Express Healthcare (Vol.10, No.12) December, 2016 by Indian Express

CONTENTS Vol 10. No 12, DECEMBER 2016

Chairman of the Board Viveck Goenka

GLOBALHEALTH LEADERS CONVENE AT WISH IN DOHA

MARKET

Sr Vice President-BPD Neil Viegas Editor Viveka Roychowdhury* Chief of Product Harit Mohanty BUREAUS Mumbai Sachin Jagdale, Usha Sharma, Raelene Kambli, Lakshmipriya Nair, Sanjiv Das, Mansha Gagneja

VALUE OF INNOVATIVE MEDICAL DEVICES

EVOLUTION OF PATH LABS

HEAL 2016 CONCLUDES SUCCESSFULLY

Delhi Prathiba Raju Design National Design Editor Bivash Barua Asst. Art Director Pravin Temble Senior Designer Rekha Bisht Artists Vivek Chitrakar, Rakesh Sharma Photo Editor Sandeep Patil MARKETING Regional Heads Prabhas Jha - North Harit Mohanty - West Kailash Purohit – South Debnarayan Dutta - East Marketing Team Ajanta Sengupta, Ambuj Kumar, Douglas Menezes, E.Mujahid, Mathen Mathew, Nirav Mistry, Rajesh Bhatkal PRODUCTION General Manager BR Tipnis

Stress on the need for meaningful collaborations to resolve the most pressing global health challenges | P8

INTERVIEWS

KNOWLEDGE

LIFE

P18: ARJUN VAIDYA CEO, Dr Vidya's

P37: GUY LITTLEFAIR Pro Vice-Chancellor Industry Development, Deakin University

26 31

AWARENESS IS KEY TO COPD MANAGEMENT EVIDENCE-BASED APPROACH TO IMPROVE QUALITY AND COST EFFICIENCY

DISSECTING DR RAKESH SINHA’S STRATEGY TO SUCCESS

P38: SAMEER BHAT

Manager Bhadresh Valia

Vice President & Co-Founder, eClinicalWorks

Scheduling & Coordination Ashish Anchan

AAKASH SHAH

CIRCULATION Circulation Team Mohan Varadkar

Director Sales National and International Market, eClinicalWorks

BENEFITING DOCTORS AND PATIENTS ALIKE

A PROPOSED INDIA-SPECIFIC ALGORITHM FOR MANAGEMENT OF TYPE II DIABETES

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

When the old leads the new

e live in a complex world, of myriad identities but the ironies are delicious. On one hand, we are promoting everything digital, from smart cities to smart healthcare. On the other hand, we are going back to our past, celebrating our heritage of holistic healing. Every nation has its own system of healing, and we've borrowed the best. For instance, the Unani system has its roots in faraway Greece but there is a strong following in India and across the world. The traditional system of healing, which was for long the only system, slowly became the alternative. Today, AYUSH is termed alternative or complementary, when shouldn't it actually be the other way around? When we talk of integrating AYUSH into mainstream medicines, wasn’t AYUSH mainstream once upon a time? Be it any one of the facets of what today has been clubbed into the acronym AYUSH, the guiding principle is to prevent illness, preserve good health and thus these systems treat the root of the problem even before it escalates into a problem. Yes, it needs patience and a willingness to make lifestyle changes but the payback is huge. In our personal lives too, we use high tech gadgets but for many moms, a hot water gargle, with the goodness of a pinch of turmeric, is the first recourse for a scratchy throat to keep that winter chill at bay. Of course, there is no way you can get a teenager to take to the latter, without a lot of nagging. It's so much easier to ignore the sore throat till it escalates into a full fledged infection. Then it's much more convenient to pop pills for the throat infection. And another set of pills for the acidity caused by the antibiotics. The heartening trend is that AYUSH players are going all out to woo a new generation of consumers, both in India as well as globally. For example, one manufacturer has packaged the goodness of Chawanprash in a capsule, to entice consumers of all ages to continue the childhood pratices of having a spoonful of this immunity boosting jam once a day. There are many more such examples of AYUSH shedding its skin and emerging as a sleeker version. The goodness of granny packaged

EXPRESS HEALTHCARE

December 2016

Today,AYUSH is termed alternative or complementary,when shouldn’t it actually be the other way around?

into a sleek capsule. As the second and third generation of promoters takes over the helm, they are coming into their own and adding their ideas to the product portfolio. And this time, they are coming back with a bang, with evidence to back their claims. AYUSH companies are thus today well placed to tap new age consumers. And in yet another delicious irony, doctors and hospitals are rediscovering the worth of this age old healing process and adding it to their armamentarium against disease. The AYUSH revival received a well-timed and long awaited push from the central government, with PM Modi himself leading the charge by instituting a world Yoga Day. Our December issue addresses this trend and its impact on the practice of medicine in India. Do read the issue for insightful articles from and interviews with industry experts. Just as modern medicine is looking for new ideas from the old, established companies are turning to start ups for new ideas. They hope to imbibe their agility, while mentoring them through the difficult start up years. For example, take Bosch India’s start up accelerator programmeDNA, which aims to Discover, Nurture and Align start-ups in a couple of areas, meditech included. What’s really interesting is that the German company was so excited by India’s start up culture that it broke with tradition and decided to make external start-ups part of this programme. The press release very candidly states that by mentoring and making these start-ups investment ready, ‘Bosch would be able to hedge itself against possible disruptions often hovering over traditional businesses.’ Many states in India too are putting out the red carpet for innovators, as they are sure that at least some of them will go on to be successful companies and generate both employment and revenue for their region. As we end 2016 and gear up for a new year of challenges and opportunities, Express Healthcare wishes all our readers the very best for 2017. With a bit of the old and the new, we are sure India will beat the odds and cement its space in the global arena. VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com

QUOTE UNQUOTE

NOVEMBER 2016

Our concerted efforts and strategies have been able to see a success story of India. We can now safely say that we can end the HIV/AIDS epidemic by 2030 Check out the online version of our magazine at

www.expresshealthcare.in

HEAD OFFICE Express HealthcareÂŽ 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.

JP Nadda Union Minister of Health and Family Welfare was speaking at a function on the occasion of World AIDS Day, 2016 organised by the National AIDS Control Organisation (NACO), Ministry of Health and Family Welfare

Mobile: +91 9999070900 Fax: 0120-4367933 Email id: ambuj.kumar@expressindia.com Our Associate: Dinesh Sharma Mobile: 09810264368 E-mail: 4pdesigno@gmail.com CHENNAI The Indian Express (P) Ltd. Business Publication Division 8th Floor, East Wing, Sreyas Chamiers Towers New No 37/26 (Old No.23 & 24/26) Chamiers Road, Teynampet Chennai - 600 018 Telephone (Board): +91 44 24313031/32/34 Fax: +91 44 24313035 BENGALURU Mathen Mathew

The Indian Express (P) Ltd. Business Publication Division 502, 5th Floor, Devatha Plaza, Residency road, Bangalore- 560025 Board line: 080- 49681100 Fax: 080- 22231925 Mobile: +91 9840826366 Email id: mathen.mathew@expressindia.com HYDERABAD E Mujahid The Indian Express (P) Ltd. Business Publication Division 6-3-885/7/B, Ground Floor, VV Mansion, Somaji Guda, Hyderabad â&#x20AC;&#x201C; 500 082 Board line- 040- 66631457/ 23418673 Mobile: +91 9849039936 Fax: 040 23418675 Email Id: e.mujahid@expressindia.com

As treatment expands, people with HIV live longer and are at risk of diseases related to lifestyles and ageing like noncommunicable diseases Dr Poonam Khetrapal Singh WHO Regional Director for South-East Asia on the eve of World AIDs Day

KOLKATA Ajanta Sengupta The Indian Express (P) Ltd. Business Publication Division JL No. 29&30, NH-6,Mouza- Prasastha & Ankurhati,Vill & PO- Ankurhati, P.S.- Domjur (Nr. Ankurhati Check Bus Stop) Dist. Howrah- 711 409 Mobile: +91 9831182580 Email id:

ajanta.sengupta@expressindia.com AHMEDABAD Nirav Mistry The Indian Express (P) Ltd. 3rd Floor, Sambhav House, Near Judges Bunglows, Bodakdev, Ahmedabad - 380 015 Mobile: +91 9586424033 Email Id: nirav.mistry@expressindia.com

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.

EXPRESS HEALTHCARE

December 2016

MARKET POST EVENTS

Global health leaders convene at WISH in Doha Stress on the need for meaningful collaborations to resolve the most pressing global health challenges

All of our countries have a healthcare system, but none of them are perfect. Each country faces its own healthcare challenges. I hope that the participants in this year’s Summit will benefit from the research produced by WISH to improve their own health systems, and I hope that they will also use WISH as their platform for observing and monitoring policy reform in their own countries Her Highness Sheikha Moza bint Nasser Chairperson, Qatar Foundation

Lakshmipriya Nair Doha

oha, the capital city of Qatar, hosted the third edition of The World Innovation Summit for Health (WISH) on November 29-30, 2016. It was organised by the Qatar Foundation (QF) and held at the Qatar National Convention Centre (QNCC). The Summit was attended by delegates from around 100 countries, including minister-level representatives, system leaders, industry CEOs, renowned academics and researchers, innovators and social entrepreneurs. In advance of the Summit, a press conference was held on November 28, 2016, wherein Professor the Lord Ara Darzi, Executive Chair, WISH; Dr Mariam Abdulmalik, MD, Primary Health Care Corporation; Buthaina Al-Nuaimi, President of Pre-University Education, Qatar Foundation; Dr Mark McClellan, Chair, WISH Accountable Care Research Forum; and Egbert Schillings, CEO, WISH. The leaders of the initiative gave a preview of the Summit, highlighted WISH 2016 research and stressed on the need for global collaboration to resolve the most urgent global health challenges. Her Highness Sheikha Moza bint Nasser, Chairperson, Qatar

EXPRESS HEALTHCARE

December 2016

(L-R) Egbert Schillings, CEO, WISH; Buthaina Al Nuaimi, President of Pre-University Education, Qatar Foundation; Professor the Lord Ara Darzi, Executive Chair of WISH; Dr Mariam Abdulmalik, Managing Director, Primary Health Care Corporation, Qatar; Dr Mark McClellan, Chair of WISH Accountable Care Forum 2016

(L-R) Stephen Sackur, BBC presenter, and host of HARDtalk; Professor Warwick Anderson, Secretary-General, International Human Frontier Science Programme Organization; Dr Maryam Matar, Founder and Chairperson of UAE Genetic Disease Association; Dr Asmaa Al Thani, Dean, College of Health Sciences, Qatar University and Vice Chairperson, Qatar Biobank Board; Dr Miklós Szócska, former Minister of State for Health of Hungary; Professor Masuhiro Kato, Project Professor, Translational Research Initiative, University of Tokyo and Dr Victor Dzau, President, US National Academy of Medicine at apanel discussion on precision medicine

Foundation (QF) presided over the opening ceremony of WISH 2016. In her address, she spoke on the diverse challenges faced by the global healthcare community and hoped that the Summit would facilitate meaningful collaborations to tackle these challenges. She said, “All of our countries have a healthcare system, but none of them are perfect. Each country faces its own healthcare challenges. I hope that the participants in this year’s Summit will benefit from the research produced by WISH to improve their own health systems, and I hope that they will also use WISH as their platform for observing and monitoring policy reform in their own countries.” She also gave an overview on the Qatar Genome Programme, launched at WISH 2011, the inaugural edition. She informed that the project has sequenced 3,000 Qatari genomes so far and it will translate into significant benefits to the local population. Professor Darzi said that global health challenges need a global response and WISH is an attempt to facilitate it. He also gave an overview of Qatar’s initiatives to provide high quality healthcare to its citizens with a special mention about the projects the country has embarked on in areas such as primary

MARKET

Around the world our health systems face enormous challenges. Never has the need for innovation been greater nor opportunity to work together larger. The World Innovation Summit for Health brings the world to Qatar and Qatar to the world - as a convenor, innovator and leader in health. Professor the Lord Ara Darzi Executive Chair, WISH

health, personalised medicine and autism, amongst others. The first key note speaker of the day, Professor Dame Sally Davies, Chief Medical Officer for England, addressed yet another serious health concern in the current times — antimicrobial resistance. Drawing attention to the enormity of the problem and its far-reaching effects, she advised global health leaders to take timely action against this growing threat. At the same time, she also informed about various resolutions taken by the gloabl health community to address it, including the WHO. Dr Julio Frenk, President, University of Miami and former Minister of Health for Mexico, was the second key note speaker on the first day. He expounded on the current healthcare education systems and highlighted the opportunities and challenges in this space. He explained how healthcare education and universal healthcare coverage are interlinked. He also advocated transformative learning to ensure that healthcare professionals adapt to the changing healthcare landscape. Genomics and personalised medicine was one of the focus areas at WISH 2016. Autism, health professional education, accountable care, behavioural insights, and genomics in the

EXPRESS HEALTHCARE

December 2016

Gulf region and Islamic ethics were some of the other topics which were addressed through in-depth panel discussions by experts and leaders of the healthcare community on the first day. Many of these discussions were parallely held in different auditoriums. The Summit also comprised policy briefings on ‘Health

Affairs – Using Evidence-Based Policy Solutions to Address Health Challenges’ and ‘Learning from International Collaboration – Lessons from LHSN’ were also part of the first day’s agenda. The latter had a special focus on patient safety. Day 2 of the Summit commenced with more policy briefings on two pivotal health topics

– affordable cancer care and addressing dementia, a growing health concern. The session on cancer revolved around forming more economically efficacious cancer care policies and making them more patient-centric. The session on dementia highlighted that it is a condition which is increasing at an alarming rate across the globe.

