mechanisms of action, Saw palmetto extracts are also used for male pattern baldness (alopecia), excess hair in women (hirsutism), acne, inflammatory skin disorder (seborrhea) and eczema.
Mechanisms of action Anti-androgenic and antiinflammatory activities: Saw palmetto extracts inhibit 5α-reductase, which is an enzyme responsible for conversion of testosterone to dihydrotestosterone. Inhibition of such conversion maintains prostate health. There are two commonly associated male physiological events that have a similar etiology. Enlarged prostate or benign prostatic hyperplasia (BPH) and male pattern baldness are both related to the enzyme 5-alpha reductase. Studies with a liposterolic extract of Saw palmetto berries showed that it reduced the uptake by tissue specimens of both testosterone and dihydrotestosterone (DHT) by more than 40 per cent suggesting anti-androgenic activity. Further, the extract inhibited binding of DHT to its receptor
Recently, a number of clinical trials have confirmed the effectiveness of saw palmetto in treating BPH. Many of these trials have shown saw palmetto works better than the most commonly used prescription drug, Finasteride. Saw palmetto is effective in nearly 90 per cent of patients after six weeks of use, while finasteride is effective in less than 50 per cent of patients. In addition, finasteride may take up to six months to achieve its full effect. Since finasteride blocks the production of testosterone, it can cause impotence and breast enlargement. Other prescription drugs used to treat BPH are doxazosin, terazosin, and tamsulosin hydrochloride. Originally prescribed to treat hypertension, doxazosin and terazosin can drop blood pressure, causing light headedness and fainting. Presently, saw palmetto is being evaluated by the US Food and Drug Administration (FDA) for treatment of BPH. If approved, it would become the first natural derived product to be licensed by the agency as a treatment for a specific condition. Since the 1960s, extensive clinical studies of saw palmetto have been done in Europe. A 1998 review of 24 European trials involved nearly 3,000 men, some taking saw palmetto, others taking finasteride, and a third group taking a placebo. The men taking saw palmetto had a 28 per cent improvement in urinary tract symptoms, a 24 per cent improvement in peak urine flow, and 43 per cent improvement in overall urine flow. The results were nearly compa-
TRADE & TRENDS rable to the group taking finasteride and superior to the men taking a placebo. A randomised, double-blind, placebo-controlled trial was also conducted to determine the effectiveness of a preparation, containing 50 mg ß-sitosterol and 200 mg saw palmetto extract (standardised to contain 85-95% liposterols) per capsule, two capsules daily, in treatment of AGA (85). Healthy male subjects with moderate to severe AGA were randomly assigned to either the treatment arm (n=10) or the placebo arm (n=9) for a treatment period of approximately 21 weeks. At study completion 60 per cent of the men in the treatment group reported improvement, compared to only 11 per cent in the placebo group. Significance was neither reported nor achieved. Saw palmetto has been extensively studied and is seen to lessen hair loss and improve hair density in women with hair loss related to testosterone levels. For women with PCOS especially if they have elevated DHT, saw palmetto helps to block 5-alpha-reductase activity – thereby reducing the amount of testos-
terone converted to DHT. It does not change hair that is already altered by excess testosterone back to fine, soft light coloured hair; it prevents new hair growth, or dark coarse hair regrowth in women who have had laser therapy or electrolysis. It is suggested for use over a six-week period, taking notes of any improvements over that time. In case of improvement, may be continued on for best results. Saw palmetto has been found safe for long-term use in most cases Suggested dosage: 400mg a day According to the Southbury Clinic for Traditional Medicines and Catalina Lifesciences, researchers have found that when testosterone undergoes the conversion process to DHT, the shifting in hormone levels can result in acne in both men and women. The cause of an increase in pimples is due to the overproduction of sebum within your oil glands. This overproduction clogs your pores, which results in inflammation and pimples. Although initial research of saw palmetto for the treatment
Several clinical trials have confirmed the effectiveness of saw palmetto in treating benign prostatic hyperplasia
of acne is promising, Dr Richard Fried writes in the report 'Saw palmetto as a Treatment for Acne' that the effectiveness of saw palmetto for acne treatment varies from person to person.
Conclusion Saw palmetto is better known for its ability to help treat BPH in men; however, the primary active constituents within saw palmetto also help reduce the severity of acne. According to the University of Maryland Medical Center the primary con-
stituents of saw palmetto include plant sterols, fatty acids and flavonoids. Saw palmetto contains a high concentration of polysaccharides, which are used by the human body to enhance the immune system as well as work as an anti-inflammatory. One of the primary benefits of saw palmetto is its ability to hinder the transformation of testosterone to dihydrotestosterone, which is also known as DHT. Saw palmetto has been proven safe to use. It has no known drug interactions and is well tolerated by most people. The only noted side effect in a very small percent of people is upset stomach. Saw palmetto can be taken with zinc, vitamin b6, and azelaic acid for a synergistic effect.