Professor Lawrence Summers, Former US Secretary of the Treasury and renowned economist, in the first key note address of the day, raised a very interesting point. He called for an increase in funding to tackle global healthcare challenges, like developing medicines and vaccines for diseases of poverty, increasing pandemic prepared-

MARKET ness, and reconsidering priorities in healthcare policy-making. Pointing out that only 20 per cent of donor support for health goes toward such global efforts, he urged the need to boost it for global healthcare efforts to 50 per cent by 2030. The panel discussions on the second day ranged on a variety of issues such as cardiovascular disease, healthy populations and investing in health. The discussion on investing in health was very interesting as experts discussed on the economics of healthcare, its significant impact on the GDP of nations, invest significantly in enhancing healthcare systems, the need for multipronged approaches to optimise current investment in healthcare etc. The day also had plenary sessions on infectious diseases and global diffusion of healthcare innovation. The final key note speaker was Mustafa Suleyman, Co-Founder, DeepMind. He emphasised on the role of technology in improving healthcare and also pointed out that several technological advancements that exist in the current scenario have the potential to transform healthcare delivery significantly.

Innovation showcases were also an interesting feature of the WISH 2016 conference. Healthcare innovations, ranging from practical devices and business models, to design-based solutions, from across the world were showcased at this yearâ&#x20AC;&#x2122;s event. Each innovation demonstrated the potential to transform global health by driving quality, affordability and access. The event had several noteworthy representatives from India. Rajeev Sadanandan, Additional Chief Secretary (Health), Government of Health & Family Welfare, Kerala; Dr Srinath Reddy, President, Public Health Foundation of India; Dr Anupam Sibal, Group Medical Director, Apollo Hospitals, etc. were some of them. In the closing session, Dr Hanan Al Kuwari, Minister of Public Health, was also a part of this discussion. She advised young health professionals to apply their learnings to good use to improve the healthcare sector in the country. The event was well received by all the attendees. lakshmipriya.nair@expressindia.com

(The correspondent was in Doha on an invitation from Qatar Foundation)

WISH, now only in its third year, has firmly established itself as an indispensable part of the global healthcare leadership agenda. Today, we saw that the world will always come together to advance the cause of human health, as long as leaders are equipped with the ideas to do so and a platform that unites them Egbert Schillings CEO, WISH

There has been an explosion in education and reform for universal healthcare coverage, which creates a unique set of opportunities for us to exploit. Transformative learning now means that healthcare professionals need to master the content and the context of the larger healthcare landscape in which they operate Dr Julio Frenk President, University of Miami and former Minister of Health for Mexico

EXPRESS HEALTHCARE

December 2016

Dr Kerim Munir, Chair of the WISH Autism Forum, addresses the audience a panel discussion at WISH 2016

If a country invests in better health clinics, its citizens capture all the benefits of the investment.If it invests in pandemic preparation or vaccine research or development of new service delivery techniques,the benefits flow around the world.So,it stands to reason that without global cooperation, the world will underinvest in global public goods and global functions

Drug-resistant diseases are fuelled by the lack of a balance in antibiotics consumption that is fast becoming a major health disaster in the 21st century. It is imperative for us to move beyond the planning phase and take tangible actions to tackle this global epidemic Dame Sally Davies Chief Medical Officer for England

Prof Lawrence Summers

We looked at many different application areas, but none seemed to struggle more with technology than healthcare, none seemed to have a margin of improvement that was as striking as the opportunities that we see in healthcare. I think digitization is absolutely critical when it comes to delivering safe and high-quality care.

Former US Secretary of the Treasury

Mustafa Suleyman Co-founder, DeepMind

MARKET

INSIGHT

Value of innovative medical devices Milind Shah Founder/ Partner, StratLead Advisors, gives an overview on how healthcare professionals are increasingly recognising the merits of innovative, safe and effective medical devices for improved patient care

Let’s count the reasons...

Why Schiller? We’ve been selling Ventilators for more than 5 years We’ve reached an installation base of over 3000 units But if you ask how many lives we’ve touched….well…it’s countless!

ADVANCES IN medical technology have helped to extend and improve patients’ lives dramatically over the last few decades. Such innovations for diagnosing, screening, treating and curing serious health conditions include not only fundamentally new medical devices and diagnostics, but also significant improvements over previous-generation technologies. These advances have had a huge positive impact on disease management in India, but more action is needed to expand patient access to these benefits. Healthcare professionals across the country are increasingly recognising the merits of innovative, safe and effective medical devices and diagnostics for improved patient care. From everyday devices such as thermometers and syringes to life-saving devices like stents, pacemakers, ultrasound machines and surgical robots, medical equipment form the backbone for timely diagnosis and effective treatment. However, application of medical Forr enquiries Fo enquiries contact contact : sales@schillerindia.com

EXPRESS HEALTHCARE

December 2016

Website Websit e : www.schillerindia.com

Toll-Fre Free e No. No. : 180 1800 0 2098998

Swiss H.Q.: Schiller AG, Altgasse 68, P. O. Box 1052, CH -6341 Baar, Switzerland, Indian Corporate Office: Schiller Healthcare India Pvt. Ltd., Advance House, Makwana Road, Marol Naka Metro Station, Andheri (East), Mumbai - 400 059. Tel. : +91- 22 - 61523333/ 2920914/ 09323799863, Fax : + 91- 22 - 2920 9142 E - mail : sales@schillerindia.com, support@schillerindia.com Factory : No. 17, Balaji Nagar, Puducherry - 605010 CIN: U33110MH1997PTC111307

MILIND SHAH Founder/ Partner, StratLead Advisors

MARKET But more needs to be done

Pictures used for representational purpose only

technology is still limited in our country. If tapped optimally, it has the potential to help India manage its huge healthcare burden far more effectively.

families, but also on the nation’s GDP. Unfortunately, such benefits of medtech innovation often go unrecognised.

Hope and opportunity Medical technology – Cost driver or cost saver In a paper published by the Journal of Political Economy in 2006, it was estimated that over the preceding 50 years, medical innovation had been the source of nearly half of all economic growth in the US. Such innovation not only saves lives — it saves money! These savings come in the form of lower treatment costs, shorter hospital stays, reduced complications, and fewer readmissions, which help patients get back to work more quickly. Innovations that treat Non-Communicable Diseases (NCDs) like cancer, heart disease and diabetes in particular, have a positive impact not only on patients’ lives and the balance sheets of individual

EXPRESS HEALTHCARE

December 2016

The medical device sector has been delivering significant answers to fast-evolving healthcare needs of India. India is one of the top twenty markets for medical devices in the world and growing at a fast pace. According to a white paper published by Deloitte in March 2016, the medical device industry in India grew at a rate of 10 per cent from 2008 to 2014, and is expected to reach $8.6 billion by 2020 at an organic growth rate of 15 per cent per annum. A case in point is technology that has upped early detection of cancers, accounting for a 30 80 per cent reduction in mortality. Colonoscopy and sigmoidoscopy detect colorectal cancer, and colonoscopy can prevent the ailment through re-

moval of polyps. Similarly, the evolution of coronary stents has significantly reduced the number of patients dying from heart attacks while implantable cardiac defibrillators have increased the chances of surviving a sudden cardiac arrest from five per cent to 98 per cent. Angioplasty, an innovative procedure used to treat heart disease, also generates substantial savings for patients. Meanwhile, millions of diabetes patients in India are able to better manage their disease and avoid expensive complications through the use of advanced glucose monitors and insulin pumps; patients suffering from musculoskeletal disease are able to eliminate their pain, improve their mobility and quality of life with artificial joint replacements; and surgical patients treated with minimally invasive technologies are able to recover faster and get back to work sooner.

Such examples show how innovative medical technologies enable physicians to deliver better outcomes and help patients lead longer, better and more independent lives. This is a key reason why medical tourism is booming in the country. Contributing to these solutions and growth is a diverse mix of local and multinational companies. Many multinationals have invested significant resources in improving access to quality healthcare in India through physician training and education, product development and research, and establishment of local manufacturing facilities that also help create good paying jobs. At the same time, Indian entrepreneurs and companies are focusing on delivering quality products at reasonable costs. Partnerships between various types of companies are also facilitating development of optimum solutions for the Indian market.

To help realise the benefits of medical technology innovation to patients and the economy, healthcare professionals, industry and the government must work together to increase patient access. This effort will require increased patient awareness, clear and predictable regulations, insurance penetration, medical technology innovation, and fair return on investment. At just over 1.3 per cent of the global medical device market, the industry is quite small in India, but pragmatic government policies will go a long way in promoting healthy growth that improves patients’ lives and the economy. Counterproductive actions, such as the recently proposed plan to cap prices of cardiac stents, act as a disincentive to innovation and should be re-evaluated. The draft National Medical Device Policy 2015 announced by the Department of Pharmaceuticals should set the ball rolling to an extent. It aims at increasing penetration of medical devices and boosting the quality, reliability and competitiveness of the industry. As the Deloitte report states: “With an enabling policy framework and ecosystem support, industry estimates indicate a potential to grow at ~28 per cent p.a. to $50 billion by 2025. This growth is expected to be driven by indigenous manufacturing and exports, and sales from local innovation.” The medical technology industry is standing at a crossroads now. The clinical and economic value of medical technology has been clearly established. Yet, its penetration in our country is very low. While the country is beginning to win the battle against infectious diseases, NCDs have already become the largest cause of death. Unfortunately, the incidence of NCDs amongst younger, productive people is rapidly growing thus increasing social trauma and impacting the nation’s GDP. Medical technology innovation and increased patient access are the clear solution for healthier patients and a healthier economy in India, allowing better patient outcomes and longer lives, as well as improved economic growth and a more prosperous future.

MARKET

INSIGHT

Evolution of path labs Dr Sushil Shah, Chairman and Founder, Metropolis Healthcare, throws light on how pathology business will transform India’s healthcare sector PATH LABS in India have undergone a colossal shift. There was an era when even basic hormone and thyroid tests were inaccessible to Indians. Doctors and patients had to wait for over ten days before medical decisions could be made. Very few labs attached to hospitals had access to ‘specialised’ tests. Today a hormone test is a ‘routine test’ because we procured the technology, the volumes increased and the price of the test went down, making it affordable for the masses. Our nation has now risen as the centre point for worldwide research and futuristic innovations. With the extension of the clinical trials market and vast openings for medical coverage, there is a pattern toward union amongst sorted out players.

DR SUSHIL SHAH Chairman and Founder, Metropolis Healthcare

Pharmalab, a name synonymous with quality and technology in the areas of sterilisation, washing, process equipment, sterility and water purification, now introduces total solutions for hospitals. Manufactured indigenously and in collaboration with world leaders.

A quick look at how the industry has progressed

Washer Disinfector

Arcania Bedpan Washer

Steam Sterilizer

Vertical Chamber Autoclave

A transformational period for pathology The business is profoundly aggressive and cost driven, the pathology business sector is at present 2.5 per cent of the general healthcare market. This period in history is all about customised and evidence-based medicines, and the coming years will witness a transformation in the healthcare industry. As our insight into genetics and diagnostics is quickly extending, the diagnostic business in India will witness a movement toward molecular diagnostics. Despite the fact that 60 per cent of the present research facility that is offered is held by clinical pathology, which incorporates immunology and haematology, the public’s mind is asserted towards preventive healthcare.

EXPRESS HEALTHCARE

December 2016

Ultrasonic Washer

Pharmalab India Private Ltd.

Registered Office: Kasturi, 3rd, floor, Sanghavi Estate, Govandi Station Rd, Govandi (E), Mumbai 400 088, INDIA. • E-mail: pharmalab@pharmalab.com • Website: www.pharmalab.com • CIN No. U29297MH2006PTC163141.

Sterilizer Test Kit

MARKET A QUICK LOOK AT HOW THE INDUSTRY HAS PROGRESSED 1970’s

Today

Test Menu: Routine tests available

Entire gamut of tests available Comprehensive testing in the areas of genetics, biochemistry, molecular oncology, anatomic pathology, microbiology, haematology, immunochemistry. Metropolis offers the widest test menu in the industry with over 4500 tests and test combinations

Technology: No latest technology available

US FDA approved technology for most of the tests

No standardisation/ No protocol

Consistent experience and reports offered to customers all across India. Standard operating protocol followed for each and every test.

No automation

Most of the tests are now automated leaving very little room for error

No regulation / No quality and report validation

About one per cent of labs in India are now accredited. Metropolis is accredited by both NABL & CAP

Customer visits doctor and lab when ill

New age customer is extremely well aware.A conscious shift towards wellness is happening

Operating in a highly unregulated and fragmented market The pathology industry in India is highly fragmented and unregulated. There are more than 1,00,000 laboratories and an appalling lack of regulation has actually slowed the growth of this sector. Corporate and branded players like Metropolis only account for over 15-20 per cent of the market share.

Quality and experience, a major driver Increase in physician awareness, better clinical outcomes and increasing patient requirement to avail high quality care has propelled the pathology business forward. The shift begun with getting as many tests to India and was further stabilised by setting quality standards. Given the highly unregulated market, quality is left to a laboratory. All laboratories that have accreditations today have availed it voluntarily. Metropolis Healthcare is accredited by CAP (College of American Pathologists), the global gold standard in accreditations and NABL (The National Accreditation Board for Testing & Calibration Laboratories), the only regulating body in India and Superior Customer Experience. Accreditations are a proof of quality; it is like a stamp. However, to give a customer a superior experience, it is important to build that kind of

EXPRESS HEALTHCARE

December 2016

Accreditations need to be made mandatory so as to ensure that labs maintain basic protocol culture in the organisation. A brand is built on the culture that it provides each and every time. Three decades ago, sample (blood) collection was painful and conducted under extremely unhygienic setting. Most of you readers will vouch for this. You would painfully remember your blood being collected in test tubes with no guarantee of an accurate and reliable report. While building Metropolis, I have been very conscious of our vision which has been rather simple ‘Treat each sample as if it was of your family member.’ This has helped us build unparalleled integrity and empathy. This automatically reflects as accuracy in reports.

Increasing burden of noncommunicable diseases The United Nations has projected that India’s population will reach 1.45 billion by 2028,

making it the world’s most populous nation. Further, India will also be faced with the challenge of 168 million people in the geriatric age group by 2026. If India were to leverage its demographic dividend, then it is imperative that it nurtures a healthier population. Although, India has made significant progress in the last six decades on various health parameters, the focus of our healthcare system has been mainly on curative care. However, with rising disposable incomes, changes in lifestyle and increasing population, we are witnessing a significant change in the disease pattern in the country. While we are still struggling with the communicable diseases, the disease burden of non-communicable diseases has increased to 60 per cent. India is estimated to lose $4.8 trillion between 2012 and 2030 due to non-communicable disorders. It is therefore critical for India to transform its healthcare sector.

Emergence of the new age customer The present interest for quality in the diagnostics business is gaining momentum through corporate sectors. As an aftereffect of this, there is a developing interest in the minds of the general society for demanding better pathological services. Henceforth, with the constantly expanding customer demands in India there has been a continuous incre-

ment in the quantity of certified pathological labs by NABL. Though the desires of the patients have expanded drastically as of late, relying upon them to comprehend the complexities of pathological operations is not reasonable. Alongside a developing feeling of qualification towards healthcare in general, patients expect that these administrations ought to be introduced to them as an exhaustive yet durable package. They hope to receive state-of-the-art facilities for every penny they spend. Subsequently, players in the pathology segment need to oversee tolerant connections viably over the continuum of the mind and coordinate their own work processes to convey clinically valuable patient data.

sacrifice for it. Hence, people now look forward to finding and treating diseases as soon as possible. These trends indicate that the collective conscious of the public has now shifted from curative to preventive healthcare. They are aware that some kind of illness is eventually going to hit everyone, but when caught early it can be eradicated from the root and full health can be retained successfully. The general public are now educated about illness and their symptoms, and what it takes to maintain good health overall. Due to the expensive nature of healthcare, more and more people aim for preventive healthcare to save themselves from heavy financial losses. And this is going to turn around both diagnostics and healthcare business in India.

From curative to preventive

An appeal for regulation

The people in general have now shifted their obsessive focus on curative measures to preventative care and devices that have the potential to more efficiently provide a higher standard of living and better healthcare overall. They are planning and executing preventive healthcare measures ahead of time when the illness have not even manifested. In today’s fast paced lifestyle people believe that maintaining a healthy lifestyle is important and individuals are willing to make all kinds of

While corporate players have ensured standardisation of processes, it is important that government takes measures to bring in regulation to the diagnostic sector. A change in the regulatory scenario can transform the landscape of the industry. Accreditations need to be made mandatory so as to ensure labs maintain basic protocol. This will ensure more accurate reports, right diagnosis and disease management and in-turn better healthcare costs for the masses.

MARKET

POST EVENT

HEAL 2016 concludes successfully The event saw students, healthcare professionals and dignitaries participate in large numbers THE THIRD edition of HEAL 2016 (Healthcare Excellence through Administration and Leadership) was recently held at Baby Memorial Hospital (BMH), Kozhikode, Kerala. Research Foundation of Hospital & Healthcare Administration (RFHHA) was the Knowledge Partner and Association of Healthcare Providers India (AHPI) was the Associate Partner. The event saw students, healthcare professionals and dignitaries participate in large numbers and industry best practices, areas that required focus and the future of healthcare were discussed at large, benefiting the audience in an effort to transform healthcare from good to great. Dr Vineeth Abraham, Director, BMH, gave the welcome address and Dr KG Alexander, Chairman, BMH, the presidential address. He highlighted the commitment of BMH and the journey of the institution from a 52-bed hospital to a 800-bed hospital. The event was inaugurated by Dr Kulbhushan Balooni, Director IIM, Kozhikode. Air Marshal (Dr) Pawan Kapoor VSM, Director General, Medical Services (Air), Ministry of Defence and Dr Girdhar Gyani, Director General, AHPI were Guests of Honour. Dr Vinoth Kumar, Conference Director proposed the Vote of Thanks for the inaugural session. Dr Kapoor started the academic session with his talk on ‘Quality and Accreditation of

Dr Vineeth Abraham, Director–BMH, Dr KG Alexander, Chairman –BMH, Dr Kulbhushan Balooni, Director – IIM Kozhikode, Dr Girdhar Gyani, Director General – AHPI, Air Marshal (Dr) Pawan Kapoor (DGMS (Air), Ministry of Defence, Dr C Vinoth Kumar, Conference Director – HEAL

The session on 'Innovations and Strategies in Healthcare’ provided factual figures from recent mergers, acquisitions and IPOs Healthcare Services,’ in which he discussed the importance and need for accreditation and also enthralled the audience with case studies and insightful thoughts. Following that, Lt Col (Dr) Madhav Madhusudhan Singh, Jt Director Medical Services (Trg & Coord), O/o DGMS (Army) addressed the gathering on ‘Smart Hospitals Gen Next Healthcare’ in which he detailed about the concept of smart hospitals and also interesting concepts and innovative devices in the market or

those in the last phase of testing which are going to bring a paradigm shift in healthcare delivery. The second day started with Neelakannan, Group COO - KIMS, Thiruvananthapuram’ talking on ‘Innovations and Strategies in Healthcare’ which was an eye-opener for many, providing factual figures from recent mergers, acquisitions and IPOs. Dr Girdhar Gyani addressed the gathering on ‘Improving Clinical Governance

by Engaging Clinicians in Quality Process.’ His session gave a blueprint for physician leadership in organisations, more so in the departmental setting thus enabling high standards and impactful clinical governance. Dr Pradeep Bhardwaj, CEO, Six Sigma Healthcare addressed the gathering on ‘Leadership in Hospital & Healthcare Management,’ ‘Power of Six Sigma’ and ‘CSR in Healthcare Management,’ in which his organisation has created a niche name for themselves as the only organisation in the country engaged in such rescues. The afternoon session started with Srinivas Rao, Director, Global Institute of Supply Management on ‘Game Changing Trends in Supply Chain Management.’ Saji Mathew, Chief of IT & HR, BMH spoke on ‘Healthcare

Analytics for Better Decision Making’ giving insights into levels of data flow and extracting meaningful information which can be put to use for gaining organisational excellence. In the penultimate session, Gracy Mathai, Chief Quality Officer, BMH spoke on ‘Green Hospitals & Clean Hospitals.’ She gave a complete account for building green and clean hospitals which is the need of the hour. The last session of the day saw S Rajarajan, Independent Healthcare Consultant, Chennai give an account on ‘Recent advances in Customer Experience Management.’ He stressed the need to build the trust and service the consumers with thought provoking insights and examples. The vote of thanks was proposed by Simon Mathews, AGM - Operations, BMH. EH News Bureau

EXPRESS HEALTHCARE

December 2016

cover )

Experts are of the opinion that AYUSH can certainly compliment modern medicine. However, this calls for the establishment of clear roles for AYUSH practitioners as well as making Indiaâ&#x20AC;&#x2122;s indigenous health systems more evidence-based BY RAELENE KAMBLI

EXPRESS HEALTHCARE

December 2016

(

yurveda, Yoga, Unani, Siddha and Homoeopathy (AYUSH) have long been practised in India. These streams of medicine even form the first line of treatment in case of common ailments in some places. Therefore, it is not surprising that the Ministry of Health & Family Welfare is looking to revitalise and mainstream AYUSH (including manpower and drugs), as a measure to strengthen the public health system in the country. One of the initiatives in this direction is the inclusion of a AYUSH medications in the drug kits of ASHA workers. Reportedly, the additional supply of generic drugs for common ailments at SC/PHC/CHC levels under the mission will also include

Establishing clear roles for AYUSH practitioners as well for protocols for interactions and referrals is pivotal for a successful collaboration between allopathy and AYUSH

awareness and the appropriate dissemination of information. As rightly pointed by Parashar, integrating AYUSH with modern healthcare systems calls for strengthening of existing infrastructure and manpower. However, the integration is no cakewalk. Many allopaths seem sceptical about integrating AYUSH because practitioners of ayurveda or homoeopathy differ in theirunderstanding of anatomy, physiology, and disease and its treatment. Lack of scientific validation and credible evidence about the effectiveness and safety of AYUSH therapies is another deterrent. Therefore there is a need for more research in this area. Chauhan, says, “There should be an understanding into each other’s sciences at both the ends, otherwise

AYUSH formulations. At the CHC level, two rooms shall be provided for AYUSH practitioners and pharmacists under the Indian Public Health Standards (IPHS) model. At the same time, single doctor PHCs shall be upgraded to two doctor PHCs by inducting AYUSH practitioners at that level. Thus, a lot of steps are being implemented to promote and mainstream AYUSH. This initiative by the government has stirred a debate within the healthcare industry. While some are in favour of these steps, there are others who question their legality. Those in favour are of the opinion that AYUSH medications can act as a complementary displicine to allopathy and it will help take a holistic approach toward healthcare delivery. It would also help to alleviate the acute human resource crunch within the sector. “We think the long-term future of healthcare is dependent on integration and each of the therapies are learning from the success and failures of each other. Undoubtedly, Ayurveda offers more advantages in comparison to modern medicines. Even researchers, scientists, healthcare professional’s world over are starting to understand that modern medicine has certain limitations and challenges by design which complete holistic natural therapies like Ayurveda can help sort out. And that is where integration becomes very interesting,” states Madhusudan Chauhan, Director, Jiva Ayurveda. Tasneem A Fidvi , Senior Manager - Administration, Saifee Hospital

adds, “Integrating AYUSH in mainstream care delivery can add value to the existing healthcare system. It can help in shifting from a curative healthcare system to a preventive model. Moreover, disciplines like Ayurveda and Yoga can add to faster recovery of patients suffering from chronic diseases as well. For e.g., we have already integrated AYUSH medicine in areas of diabetes management, gynaecology, orthopaedics, neurology etc. This helps to provide better care to patients and facilitates faster recovery.” Anika Parashar, COO, Fortis La Femme informs that prestigious healthcare institutions globally now offer holistic support to their patients to complement their clinical treatment as the focus moves more aggressively towards preventative care. She points out that the first steps towards integrating AYUSH would be education and acceptance. She says that unless AYUSH practices are embraced by the mainstream medical fraternity and their benefits are better understood by Indian patients, mandatory inclusion will not serve the purpose. AYUSH practitioners should work closely with clinicians to sustainable synergies. Patients should be given additional consultations with AYUSH practitioners and pharmacists post diagnosis and prognosis from their clinician. She says that in order to successfully mainstream AYUSH, measures such as strengthening infrastructure – building, equipment and dispensaries, has to be taken up on priority across the healthcare industry. However, it all begins with

it would be very difficult to integrate.” He recommends that there should be an understanding of the scientific basis of all alternative streams of medicine and these scientific evidences should be properly documented. Dr Lipsa Shah, Ayurvedic Consultant, Saifee Hospital, adds, “Clear role setting is a must, especially when it comes to cross-referrals between allopathy and AYUSH practitioners. Moreover, AYUSH centres need to be encouraged to go in for NABH accreditation to ensure quality services. This will help to create trust among patients as well.” Similarly, Samir Somaiya, Trustee KJ Somaiya Hospital opines, “The healthcare industry will surely integrate AYUSH practice in mainstream healthcare, but there needs to be more scientific research done in this area. Scientific evidence is key to such integration and can become more effective in building a better healthcare system where both disciplines can compliment each other.” Thus, the future of healthcare lies in effective collaboration between allopathy and the AYUSH sector. However, establishing clear roles for AYUSH practitioners as well for protocols for interactions and referrals is pivotal to the success of this collaboration. Moreover, it is also important to regulate the sector and make AYUSH more evidence-based. Express Healthcare presents various insight ful articles by experts that present various aspects of AYUSH that can be integrated into mainstream.