References: Castor TP. (2010). Compositions and Methods for Inhibiting 5- Reductase. Dvorkin L. (2013). Introduction To Herbal Supplements for Pharmacists and Other Health Care Professionals. Center for Integrative Pharmacy, Massachusetts College of Pharmacy and Health Sciences. http://www.longwoodherbal.org Feifer A, Fleshner N and Klotz L.
(2002). Analytical accuracy and reliability of commonly used nutritional supplements in prostate disease. J Urol. 168:150-4. Fagelman E and Lowe F. (2002). Herbal medications in the treatment of benign prostatic hyperplasia (BPH). Urol Clin N Am. 29:23-9. Suzuki M, Ito Y, Fujino T, Abe M, Umegaki K, Onoue S, Noguchi H and Yamada S. (2009). Pharmacological effects of saw palmetto extract in the lower urinary tract. Acta Pharmalogica Sinica. 30: 271-281. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001876/ PubMed Health: Acne http://www.bottomlinesecrets.com/article.html?article_id=44661 Bottom Line Secrets: Saw palmetto as a Treatment for Acne http://www.umm.edu/altmed/articles/s aw-palmetto-000272.htm University of Maryland Medical Center: Saw palmetto Palatsi, R., Ruokenen, A., Oikarinen, A. (1997) Isotretinoin, tetracycline and circulating hormones in acne. Acta Derm Venereol. 77(5):394-396. Mauvals-Jarvis, P. (1986) Regulation of androgen receptor and 5 alpha-reductase in the skin of normal and hirsute women. Clin. Endocrinol. Metab. 15(2):307-317.
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Carestream wins 2016 North America Frost & Sullivan award ..... This device was developed in response to the relative lack of product and technology innovation in this specialty area. It presents healthcare providers with considerable savings by enabling them to share flat-panel detectors among multiple radiography and fluoroscopy rooms and systems. Similarly, Carestream’s recent entry into ultrasound modality is a perfect example of the design philosophy at the company. The Touch Prime and Touch Prime XE premium ultrasound imaging systems underline Carestream’s focus on performance and usability across its product lines. Carestream was able to optimise features based on the actual needs of ultrasound professionals. The all-touch control panel, which is extremely easy to clean and offers tactile feed-
back on home keys so that operators can stay focused on the patient, is garnering praise from the marketplace. The user interface also can be customized to the preferences of the sonographer. The Touch Prime and Touch Prime XE systems are positioned as the first two models of a new generation of ultrasound systems from Carestream. The product line has a scalable, high-performance platform, which promotes both technology migration as well as transducer migration. These systems provide an ideal entry point for Carestream into the ultrasound space, setting the stage for gradual percolation down to the mid-range and point-of-care ultrasound market. Carestream’s vision to continually advance the medical imaging marketplace through
new technology can be seen in the design of its investigational cone-beam computed tomography (CBCT) system intended for orthopedic imaging. With this new technology, it is evident that Carestream realised that medical professionals are in dire need of a cost-effective, low-dose, 3D and weight-bearing imaging technique. When available, the CBCT system will combine the best of two modalities, namely the high-resolution, 3D imaging capabilities of CT, and the speed, convenience, radiation dose efficiency and affordability of DR. Further proof of the company’s success can be seen in how Carestream has elevated its clinical content management to a third-generation, vendor-neutral, standardsbased Clinical Collaboration Platform. Its industry-leading data aggregation and data fed-
eration capabilities allow it to integrate additional types of multi-disciplinary and unstructured content into the clinical workflow. “Complementing its growing portfolio of imaging systems, Carestream’s imaging informatics solution set serves to solidify the company’s overall value proposition to an extended imaging enterprise,” noted Daher. “By continually advancing workflow, data management and reporting solutions a where imaging services are consumed, Carestream has gained a competitive edge with its enterprise imaging IT portfolio.” Each year, Frost & Sullivan presents this award to the company that has developed an innovative element in a product by leveraging leading-edge technologies. The award recognises the value-added fea-
tures/benefits of the product and the increased ROI it delivers, which, in turn, increases customer acquisition and overall market penetration potential. About Carestream Health Carestream is a worldwide provider of dental and medical imaging systems and IT solutions; X-ray imaging systems for non-destructive testing; and advanced materials for the precision films and electronics markets—all backed by a global service and support network. For more information about the company’s broad portfolio of products, solutions and services, call 888-777-2072 or visit www.carestream.com. Contact Robert Salmon 585-627-6560, robert.salmon@carestream.com
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TRADE & TRENDS
Fujifilm launches Amulet Innovality, a new-age digital mammographysystem Amulet Innovality combines state-of-the-art, Hexagonal Close Pattern image capture technology and intelligent image processing, optimising contrast and dose based on breast density IT’S INTERESTING to know that Fujifilm’s Amulet Innovality has made a roaring success within a short span of time, both in India and Globally. So, what made the Fujifilm’s Amulet Innovality – the new leader in Full Field Digital Mammography (FFDM) segment? Let’s look at the key reasons for its phenomenal success. Amulet Innovality, Fujifilm’s newest digital mammography system, combines state-of-theart, Hexagonal Close Pattern (HCP) image capture technology and intelligent image processing, optimising contrast and dose based on breast density. This resulted in exceptional imaging, optimised contrast, low dose and fast acquisition time. The motivation for Fujifilm’s Imaging Technology Center (R&D) team is to meet the challenges and requirements of radiologists, mammography technologists, administrators, and patients alike.