FO C U S : AY U S H

AYURVEDA YOGA NATUROPATHY UNANI SIDDHA HOMEOPATHY

EXPRESS HEALTHCARE

December 2016

cover ) I N T E R V I E W How has Ayurveda evolved over the past couple of decades? Do you see more acceptance to Ayurveda as a medical science? Ayurveda as a science has seen a spurt of interest in the last three to four years. From the mid 80s to mid 2000s, this science had lost its appeal among the modern consumers. Consumers had moved towards allopathic products because Ayurvedic products did not appeal to the consumer in terms of packaging and ease of use. With consumers understanding the harmful effects of chemicals, Ayurveda is undergoing somewhat of a renaissance. Education and acceptability are key drivers to capture the modern consumer. Has the new government measures helped in growth of the sector? The government has understood the value of Ayurveda as a science. Yoga was taken to the west, re-branded in a form that appeals to modern consumers and today, is a mammoth multi-billion dollar industry in the US. With the formation of the Ministry of AYUSH, the government wants to safeguard the science and ensure that Indian companies take it to the world. Grants to build hospitals, promotion of Ayurveda through Indian embassies and the observation of National Ayurveda Day (on October 28, 2016) are a few key measures by the government to garner support to this science and its propagation. What other measures are required to drive more growth in the sector? Modern consumers need to know more about Ayurveda. Consumers above the age of 55 in India are generally aware of herbs and their benefits. This knowledge has been lost in the generations after and today’s modern

EXPRESS HEALTHCARE

December 2016

Ayurveda undergoes a renaissance Understanding the harmful effects of chemicals, the modern consumer inclines toward the traditional Indian science. Arjun Vaidya, CEO, Dr Vaidya’s, shares insights about the changing trends and new age products in conversation with Mansha Gagneja

We aim to create new age products,like HERBOfit and LIVitup, for the modern consumer in a form that is appealing and convenient

consumers, unfortunately, know very little about our science. The first step towards building our category is to increase the basic knowledge among our consumers. What are the challenges that hinder the growth of the sector? How can they be tackled? Lack of knowledge among consumers and poor infrastructure are the two biggest challenges. With efforts by the government and private players to propagate Ayurveda as a way of life, awareness can be built. Providing doctors access to high quality hospitals and a uniform policy framework will help improve the infrastructure. Although the process has begun, the government is still working towards giving more to aid the sector. How can players like Dr Vaidya’s contribute towards widespread adoption of Ayurveda? Dr Vaidya’s is a new age Ayurvedic products business founded by a family with 150 years of Ayurvedic heritage. Over the years, family members have passed down formulations from generation to generation and treated of patients in the process. Today, the company owns 96 FDA approved formulations for Ayurvedic proprietary medicine which are manufactured in-house. We are looking to revolutionise the way Ayurvedic products are marketed. We aim to create new age products for the modern consumer in a form that is appealing and convenient. For example, HERBOfit: the goodness of Chyawanprash in a capsule form for adults and LIVitup: an Ayurvedic hangover cure that doubles up as a long-term liver protector are the first few launches of the business. We aim to launch with the longterm vision of taking this

traditional Indian science to the modern consumer. What are your organic and inorganic growth plans for the next three years? Products have been launched through retail in Mumbai. In next three months, we aim to launch these products in Pune and then across Maharashtra and Gujarat in the next six to nine months. The reason behind this approach is that as a brand we are investing to get the market right before expanding. Even as a new brand, we have already invested on our own on the ground sales team because more than just selling the products, we are selling a concept or a new way of life. For this reason, we are expanding at a pace that we can keep up with and ensuring that we get a market right before spreading further. How do you test the efficacy of your products? Are they done through clinical trials? Can you elaborate on them? Currently, our factory is FDA approved and has ISO 9001:2008 certification as well as GMP certification. Given these licenses, we follow stringent processes in manufacturing. Each batch of product undergoes rigorous testing at government-approved laboratories before hitting the market or consumers. What are your strategies to increase your footprints in other geographies? Our brand LIVitup! has already received significant traction among international markets. The product has already been exported to China and our company is now in talks with partners across Japan, Vietnam, Singapore, Malaysia, Australia, the UK and Germany to establish our presence in these markets. Although we thought export would be a long-term game, inbound interest has made us focus on this part of the business earlier than we expected. manshagagneja@gmail.com

cover ) NEWS

7th World Ayurveda Congress and Arogya Expo inaugurated in Kolkata MoUs were signed by the Central Council for Research in Ayurvedic Sciences (CCRAS), Chennai, under the Union Ministry of AYUSH with Universities in Argentina and Israel

he Union Minister of State (Independent Charge), AYUSH, Shripad Yesso Naik inaugurated the 7th World Ayurveda Congress and Arogya Expo, in Kolkata. Earlier, two important Memorandum of Understanding (MoU) were signed by the Central Council for Research in Ayurvedic Sciences (CCRAS), Chennai, under the Union Ministry of AYUSH with Universities in Argentina and Israel in the presence of Secretary, Ministry of AYUSH. These MoUs will pave the way for introducing study of Ayurveda in those countries. Ajit M Sharan, Secretary, Ministry of AYUSH, Anil Kumar Ganeriwala, Joint Secretary, Dr Vijay P Bhatkar, National President of Vijnana Bharati, Shomita Biswas, CEO of National Medicinal Plants Board, Bandula Yalegama, Provincial Minister, Sri Lanka and Dr Maurizio Romani, Senator from Italy were also present among the dignitaries. The event is being organised by the World Ayurveda Foundation with support of Ministry of AYUSH, and the State Government of West Bengal. To facilitate development and growth of AYUSH system of medicine, the Ministry of AYUSH also organised AROGYA Expo at Science City, Kolkata to coincide with the 7th World Ayurveda Congress. This yearâ&#x20AC;&#x2122;s World Ayurveda Congress was the largest ever as compared to the earlier World Ayurveda Congress at Kochi 2002, Pune 2006, Jaipur 2008, Bengaluru 2010, Bhopal 2012 and Delhi 2014. Over 3500 delegates, including over 350 in-

EXPRESS HEALTHCARE

December 2016

The DG, Central Council for Research in Ayurvedic Sciences, Prof Vd KS Dhiman and the Principal Investigator for Medical Research Infrastructure and Health Services Fund of the Tel Aviv Medical Centre in Israel, Dr Shahar Lev-ari signing the MoU for co-operation in the research and development in the field of Ayurvedic Science, in the presence of the Secretary of AYUSH, Ajit M Sharan, at Kolkata

The DG, Central Council for Research in Ayurvedic Sciences, Prof Vd KS Dhiman and Lic Rosa Ana Molho along with Dr Gorge Luis Berra, representing Instituto Universitario del Gran Rosario and Fundacion de Salud Ayurveda Prema of Argentina signed a MoU for establishment of an Academic Chair in Ayurveda, in the presence of the Secretary of AYUSH, Ajit M Sharan, at Kolkata

ternational delegates from 24 countries representing the Global Ayurveda fraternity are expected to participate. Students, Ayurvedic practitioners, traditional healers, academics, research scientists, policy makers, industry, cultivators and collectors of medicinal plants, agricultural and forestry experts, buyers from overseas, regulators from developed nations and members of society in

and around Kolkata interested in Ayurveda also took part in the event. More than 1893 scientific papers of international caliber were being considered for presentation in over 30 multi-track scientific sessions. Pre Congress workshops have already been conducted on scientific writing, Panchakarma, Ksharkarma, afforestation of medicinal plants, mental health

and other matters concerning Ayurveda. For the Ayurvedic industry the B2B meet, Conclave on Ethno Seminar and scientific lectures were the added attractions. Speaking about the history and evolution of ayurveda, Sharan said ayurveda reached South-East Asia, the Far-East and China when Hindu and Buddhist monks from India went to those countries where

this ancient Indian science blended with local traditions for further improvement. In modern times, ayurveda has reached Europe, the US and the other western countries too, where medical fraternity and health researchers are looking for leads in traditional medicines, especially in cases where conventional medicine has failed, Sharan said. The Centre has announced 150 research fellowships in the field of Ayush out of which 100 or so would be awarded to ayurveda researchers, he added. The Ayush Ministry works for the development of education and research in ayurveda, yoga and naturopathy, unani, siddha and homoeopathy. Ayurveda must appeal to the modern generations to create demand and thus to make further headway and this ancient science must be explained in a language understood by the modern scientific community, he said. Stating that basic fundamentals of ayurveda must be interpreted through the prism of modern science, he asked ayurvedic community and researchers to create research protocols that would be at par with modern science. In this context, Sharan also stated that Ministry of Ayush has signed an agreement with WHO to develop benchmarks for research and practice of ayurveda. This will lead to standardisation of ayurveda practice and convergence will happen between ayurveda terminologies and International Classification of Diseases (ICD). EH News Bureau

(

FO C U S : AY U S H

INSIGHT

Government initiatives for AYUSH Dr Manish Soni, District Fluorosis Consultant, Govt of Rajasthan, elaborates on the efforts taken by GoI to integrate AYUSH in mainstream healthcare

omplementary and alternative medicine or traditional medicine is rapidly growing worldwide. Now-adays people are becoming concerned about the adverse effects of chemical-based drugs and the escalating costs of conventional healthcare. Due to the increased risk of lifestyle-related diseases, patients are now looking for simpler, gentler therapies for improving their quality of life and avoiding iatrogenic problems. AYUSH is an initiative of Government of India (GoI) to promote the Indian Systems of Medicine and Homeopathy. AYUSH, as the name itself represents, is an acronym for the Indian system of medicines i.e. Ayurveda, Yoga, and Naturopathy, Unani, Siddha & Homeopathy. These systems are in practice for a long time. These treatments are now well known globally and are much accepted as well. These are not only used for various treatments but are also becoming a way of life. This alternative medicinal system is widely accepted due to their easy accessibility and is within the financial reach of patients. For the development of education and research in AYUSH, the GoI has formed a separate Ministry of AYUSH on November 9, 2014 to ensure the optimal development and propagation of AYUSH systems of healthcare. Ayurveda: Ayurveda is the science of life which is described as fundamental philosophies about life, disease, and health. Ayurveda believes that positive health is the basis for attaining four cherished goals of life (chaturvidh purushartha) viz.,

Dharma, Artha, Kama, Moksha. All these four goals cannot be achieved without sound positive health. Yoga: It was founded by saints and sages thousands of years ago. Maharshi Patanjali is called the Father of Yoga. He advocated the eight folds path of Yoga, popularly known as ‘Ashtanga Yoga’ for all-round development of human beings. Yoga brings harmony between body and mind. Naturopathy: It is merely based on philosophy and is a science of drugless system of healing. Naturopathy has a great health promotive and restorative, disease preventive and curative potential. Unani: This system of medicine originated in Greece, but India is one of the leading countries that follows the Unani medicinal system. The Science of Unani medicine studies various states of the body. It is based on the wellknown four- humour theory of Hippocrates.

Siddha: The term Siddha means powers and Siddhars were Tapasvi’s who gained powers and helped cure people using these powers. It is one of the oldest systems of medicine in India. This system is therapeutic in nature, and its literature is mainly in the Tamil language. Sowa Rigpa: It is a very recently recognised system of medicine which is mainly popular in the Trans-Himalayan region. Homeopathy: The word ‘Homoeopathy’ is derived from two Greek words, Homois meaning similar and pathos meaning suffering. It is based on the natural law of healingSimilia Similibus Curantur which means ‘likes are cured by likes.’ It is now practiced across the globe. It is a method of treating diseases by administering drugs. Objectives of GoI ◗ Mainstreaming Ayush to Sub Centres, primary health centres, and community health

centre level in the healthcare system ◗ Improving access to and public health delivery through Ayush system ◗ Promotion of health and prevention of disease by propagating Ayush practices ◗ Development of human resource in Ayush system ◗ The growth of medicinal plant sector ◗ Quality research in AYUSH system ◗ To provide cost-effective AYUSH Services, with a universal access through upgrading AYUSH hospitals and dispensaries, co-location of AYUSH facilities at Primary Health Centres (PHCs), Community Health Centres (CHCs) and District Hospitals (Dhs). ◗ To strengthen institutional capacity at the state level through upgrading AYUSH educational institutions, state govenrnment ASU&H Pharmacies, drug testing laboratories and ASU&H enforcement mechanism

DR MANISH SONI District Fluorosis Consultant, Govt of Rajasthan

◗ Support cultivation of medicinal plants by adopting Good Agricultural Practices (GAPs) so as to provide a sustained supply of quality raw materials and support certification mechanism for quality standards, good agricultural/ collection/storage practices ◗ Support setting up of clusters through convergence of cultivation, warehousing, value addition and marketing and development of infrastructure for entrepreneurs. Greater infrastructure which is available with AYUSH system to provide healthcare to our people, which are underutilised. Certain measures should be taken for maximum utilisation of these facilities. Integration of these services, at the appropriate levels is required. GoI is emphasising on a meaningful phased integration of Indian Systems of Medicines with the modern medicines, plans for health and human development. It has a special focus on agriculture and food products, rural development, education and social welfare, housing, water supply and sanitation. The resurgence of interest in Ayurveda and other Indian Systems of Medicine in India and abroad and the opportunities created by such interest have been well perceived in the government. As per recommendation of the Central Council for Health and Family Welfare (in 1999) at least one doctor from the AYUSH system should be available in every primary healthcare centre and AYUSH doctors should fill the vacancies caused by non-availability of the allopathic doctor. Continued on page: 23

EXPRESS HEALTHCARE

December 2016

cover ) INSIGHT

Integrating AYUSH in main stream healthcare delivery Dr Geetha Krishnan, HoD Integrative Medicine, Medanta - The Medicity, envisages that integration would usher in an era where medical science would offer better patient care

ndia is credited to be at the frontiers of medicine since immemorial time, until about 150 years ago, when the world was swept by a healthcare revolution that largely advocated a negation of the past. However, new studies have increasingly found merit in many areas of traditional medicine and spurred the revival of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) in our country. However, modern healthcare cannot be treated as a simple binary of traditional (AYUSH) vs. modern medicine anymore. The answer lies in integrating AYUSH in mainstream healthcare, which involves two distinct streams, firstly including AYUSH services within mainstream healthcare infrastructure, and secondly integrating AYUSH within the mainstream healthcare programmes. The former is similar to the existence of two branded shops for the same commodity, working inside the premises of the same mall. Existing, but not working together and often spawning unhealthy competition. The latter is like a supermarket, where both the brands available simultaneously, with an added informative guide cum advisor available to the customer— in this case the patient-advising her on the right choice of products, or a mix and match of it, based on her needs. Inclusion of AYUSH services within the mainstream

EXPRESS HEALTHCARE

December 2016

AYURVEDA

YOGA

NATUROPATHY

SIDDHA

HOMEOPATHY SOWA RIGPA healthcare infrastructure is a process which has been initiated more than two decades ago, by several governments, including the one at the centre. There are PHC / CGHS / ESI dispensaries, where more than one AYUSH system has been co-located with modern medical infrastructure. There are thousands of patients, thus being served with the freedom to decide, of which system to choose for their ailments. Patients approaching these centres take decisions based on their current but layman understanding of the strengths and weaknesses of each system. Many of them usually decide to try more than one; often all systems available within the

UNANI

sugar levels. In such a case, addition of another anti-diabetic drug is warranted only if the current medication, though effective in blood sugar control, is causing an unwanted side-effect to the patient, or is unable to prevent and manage the complications of diabetes, or is unaffordable to the patient. Thus integrative medicine is a professional advice from patient perspective, and considers possible benefits and adversities from her perspective. The hallmark of such an advice should be (1) better clinical outcomes, (2) fewer sideeffects of medications, and (3) lesser costs. An integration process without the promise of any of the above three - if not all - would be futile and more of a cosmetic venture.

premises, with the hope that at least one of them will help.

Integrative medicine: How India merges two streams of medicine

Personalised healthcare

“The aim of integration is to offer the best possible cure, care, and management to the patient”, advises Dr Naresh Trehan, cardiothoracic surgeon and Chairman, Medanta Group of Hospitals. Dr Trehan is the most ardent proponent of integrative medicine and has been trying to find a degree of clarity to the idea of integrating AYUSH systems into mainstream medicine, since many years. He envisages that integration would usher in an era where medical science would offer better patient care through prudent combination of strengths of different medical systems. In

Integrating medical systems is an expert-guided process. It relies on evidence-based medicine and takes into consideration, the strength of evidence available for each treatment possibility across multiple systems. It also considers the patient’s requirement holistically and calls for judicious integration of therapeutics. For example a diabetic patient, whose blood sugar levels are very well managed under the care of a particular system’s medication and lifestyle advice, might not require another medication to control blood

DR GEETHA KRISHNAN, HoD Integrative Medicine, Medanta - The Medicity

his own words he is, ‘a true believer’ who from his heart wishes to see the evolution of the ‘One Medicine’ from India, which combines the strengths of the west and east. Western medicine or allopathy, in his words, cures from outside. It uses everything in its capacity to eradicate the cause of the diseases and cover-up its symptoms. In the process it cuts, burns and poisons, often leading to trauma or outcomes, more severe than the disease itself. Whereas eastern medicine, like Ayurveda, and Yoga heals from within. It enhances the body’s strengths and helps it overcome the disease. He compares the two to the air force (Allopathy) and the army (AYUSH systems). He says effective win in any war lies in the use of both, synchronised and simultaneous. It is with this vision that he created the first integrative medicine department in the country, built into the functional dynamics of his new mega venture, the Medanta. The Department of Integrative Medicine at Medanta, since its inception six years before, has catered to more than 14,000 individual patients. Co-located within one of the most modern medical facilities of the world, the department is unique through the success of functional integration achieved. Nearly 100 different diseases are managed by the department making use of Ayurveda, including all its aspects such as Yoga, drugs, therapeutics, Panchakarma, and life regimen advices. The department, services the needs of three different kinds of patients. Those who independently approach the department (30 per cent), those who are referred by allopathic practitioners (50 per cent),

(

FO C U S : AY U S H

and those who are enrolled in integrative medicine programmes (20 per cent).

Proof points: How has AYUSH integration in healthcare helped? The Medanta department of Integrative Medicine successfully and efficiently treats patients with back pain- including vertebral bone and disc diseases, osteoarthritis knee, rheumatoid arthritis, migraine, sinusitis, fibromyalgia, melasma (hyper-pigmentation of skin), hair-fall, acne, constipation, hyperacidity (GERD), allergic dermatitis, frequent upper respiratory infections, and stress among many others. On several occasions it remains a matter of pride for the department, that patients select the system over the best of allopathic options available to them, or after trying modern medical interventions over considerable periods of time, to find success in systematic Ayurvedic care. Another set of patients who approach the department are referred by Allopathic practitioners aimed at achieving specific clinical end-points. Major categories in this group are gastric symptoms including constipation post coronary bypass surgery, long standing pain of neurogenic origin post thoracic surgery, pelvic pain syndrome – a type of moderate to debilitating

pain, usually occurring in men and associated with urination, in the lower abdomen, groin and perineum, inflammation of the inner lining of the mouth during radiation therapy and neck muscle stiffness – post radiation therapy, breast cancer patients under concurrent radiation / chemo therapy, reduced platelet count in Dengue fever, insomnia, along with many referrals for back and knee joint pain. These referrals have been built over a period of time, through systematic collection of data, independent analysis of the same, and discussion and dissemination of results (positive and negatives) as part of the ongoing outcomes research efforts of the hospital. Yet another group of patients cared for in the department are enrolled under integrative medicine programmes, designed and implemented in the hospital. There are four such programmes being explored in the hospital. It includes heart disease reversal programme under Dr Ravi Kasliwal, Chief Cardiologist of the hospital, where we are exploring the possibilities of reversing the heart diseases of patients identified with very early changes in the cardiac blood vessels. Addition of Yoga before and after major cardiothoracic surgeries is another attempt in generating improved clinical outcomes, which involves working with Dr

Integrating medical systems is an expert-guided process. It relies on evidencebased medicine and takes into consideration, the strength of evidence available for each treatment possibility across multiple systems Yatin Mehta, chief of critical care, and Dr Ali Zamir Khan, Director Robotic thoracic surgery and led by Dr Naresh Trehan himself. The department also runs an integrative programme with the Institute of Neurology under Dr Arun Garg, Director and specialist in Stroke management. The programme improves recovery

outcomes among stroke patients, with the addition of Ayurvedic medicines and therapies introduced early in stroke management, together with a consistently high standard of personalised care. The department also runs an integrative programme with the preventive health and wellness centre of the hospital, offering Prakruti-based advises on ‘Predictive, Preventive medicine and Promotive healthcare’. This approach, focusing on improving the quality of life and longevity has altered the prevailing trends of preventive health check-up, which boulders down to analysing one’s lab reports and writing a paragraph explaining the tabular data, for easy understanding. There are many attributes, in the Medanta model of Integrative medicine, which are laudable and replicable in a wider social spectrum. One example is in the management of knee-joint pain – a simple five week protocol, which has been found effective in hundreds of patients. A very large number of patients who were identified with early osteoarthritic changes, were administered this protocol so as to save them the trauma of a future knee replacement surgery. In my capacity as head of the Department of Integrative Medicine at Medanta – The Medicity, I was acutely aware of the sub-

stantial savings in costs - financial, human capital and lost work hours. An example of such savings can be seen in the pan-India campaign we have proposed, along with the Ministry of AYUSH, for mitigating the need for knee surgery by employing AYUSH-based treatments. The ‘Save Your Knee’ campaign will be the first and largest private-sector led initiative with a pan India presence, when fully implemented in the field of integrative medicine. The management of migraines and sinusitis are two other areas which can and should be handed over to Ayurveda, before any other system. So are fibromyalgia, early sleep disturbance, GERD and constipation.

The way forward for AYUSH Integrative medicine is one which needs to be implemented in all PHCs across the country, no doubt. Nevertheless, its baby steps should be taken in large private hospitals, where the practice can grow, gain social acceptance, and gradually flow down to the PHCs. It would be a clear top down model of growth, as is with most of the advanced medical technology. The involvement of the private sector is an irreplaceable step in the growth and public utility of Integrative medicine.

Continued from page: 21

AYUSH - Government... Strengthening the medical education of AYUSH system Medical education in AYUSH system has been a cause of concern. The Central Councils have implemented various educational regulations to ensure minimum standards of education.

the wild as a natural component of the vegetation of particular regions. In the absence of a scientific system for collection and fostering regeneration of such plants, several species have either been completely lost or become endangered. Raw material supply and its quality is a common problem for AYUSH system.

Medicinal plants AYUSH doctors use predominantly organic materials for the preparation of their drugs. Most of these plants grow in

Revitalisation of local health traditions Revitalisation of folk health traditions related to birth atten-

dants, herbal healers, bone settlers, Visha healers etc., would figure in the agenda of the AYUSH sector to be selectively identified, reinforced, validated and then propagated for use in a wider community.

Medical tourism and export of ISM practitioners The interest in our systems overseas for gentler and plant-based treatment has been growing rapidly. More than that, certain therapies

are becoming extremely popular and tourists/visitors come to India for such therapies like Panchkarma and Yoga. Medical tourism not only popularises our system but offers a good avenue for foreign exchange earning. Along with implementing the policy of the Central government, State Govenrment of Rajasthan has taken one step ahead and initiated an Adarsh PHC Yojana in which a PHC in every block is identified and named it as Adarsh

PHC. It is further strengthened by appointing an AYUSH doctor along with a medical officer and providing AYUSH medicines and started cultivating medicinal plants in PHC. AYUSH doctor has the responsibility of conducting YOGA session every morning. In the second phase of Adarsh PHC yojana, the government is planning to appoint two PHC in every block. Source: http://AYUSH .gov.in/ http://www.nhp.gov.in/ayurveda_mty

EXPRESS HEALTHCARE

December 2016

cover ) INSIGHT

AYUSH AWAYTO INCREASE HEALTHCARE ACCESS Akshar, a Himalayan yogi, Founder and Owner, Akshar Power Yoga, gives an insight on understanding the potential of Yoga and how Government of India has made AYUSH a critical part of NRHM

ith history dating back to time immemorial India has a unique advantage as far as healthcare is concerned. While this may sound surprising, it is actually true. India’s health history dates back to centuries and systems like Ayurveda, Yoga, Unani, Siddha and Homoeopathy (AYUSH) are all native to India. Incidentally, AYUSH is a governmental body in India that has been formed under the aegis of the Ministry of

EXPRESS HEALTHCARE

December 2016

GRAND MASTER AKSHAR Founder, Akshar Power Yoga Academy

AYUSH with the intention to develop, educate and research in ayurveda, yoga, naturopathy, unani, siddha, and homoeopathy, traditional Tibetan medicine and other indigenous medicine systems. The Department of Indian System of Medicine and Homoeopathy (ISM&H) was created in March 1995 and was re-branded as AYUSH in March 2003. AYUSH also means ‘Life’ in Sanskrit and it is the perfect way to integrate all traditional health streams in one platform.