Unique and disruptive design of detector The detector is the heart of any digital mammography system which has direct impact on the image quality obtained and on Xray dose. It is very important to detect even a small sign of calcification during breast cancer screening. Two types of flat panel detectors (FPD) are used for mammography: a direct conversion-type detector and an indirect conversion-type detector. The resolution of the direct conversion-type detector is generally higher than that of the indirect conversion-type detector. Therefore, Fujifilm preferred direct conversion-type A-Se detector because of its high spatial resolution.
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In the conventional detector design, the Thin Film Transistors (TFTs) incorporate the spaces between neighboring pixels for the laying of signal wires. Owing to these gaps, the electrical field intensity is naturally weak and thus reduces the collection efficiency of the signal charge generated from X-rays. And the design of square shaped pixels constituting the TFTs will further decrease the signal charge. In order to overcome these detector inefficiencies, Fujifilm’s design team has introduced the unique disruptive technology of Hexagonal Close Pattern (HCP) structure into TFTs as Hexagonal pixels can be arranged to reduce the spaces that suppress the disturbances of electrical field intensity. Also, a hexagonal pixel is preferable to a square pixel because of its higher sampling efficiency, consistent connectivity and angular resolution. As a result of this radical new HCP design, Fujifilm is able to increase sensitivity by about 20 per cent compared with conventional TFTs that used square pixels. The detected data by the hexagonal pixels were converted into a 50 μm square image matrix by the imaging processing unit for a 50 micron image display. The HCP design also increased DQE and MTF and reduced the exposure dose while maintaining a high image quality.
Optimised X-ray dose and contrast for each breast type In general, images taken with the Molybdenum (Mo) anode represent stronger contrast than with the Tungsten (W) anode, which allows physicians to
Phanesh Atmuri National Sales Manager - DR, FUJIFILM INDIA PVT LTD
ake diagnoses more easily. X-rays generated from the Mo anode have a low energy distribution; therefore, they are easily absorbed in the breast. That enables high-contrast imaging. However, with the Mo anode, the radiation dose is definitely larger than with the W anode. Fujifilm addressed this challenge and developed a radiation quality-correcting technology, to create the same high quality of images with the low-radiation W anode as is possible with the Mo anode and the technology is known as Image-based Spectrum Conversion (ISC). In a nutshell, ISC technology optimises contrast in an image, offering the dose advantages of a tungsten target for all exposures and breast types. The conventional AEC uses multiple sensors to detect X-rays that passes through the subject. It calculates the required dose, based on the sensor that received the smallest quantity of X-rays through the subject during pre-irradiation, that is, the sensor for the region where the glandular density is considered to be the highest. Fujifilm has de-
veloped i-AEC technology that detects the mammary gland region based on the morphological characteristics recognised within the images taken during pre-irradiation. iAEC has realised radiation dose control that optimises the quality of images of the mammary gland region, regardless of the state of the breast, such as being fatty, with the scattered mammary gland and having implants.
Digital Breast Tomosynthesis (DBS) Tomosynthesis is a technology to generate a tomographic image from multiple images taken from different angles via reconstruction so that the information can be utilised in diagnosis. In addition to images at a high resolution, tomosynthesis required imaging at a lower radiation dose, as the examinees need to undergo mammography several times. During the tomosynthesis process, the wider the imaging angle, the higher the depth resolution of the image obtained. In view of this, Fujifilm has incorporated two different tomosyn-
thesis mammography modes, i.e., ST mode and HR mode. ST mode achieves imaging as quickly as just four seconds by narrowing the imaging angle. Quick and low-radiation tomosynthesis mammography is possible in this mode. HR mode provides high depth resolution by widening the imaging angle. That enables observation focusing on the region of interest. Providing those two distinctive modes allows users to make purpose-specific selection.
Patient Comfort Most of the cases, the patients are not comfortable during a mammo examination as the compression of the breast causes pain /discomfort. Keeping the patient comfort as pivotal to its design, Fujifilm has developed a unique patented comfort paddle that allows pressure to be more evenly and gently distributed across the breast compared to conventional, flexible paddles. This design improves the patient comfort during mammogrammes significantly.
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