Back to the roots As per the Ministry of Health & Family Welfare (MoHFW), the Indian systems of medicine have age-old acceptance in India as they have a history of being effective. Inspite of rapid urbanisation, in many places these also form the first line of treatment for several common ailments. This is exactly the reason why MoHFW is now seeking to revitalise and mainstream AYUSH (including manpower and drugs) to strengthen the public health system at all levels in the coun-

try. It has been decided that Accredited Social Health Activist (ASHA) workers will include AYUSH medications in their drug kit. The new mandate is that the additional supply of generic drugs for common ailments at sub-centres, Primary Health Centres (PHCs) and Community Health Centres (CHCs) levels under the mission shall also include AYUSH formulations. At the CHC level, two rooms shall be provided for AYUSH practitioners and pharmacists under the Indian Public Health

( Standards (IPHS) model. At the same time, single doctor PHCs shall be upgraded to two doctor PHCs by inducting AYUSH practitioners at that level. Naturally this has triggered a debate with both pros and cons of this initiative being discussed.

Special initiatives The concept of ‘Mainstreaming of AYUSH’ has been mentioned in the policy documents of the Government of India since the Sixth Five Year Plan. The government has taken several steps to mainstream and strengthen Ayush as there is an increase in the number of new age lifestyle diseases. This has caused resurgence in the interest levels towards the AYUSH system of medicine both inside the country and abroad. Understanding the potential of AYUSH, the Government of India has made it to be a critical part of the National Rural Health Mission (NRHM). Before the launch of NRHM in 2005, the Department of AYUSH has been implementing a ‘Hospitals and Dispensaries’ scheme from the 10th Plan onwards, which has now been subsumed under NRHM. In fact a key aspect is to revive the Local Heath Tradition (LHT) by ensuring that its health promotion, preventive and curative methods start having more general acceptance and prevalence among household of different economic strata. LHT is important to sustain and strengthen the AYUSH system, which is another strategy of NRHM. The vision of this programme is to ensure that there is sustained availability of raw materials as well as continued research and development on the efficacy of the system. The government is working on an awareness creation as well as information dissemination drive among the people highlighting the gentleness, local availability, cost effectiveness and no side-effects aspects of AYUSH. Providing affordable and quality healthcare to the rural population especially the vulnerable section is the key and AYUSH seeks to do the same. The objective of this pro-

gramme is to provide comprehensive healthcare along with the modern system of medicine and encourage and facilitate to set up speciality as well as AYUSH clinics. These are being aimed in areas of geriatric care (Ayurveda), mother and child (Homoeopathy), psychosomatic disorders (Yoga) and skin problems (Unani). The idea is also to promote the culture of cross referral system and give an integrated healthcare delivery system including the national programme to the public.

Private player push The move to popularise AYUSH cannot be done by the government alone and so they are seeking private players to play an active role to help integrate Ayush with mainstream health offerings. We care about individuals and believe in the importance of actual transformation. This is not just limited to physical well being but also mental wellness, which is a vital aspect on which we work on. In the US, the government is spending millions of dollars for psychological well being of its citizens. I feel that the Indian government must work aggressively with the private players to ensure that they offer holistic health solutions. We work closely with the people including patients to understand how well they are able to reciprocate these lifestyle changes. This in turn will give us insights to alter our programmes to benefit people.

Government initiatives The vision of Ministry of AYUSH is to position AYUSH as a preferred system of holistic healthcare for all. In order to achieve this, the Ministry has undertaken various public health-related activities. The Group of Secretaries to PM has backed the proposal to allow Ayurvedic, Homeopathic and Unani practitioners to practice at primary healthcare level. They have proposed a bridge course for AYUSH practitioners for primary healthcare and an MoU with IGNOU has been worked out as well to allow AYUSH practi-

tioners and nurses to operate at primary healthcare level. Primary healthcare includes basic medicines, immunisation, elementary drugs for minor ailments, antenatal, natal and postnatal care, common childhood diseases. As part of its ‘Swastha Bharat, Shikshit Bharat’ programme, the government proposes to promote Yoga for promotion of health in schools. Under this programme, two separate modules on health promotion through AYUSH systems will be prepared for school going children, one for the primary and one module for secondary school children. The idea is to drive these measures early on so that it becomes a part of life.

Allopathy and AYUSH The core question is how to create a cross-referral between allopathic and AYUSH streams effectively as the Indian Medical Association (IMA) has strongly opposed to allow AYUSH doctors into the modern medicine system. The new health policy projects AYUSH as a panacea for health problems and that the potential of these alternative therapies is untapped. Our diagnostic and therapeutic methods that complement mainstream medicine has gained global acceptance. AYUSH systems can be exploited to their full potential when they become a part of mainstream medicine. This calls for a clear establishment of the roles of AYUSH practitioners, thumb rules for interactions and referrals and a communication between AYUSH and allopathic doctors. Usually when people recover from ailments, a relapse is common as there are no lifestyle changes, even as a part of the recovery solution. One of the essential ways is to change your food habits and turn vegetarian. Unless the nature of compassion towards animals is adopted, things will not change.

Ayush – A way to increase healthcare access Statistics have repeatedly indi-

FO C U S : AY U S H

The core question is how to create a cross-referral between allopathic and AYUSH streams effectively as the Indian Medical Association (IMA) has strongly opposed to allow AYUSH doctors into the modern medicine system.The new health policy projects AYUSH as a panacea for health problems and that the potential of these alternative therapies is untapped cated that there is a severe shortage of doctors in India with a mere 80 doctors per lakh population. A recent World Health Organisation (WHO) report states that close to 57 per cent allopathic doctors in the country did not have a medical degree which makes the number of doctors per lakh fall to a mere 36. According to WHO, 53 per cent of AYUSH doctors had degrees in their respective fields as compared to 43 per cent for allopathic ones and this is where the government can work to expand its AYUSH programme across all segments. India has a unique advantage as far as traditional system of medicines are concerned being one of the 17 countries in the world having rich biodiversity with varied medicinal plants. The Central government has committed to provide medicines at reasonable rates and

creation of better healthcare infrastructure facilities. This is also being done through the Jan Aushadhi programme. The Central government under the National AYUSH Mission (NAM) is also setting up AYUSH educational institutions in states and Union Territories where such facilities are not available. Upgradation of state government AYUSH hospitals and dispensaries and setting up of integrated AYUSH hospital are other initiatives under the NAM. The Ministry of AYUSH spends around `20-crore annually on its five research centres. The Union Minister of State for AYUSH (Independent Charge) recently issued a statement that the Centre is committed to propagate AYUSH system in the field of healthcare and will move in the right direction to achieve the goal.

EXPRESS HEALTHCARE

December 2016

KNOWLEDGE KNOWLEDGE EXCHANGE

Awareness is key to COPD management Express Healthcare along with S P A G organised a Knowledge Exchange with Dr Prashant N Chhajed, Chief Pulmonologist: Lung Care and Sleep Centre, Fortis Hospitals, Vashi and Mulund and consultant, Lilavati & Nanavati Hospitals and Dr Lancelot Pinto, Consultant Respirologist, Department of Respiratory Medicine, PD Hinduja National Hospital and Medical Research Centre, on the occasion of World COPD Day, in order to spread awareness on the right diagnosis and management of the disease. Excerpts from the programme

hrow some light on the prevalence of Chronic Obstructive Pulmonary Disease (COPD) in India. What are the determinants for the rise of COPD ? What are the treatment protocols currently available in our country? Dr Prashant N Chhajed: Various studies conducted have stated that the prevalence could be between four to nine per cent. Presently, in India, we have at least 30 million people suffering from COPD.

EXPRESS HEALTHCARE

December 2016

One of the dominant causes of COPD is smoking. Long-term smoking is definitely linked to COPD. There is another concept known as non-smoking COPD. The elements for non-smoking COPD are: ◗ Indoor pollution particularly in countries like India and other developing countries is basically due to chula fume exposures. ◗ Exposure to biomass fuel, which is widely used across the country

◗ Environmental pollution also contributes to COPD particularly in areas where there are high urbanisation or high pollution levels. People living in those areas have a high risk of developing COPD. What are the current treatment protocols available for Indian COPD patients today? Dr Chhajed: I think the treatment protocols are uniform. The therapy for COPD is at multiple levels. There is a multi-disciplinary approach to the man-

agement of COPD. It includes giving inhalers, particularly inhaled bronchodilators. We also recommend use of oral tablets, oral Theophyllines, pulmonary rehabilitation, vaccinations, taking care of osteoporosis and patients who are at advanced COPD might need oxygen therapy at home and noninvasive ventilation. The therapy for COPD should be uniform everywhere. Give us an overview of what is happening abroad and how it’s different in India (with reference to the treatment protocols)? Dr Lancelot Pinto: When we talk about management, we begin with the first step that is prevention, then treatment and lastly follow up. So in terms of prevention, worldwide smoking rates are dipping. We know for the fact that regulations have played a significant role in curbing smoking habits, with stringent taxes being implemented it will further reduce the number of smokers. In India, smoking among women is on the rise and these are the people who eventually are going to develop COPD. In terms of prevention, we aren’t really doing enough. Although the government has taken a couple of very good steps in terms of universal packaging of cigarette packets, the warning etc., is a step in the right direction. Biomass fuel is a big contributor to COPD in India. As compared to the rest of the world, where only 25 per cent of the world’s population use solid fuels for cooking, 75 per cent of Indian households use coal and solid fuels for cooking. This leads to lot of pollutants, which eventually has a strong link with COPD. We definitely need to do a lot more in terms of prevention as compared to the rest of the world. Diagnosis will involve the use of a spirometer which is the gold standard for the diagnosis of COPD and it is what is used all over the world. A recent study in India among general practitioners states that less than 25 per cent prescribe spirometry to their patients, which means if we are not diagnosing them then treatment is still far off. When it comes to the treatment, it is pretty uniform all over the world. What you need is a good dual bronchodilators which are used everywhere in the world but there is a big phobia in India to prescribe inhalers. Inhalers are associated with all sorts of myths in India. Patients constantly ask if they will get addicted to inhalers. They don’t ask a diabetologist if they will get addicted to their diabetes medication but for some reason, the concept of ‘you need inhalers’ is equivalent to ‘you will get dependent on inhalers’. As a result, most physicians end up prescribing tablets instead of inhalers. And that is not recommended globally. This is where we lack and there is huge reluctance to prescribe. When it comes to follow up, vaccinations or pulmonary rehabilitation for example which are shown to alter the quality of life to a great extent, hardly anyone practices pulmonary rehabilitation and there are a various reasons associated with it. It involves intense follow up, a system where a patient has a referral point and can visit again and again. We don’t have the kind of infrastructure to deal with the situation. What is the ideal treatment protocol that Indians should follow?

Dr Prashant N Chhajed

Dr Lancelot Pinto

Dr Chhajed: There should be an uniform protocol as also pointed out by Dr Pinto. A lot of effort should be put in preventing COPD. As Dr Pinto mentioned, it is more difficult to smoke in public places. But it needs to be implemented in a much stronger way. Exposure to bio-mass fuels need to be tackled in a big way because a large chunk of patients who are non-smoking COPD end up inhaling polluted air. Hence, prevention at that level is very important. Once preventive aspects are taken into account, you need to diagnose them properly. Early diagnosis is important as progression of the disease can be delayed and you can actually give them a better quality of life. Exacerbations can be reduced. Every time a patient has an exacerbation, he/she loses lung function. So, I think the treatment protocol has to be same. The Indian guidelines have been slightly tweaked so that Indian practitioners can implement them properly. But mind you, the mean principles of therapy remain the same. A few recommendations may go up and down based on the availability of medication, cost of medication etc., but overall, I think the approach is same. Being part of various committees in India also, we would not like to have something tangent to what the world is doing.

there has been a lot of evidence emerging that the focus should be mainly on inhaled bronchodilators or rather inhaled dual bronchodilation which actually improves the symptoms of the patient and gives them a better quality of life. This is the first approach. As Dr Pinto also mentioned, many patients are being prescribed oral tablets first. Oral tablets should be prescribed much later, as they are more of an add on therapy rather than the main stay therapy. Of course inhaled corticosteroids, which are the main stay of asthma treatment are again add ons, which can be used on selected number of patients. Hence, according to me, these protocols should be followed by our physicians. A general physician should ask for a spirometry on the same lines as asking for for an X-ray or for a complete blood count. Once the practise is inculcated, the next step would be to enquire about the lung function followed by what is going to be the therapy.

What are the Indian protocols followed currently? Dr Chhajed: Prevention protocols remain the same. As for the treatment protocols, we provide inhaled bronchodilators. Inhaled bronchodilators are important for patients with COPD. And now recently,

Dr Pinto, you talked about the myths that patients have about inhalers. How much do doctors have these myths and how do we break it? Dr Pinto: Education is the answer to all problems. Whether doctors genuinely believe in these myths themselves or whether they are catering to their clientele, it’s a difficult question to answer. Very often, you do not, not want the patient to come back to you simply because you prescribed a medicine which is not in line with their social believes or what they believed to be right. There is a stigma associ-

EXPRESS HEALTHCARE

December 2016

KNOWLEDGE

ated with inhalers. People believe that if you are put on inhalers, you have a disease. And physicians also to a large extent, are reluctant to prescribe them to patients. One of the ways we can dispel such myths is through educating people that the dose which you get in an inhaler is a minute fraction of the dose that you would take as a tablet because it directly gets deposited into the lungs versus going into the circulation, going to the blood stream, then reaching your lungs. Explaining that to patients often helps. I usually put down numbers down to explain patients saying that if I had to give you something orally it would be in milligrams, what I am giving you now is in micrograms. In this way patients understand that an inhaler is a milder dose. Therefore, I think educating physicians as well as patients will make a huge difference. Another reality is that inhalers are more expensive than tablets and there is also a cost dynamic to the whole situation. So it’s not just the myth. Bringing down the price of inhalers would also help. Dr Chhajed: Having said that , acceptance of inhalers in on the rise. Particularly in the urban areas where we practice, we see it is not as difficult to initiate someone on a inhaler therapy than it was some years ago. Thanks to educating patients and multiple campaigns, CME’s, media etc., which have actually promoted this. Do you see a lack of understanding in treatment protocols among physicians? Dr Chhajed: I think it is universal problem. What is happening is that within few years, you are having newer guidelines. But I think an important step has been taken as far as the medical council requirements are there, which is called as the CME points. It is forcing people to attend CME’s, which allows us to dissipate knowledge to the physicians or the practitioners at large. Do you see a lack of diagnosis happening ? Dr Pinto: That’s a huge problem for sure. There is a lack of spirometers in the country. Studies that have looked at the diagnostics skills of physicians have found that if a physician solely relies on the diagnostic skills for diagnosing COPD, about half of all the patients will be missed. OS spirometry should be performed on patients suspected of having obstructive airway disease. And that is solely lacking in our country and the lack of trained technicians to conduct spirometry. That is the unfortunate part. Unlike an ECG, where you can pretty much train anybody to just get it done, spirometry is a patient-effort dependent process. So the same patient going for spirometry with three different technicians all of whom are variably trained will have different results with all those technicians. Good quality spirometry makes a huge difference and is the first step towards diagnosing COPD. People usually associate Asthma with COPD. I want you to throw some light on whether asthma literally means COPD or there is a difference between the two diseases. Dr Chhajed: There is a difference between asthma and COPD. In India, asthma has different names in local languages, Dama etc. Unfortunately, COPD

EXPRESS HEALTHCARE

December 2016

Education is the most important thing in terms of empowerment of patient. Educating people on the ill effects of indoor and outdoor air pollution could lead to a mass movement does not. So most often, asthma and COPD get clubbed as dama and the approach for treating both have been the same. However, it is important to highlight the difference between them. Asthma can happen in young patients. COPD typically happens in people who are elderly who have a history of smoking or those who have exposure to some air pollutants. In asthma, patients can have symptoms and once they are treated they completely become normal. However, if you look at COPD, it is a progressive disease. So the symptoms stay for a long time and patients require regular therapy. In case of asthma patients, they require regular therapy especially in cases of progressive asthma. Another thing to differentiate between asthma and COPD is that asthma is a reversible disease, but COPD is not. So if someone is getting an airway narrowing, providing inhalers to patients with proper treatment will help the airway become normal. COPD patients will get symptomatic benefit but the airways do not open up completely therefore, it is not a reversible disease. Another important reason that we must differentiate between the two is the change in the therapy approach. We have emerging evidence to say that it is important to differentiate between the two. What role should physicians play in creating awareness about asthma and COPD and the difference between the two? Dr Pinto: Asthma is predominantly an allergic diseases. In patients who have nasal allergies, skin allergies and have shortness of breath it is most likely asthma than COPD. In terms of awareness, putting a label to a disease makes a huge difference. One of the things we commonly notice is physicians are normally little reluctant to tell a patient with asthma that he has asthma so we have a lot of terms floating around like bronchitis, like allergic lung disease,

We stand very low as far as research activities are concerned.There is a potential to do more, as far as research activities are concerned

like allergic bronchitis etc. Just informing a patient that he/she has asthma is empowering because you have given him or her a diagnosis, you have given him/her a prognosis on a disease which can be worked on. Going for regular treatments, one can live an absolutely normal life. And the same holds true for individuals with COPD. Putting a label on their diseases makes them sensitise towards how important it is to stop smoking, will sensitise them towards new treatments available. And as physicians of course, all of us play a role in disseminating information as part of CME’s, as part of like world COPD day where you go out and educate people about the diseases such as COPD whether it is in the media or newspapers, through whatever channels you have access to that is very important as well. Since you are into management of COPD and empowering patients, what should be done to empower patients to better understand COPD and to manage their disease on their own? Dr Pinto: Education is the most important thing in terms of empowerment of patient. Starting with diagnosis, giving them a diagnosis and letting them know what they have and giving them all the treatment options that are available. In terms of education, prevention again is the most important key, so educating people on the ill effects of indoor and outdoor air pollution could lead to a mass movement where you pressurise your local government and try and make a difference in terms of air pollution. Switching over to healthier fuel for example is extremely important and I think that kind of empowerment is needed. We are seeing a lot of public campaigns that can change things. Educating your patient about their medical condition and treatment provided is important. There is a rising population of people with CVD’s and COPD, so how can physicians educate their patients and firstly diagnose this dual condition and how to manage it? Dr Pinto: Some are them are what we call shared co-morbidities. The fact that an elderly person is already prone to developing heart disease whether he has COPD or not. Then also there is a clear link that has been established between COPD and CVD’s. The no 1 cause of death for COPD patients is cardiovascular disease. One fifth of the patients with COPD will have underlying chronic heart failure. A clinical examination of course makes a difference. When a physician is seeing a patient and you suspect COPD, you need to look at signs of heart failure as well. Doing a screening always help simple things like an

KNOWLEDGE

ECG to begin with. What also helps is if a person has shortness of breath, which seems to be out of proportion to the degree of impairment seen on a spirometry or once you optimised the treatment for the COPD and if the patient still feels short of breath, then you definitely need to think in terms of other possibilities for that shortness of breath such as heart disease. You need to look out for signs of comorbidities and those include heart disease, high blood pressure, metabolic disease such diabetes, OSA and of course diseases such as osteoporosis and even depression. So, patients with COPD are about 2.5 times likely to be depressed than patients without COPD. And therefore it becomes important to screen COPD patients for these diseases because it is not enough just to treat COPD and ignore all these other conditions along with it. Share some insights on the research activities happening on COPD in India? And where do we stand when compared to other countries? Dr Chhajed: We stand very low as far as research activities are concerned. There is a potential to do more, as far as research activities are concerned. Because we have local factors that influence COPD, which is the patient’s locality, understanding of the disease, factors leading to COPD for these patient’s, what therapies are feasible, for example first line molecule and is it easily available to the common man. There is a big need that we should initiate and increase the research in this field. An important step has been taken in India. For example, the non-smoking COPD, the dominant research in this area has actually come from India. So it’s not completely bad. There is some research activity happening in India as well. We are contributing to the literature in the science and medicine of COPD. But it is also important to understand the local factors so that we can identify our special cases. We can identify our patients who are at a higher risk, diagnose them early and put them onto the therapies earlier. For example in the West you will see that most of the teaching institutions or university hospitals will have a COPD cohort for example. A COPD cohort is a group of COPD patients who come to a clinic and they are monitored over a period of time. And that gives a tremendous insight into how local patterns are, local behaviour, how are the patients responding. The co-morbidities which the patient will face, is it similar in the West or different. You will have an answer to these questions only if you study your local COPD population. I think there needs to be a concentrated effort at all levels, private research institutes, medical institutions, industry support, government support. Support is required at all levels just because COPD is becoming the third leading cause of death and is becoming a huge cause of morbidity worldwide. The current expenditure cost of COPD burden is at `35000 crores and in the next few years is expected to reach `48000 crores. I think a little bit of investment in research will go a big way in tackling this problem. How important is it for the medical fraternity to work with the government to streamline air control policies and implement them? Dr Pinto: It is extremely important for the medical fraternity to liaison with the government and some of

There are government funds and research institutes, that are doing some research. However, it needs to be done on a much larger scale

it comes from research. There is a paper that highlights incidence of obstructive airway disease and the distance to the highway, the closer you are to the highway the more likely you are to have an obstructive airway disease. Our primary role would be to present data / evidence to the government and lobbying from both the community at large and from physicians in terms of sensitising the government. It is tricky because there are religious sentiments attached to these festivals like Diwali and bursting crackers. So, it is definitely not going to be an open and shut legislative thing, but engaging everybody and sensitising people on how important this and how it can go a long way in changing policy. People now realise about the ill effects of smoking. For example, if in a restaurant a person next to you is smoking, you would point it out and make him stop smoking. But this is not enough to tackle the air quality outside. I think that kind of momentum has to come from the public as well. At present, if we can’t stop people from bursting crackers, are there any other strategies that can be implemented to control some amount of pollution? Dr Pinto: Publish air quality indices. People with COPD can be advised not to venture outside when the air quality is extremely poor because it is linked with exacerbations. Having that kind of transparency on an on-going basis will help. There are websites where you can check out the air quality index. But doing that on a mass scale, for example having it at a traffic signal, telling people what the air quality is like on a daily basis would help. At the end of the day, disseminating information that you need air purifiers in the house would take the burden away from the government to ensure that we get clean air and would just shift the burden onto individuals to look after air quality for themselves. Dr Chhajed: We need to think about the industrial pollution, vehicular pollution as well. As mentioned earlier, it helps to have healthier fuels or greener fuels and I think emphasis has to be made on this aspect as well. In Mumbai, we face this huge problem about the dumping areas which catches fire etc., and leads to a tremendous health hazard. Are we genetically more susceptible to COPD? Dr Pinto: There was a study done when the lung function of different countries (pure study) were looked upon. Indians have around 33 per cent lower function than the reference which is Caucasians. We have one of the lowest lung functions in the world

even lower than sub-Saharan Africa. We don’t know what the cause is, so if we begin at a lower lung function and then we smoke or are exposed to biomass fuels, then yes, we are definitely more susceptible to developing COPD. Dr Chhajed: Cardiologists say that coronaries are much smaller than the Caucasians, hence you are a higher risk of coronary disease then your counterparts around the world. We have been talking about a lack of data so how can we make COPD management more evidence based? Dr Pinto: All of us can contribute in our own way in terms of developing this evidence. For example is Biomass-related COPD identical to smoking associated COPD, a question as simple as that, yet there are various studies related to that. And the few studies suggest yes they are different. Biomass fuel associated COPD is more likely to be associated to chronic bronchitis where you can produce a lot of sputum and would probably respond to inhaled corticosteroids. And that is not the same for smoking-related COPD. That is in creating and collection of evidence. The other part is in the dissemination of the evidence. Dr Chhajed: How many institutions are providing research, how many teaching institutions are giving out quality publications? Is research encouraged in the curriculum? Can a doctor, who has finished his MBBS or MD, get into research for a few years? Does he have any person to support him? These are some of the important questions that need to be answered. In the western world, where we have both spent time, we could do research because there was a support which encourages research. As a clinician also there are systems that allow you to do research. Funding is available and yes research is in fact important and that needs to be inculcated more and more into our systems. Is there a need for the government to create a fund in India for research? Dr Chhajed: There are government funds, there are research institutes, we do have government centres of excellence and medical institutions that are doing research. However, it needs to be done on a much larger scale. And it needs to be a priority which shows that we are looking at a long term goal and not a short term goal. (The session was moderated by Raelene Kambli)

EXPRESS HEALTHCARE

December 2016

KNOWLEDGE I N T E R V I E W

We aim to start new research programme in India on cancer immunology and immunotherapy in collaboration with MSCTR and STRAND Dr Rafi Ahmed, Vaccine Center Director at Emory Vaccine Center; Professor at Department of Microbiology and Immunology; Scholar at Georgia Research Alliance and Investigator at Emory Center for AIDS Research, recently visited India. The renowned immunologist shared in details about the reason behind his visit, his current research projects and the evolving role of immunology is clinical practice, in a short interview with Lakshmipriya Nair What is your agenda on this visit to India? Are there any research collaborations in the offing? Yes, we have an ongoing research collaboration on 'Dengue Virus Infection in India' that is funded by the US NIH. This research is being done at the Emory University Vaccine Center Laboratory at ICGEB in New Delhi. The project involves collaborations with physicians and scientists from ICGEB, AIIMS (Delhi), CMC (Vellore), NIV (Pune) and THSTI (Delhi). In addition, on this trip I visited Strand and MazumdarShaw Cancer Center in Bengaluru and we are looking forward to starting a new and exciting research programme in India on cancer immunology and cancer immunotherapy in collaboration with MSCTR and STRAND.

EXPRESS HEALTHCARE

December 2016

You have received a five-year grant of $35.6 million grant from the National Institutes of Health for HIV/AIDS research? Can you give us more details about the progress of the project? This grant was awarded to the Emory Vaccine Center in Atlanta to develop strategies for developing an effective HIV vaccine that will induce longlived immunity. The PIâ&#x20AC;&#x2122;s of the project are Dr Eric Hunter and Dr Rama Amara. One of your long-term goals have been to understand the mechanisms of B and T cell immunological memory and develop vaccines to tackle AIDS. How close are you to achieving this goal? We have several projects addressing this most critical question about vaccine-induced immunity. Dr Bali Pulendran at

the Emory Vaccine Center has identified adjuvants that promote the generation of longlived plasma cells that reside in the bone marrow and are essential for long-term antibody responses.

This is an active research programme at the Emory Vaccine Center

Why has an effective HIV vaccine eluded us so far? What are the challenges which have not been tackled? The key challenges are inducing neutralising antibody responses that can protect against diverse HIV strains and making sure that such antibody responses can persist for many years. Cancer is yet another serious menace plaguing today's world. How can immunotherapy change the way cancer care is delivered? Cancer immunotherapy is now one of the most exciting areas

of biomedical sciences. striking progress has been made during the past few years showing that blockade of inhibitory receptors such as PD-1 can have promising results in the treatment of many different types of cancers. We hope to initiate research collaborations in this area with Mazumdar-Shaw Cancer Center and Strand in Bengaluru. You and your team were also working on project to develop a universal flu vaccine. Can you share some key highlights of this areas of your research over the years? Yes, this is another very active research programme at the Emory Vaccine Center and it is headed by Dr Walter Orenstein and Dr Richard Compans. lakshmipriya.nair@expressindia.com

KNOWLEDGE

INSIGHT

Evidence-based approach to improve quality and cost efficiency

DR PETER EDELSTEIN Chief Medical Officer, Elsevier Clinical Solutions

Dr Peter Edelstein, Chief Medical Officer, Elsevier Clinical Solutions, gives an overview of how the healthcare scenario in India can be improved by implementing clinical decison support solutions which are broadly classified into ‘Pull CDS’ and ‘Push CDS’ solutions “HEALTH AND healthcare are changing across the world.” I’ve not only repeatedly heard it, but have also witnessed it. My journeys across the globe have allowed me to meet with healthcare thought leaders, government officials, and hospital administrators, all seeking to address the significant quality and cost-efficiency challenges that are inherent in healthcare delivery. Many countries are experiencing a shift in the definition of healthcare, moving away from the traditional focus on ‘the doctorpatient relationship’ towards a broader goal of ‘Population Health.’ India, being the most diversified country, in terms of culture, language, and health, holding nearly one-fifth of the entire world’s population is predicted to become the most populous by the early 2020s. Adding to these demographics, the growth in medical malpractice litigation as well as the financial realities associated with maintaining such a nation, and the significant dangers posed by poor quality, high cost healthcare becomes very clear. So what does it mean for India to drive towards ‘Population Health?’ It means implementing sweeping changes in operations and, more importantly, in the perspective of doctors, patients, and government leaders to force a dramatic shift away from reactive, acute, primarily inpatient care to proactive, out-of-hospital, preventative care and health maintenance. It requires abandoning the belief that physicians and the Indian government are primarily responsible

for individual Indians’ health; that is, Indian patients themselves must accept responsibility for owning their health and participating in healthcare decisions and activities. It means a significantly greater dependence on nurses and other nonphysician providers to support preventative health and health maintenance across the nation. What I am proposing is truly radical change. And India, with its entrepreneurial spirit and democratic principles, is among the few nations with the potential to successfully execute such difficult changes now and in the future. But real healthcare reform cannot be a wedding; it must be a marriage. That is, changing the Indian population’s perception of responsibility for health and healthcare is not a onetime event. Rather, meaningful healthcare reform represents a commitment to continuous improvement and maintenance of the health of all of India’s varied populations, to consistently and sustainably deliver high quality, cost efficient care at all points across this vast nation. Of course, such seismic change requires investment. But just as important as how much a nation spends on the health and healthcare of its people is how wisely it spends its money. India’s current healthcare spending (as a percentage of GDP) has been criticised as being too low; while that may be true, it is most important that how India spends its healthcare dollars offers the greatest return-on-investment. Fortunately for India (and the rest of the world), the basic economics of healthcare are oppo-

site those of other industries. In non-healthcare sectors, better quality costs more. If you want a nicer car, home, dinner, you must pay more for the better quality. But not so in healthcare. In healthcare, better quality costs less. Thus, patients who undergo cancer screening and are diagnosed with early stage malignancies have better outcomes at lower costs. Heart failure patients who weigh themselves daily avoid emergency hospitalisations, better quality for the patients and less expense for the system. Prevention of millions of preventable errors annually will dramatically improve the lives of Indian patients while saving hundreds of billions of rupees. Thus, wisely investing will not only improve the health of the Indian people, it will ultimately reduce the cost of healthcare. And the goal of investment

is simple: reduce variability. Why do you take the same train to work each morning? Why must pilots complete a check-list before every flight? Because in virtually all aspects of our lives, variability is damaging. If you take a different train to work, you’re more likely to be late. If we leave it up to each individual pilot to decide if a plane is safe for flight, planes will crash and people will die. And in healthcare, variability leads to patient injury, patient death, and significant wasted resources and money. Even within the same hospital, the variability provided by two orthopedic surgeons in treating identical patients leads to different clinical outcomes and costs of care. A surgical nurse assigned for one shift to care for cancer patients likely provides care of lower value (quality divided by cost) than the

LESS VARIABILITY, LESS COSTS, BETTER HEALTHCARE Clinical Decision Support (CDS) Educating and empowering nurses People investment

care provided by an experienced oncology nurse. A recent nursing school graduate may waste resources or provide poorer quality care as a result of inexperience. Nor are patients immune from the damage caused by variability: A majority of Indians are unaware about the preventive measures of cancer and type-II diabetes. To implement reforms, India must commit to invest in two major areas: information and people. While approaching reforms, information is often confused with technology. In India, people believe that implementing electronic health records (EHRs) will dramatically improve health and the value of delivered care. While it is true that EHRs reduce some dangerous variability (for example, medication orders are clearly entered and presented for all to see), in reality, EHRs serve only as a vehicle to deliver the powerful solution to dangerous variability: current, credible, evidence-based information. It is knowledge of best practices that reduces variability, improves clinical outcomes, and drives down costs. Whether delivered most efficiently via EHR, read off of a smart phone, or provided in ink on a piece of paper, current, credible, evidence-based information is what can reduce preventable medical deaths and injuries and increase the cost-efficiency of healthcare. Such information, broadly defined as Clinical Decision Support (CDS), is the most impactful answer to the vast and destructive problem of variability, whether due to variability in physician, nurse, or

EXPRESS HEALTHCARE

December 2016

KNOWLEDGE

patient knowledge. While there are many types of CDS solutions, they fall broadly into two categories. The first category I call ‘Pull CDS Solutions.’ Reference solutions are an example of a Pull CDS Solutions. Like the seatbelt in your car, which is enormously helpful in reducing the risk of death or injury when driving, but only when buckled, Pull CDS Solutions are very beneficial in reducing risk and cost by providing current, credible, evidence-based information, but only if they are used. Don’t buckle your seatbelt, and the seatbelt can’t protect you. Don’t actively access a reference or other Pull CDS Solution, and it can’t protect the patient. The challenge of such Pull CDS Solutions is that physicians, nurses, and patients often “don’t know what they don’t know.” Because they don’t realise that they have a knowledge gap, they are unable to actively search for information on a Pull CDS Solution. So again similar to your car, there are airbag analogs: Push CDS Solutions. Order sets are one example. Push CDS Solutions (like your airbag) automatically provide protection whether or not the target of the push realises they have a knowledge gap. Thus even when a physician fails to appreciate that a cancer patient should undergo blood testing for a genetic syndrome, an order set can push this evidence-based suggestion

to the physician. Best practices can be pushed to nurses to drive quality and cost efficient care regardless of the nurse’s experience (or lack thereof). Health screening, medication, and other credible preventative and care maintenance information can be pushed to patients and their loved ones. And the best value? A combination of seatbelts and airbags; that is both Push and Pull CDS Solutions. Thus, an early major Indian investment should be in a combination of Push and Pull Clinical Decision Support Solutions which deliver current, credible, evidence-based information to doctors, nurses, other traditional providers, and patients. India should not wait until EHRs are widely in use; rather, powerful CDS solutions can immediately improve the quality and cost of healthcare across India via EHRs, the internet, or even through print. Why should patient care suffer just because an EHR is not available when the answer is information? CDS solutions can be added in a modular fashion (particularly if purchased through one or a limited number of vendor partners). Order sets, reference solutions, care plans, drug information, nursing skills, patient engagement and education. There are many Push and Pull CDS Solutions to implement and add based on the specific needs and strategies of individual population health providers.

HEART FAILURE PATIENTS WHO WEIGH THEMSELVES DAILYAVOID EMERGENCY HOSPITALISATIONS, BETTER QUALITY FOR THE PATIENTS AND LESS EXPENSE FOR THE SYSTEM The second area for India to initially invest in is human capital; that is, people. It is unrealistic for India to rely solely on its limited number of physicians to drive impactful healthcare reform. After all, virtually all of every Indian patient’s time is spent away from a doctor. India’s greatest potential to improve the quality and cost efficiency of healthcare is by empowering two critical nonphysician provider groups: nurses and patients. Unlike the U.S. and some other countries, India’s nurses are limited in education, in responsibilities, and, most importantly, in perceived value to impact population health. But given that there are many more nurses than doc-

tors, and given that with advanced practice training, Indian nurses could mimic their American counterparts in providing safe, high quality, cost efficient basic care activities currently delegated to physicians. Educating and empowering nurses can significantly and favorably shift the Indian healthcare value curve. Indian nurses (both with and without advanced training) supported by nurse-specific Push and Pull CDS Solutions would dramatically improve health and healthcare across the country. And to truly reform, India must commit to an even more challenging “people investment”: patients themselves. It is critical that India begin the long

process of radically altering the entire population’s view (including that of physicians and governmental health authorities) as to who truly owns health and healthcare: the patient. As individual adults, we are responsible for our debts; our children’s safety, education, and care; showing up for work and doing our jobs; our behavior; virtually every aspect of our lives. Yet when it comes to health, Indians join hundreds of millions of others around the world (including millions of Americans) who somehow feel that their health and healthcare are the responsibility of others (physicians, the government). Until Indian patients truly begin to own their health, healthcare reform cannot realize its full potential. Such a monumental change in perspective requires investments in public education (such as via public awareness campaigns for sub-populations) and Push and Pull CDS Solutions geared specifically to engage and educate patients and their families about preventative and maintenance healthcare. The challenges and obstacles posed by radical healthcare reform are indeed great. But the reality is that particularly for densely populated India, the danger of waiting to initiate and invest in meaningful reform activities is much greater, as without real change, both the quality of life for Indians and the ultimate cost of healthcare will become unacceptable.

CONTRIBUTOR’S CHECKLIST ●

●

Express Healthcare accepts editorial material for the regular columns and from pre-approved contributors/ columnists. Express Healthcare has a strict non-tolerance policy towards plagiarism and will blacklist all authors found to have used/referred to previously published material in any form, without giving due credit in the industry-accepted format. As per our organisation’s guidelines, we need to keep on record a signed and dated declaration from the author that the article is authored by him/her/them, that it is his/her/their original work, and that all references have been quoted in full where necessary or due acknowledgement has been given. The declaration also needs to state that the article has not been published before and there exist no impediment to our publication. Without this declaration we cannot proceed. If the article/column is not an original piece of work, the author/s will bear the onus of taking permission for re-pub-

EXPRESS HEALTHCARE

December 2016

●

lishing in Express Healthcare. The final decision to carry such republished articles rests with the Editor. Express Healthcare’s prime audience is senior management and professionals in the hospital industry. Editorial material addressing this audience would be given preference. The articles should cover technology and policy trends and business related discussions. Articles by columnists should talk about concepts or trends without being too company or product specific. Article length for regular columns: Between 1300 - 1500 words. These should be accompanied by diagrams, illustrations, tables and photographs, wherever relevant. We welcome information on new products and services introduced by your organisation for our Products sections. Related photographs and brochures must accompany the information. Besides the regular columns, each issue will have a special focus on a specific topic of

●

relevance to the Indian market. You may write to the Editor for more details of the schedule. In e-mail communications, avoid large document attachments (above 1MB) as far as possible. Articles may be edited for brevity, style, relevance. Do specify name, designation, company name, department and e-mail address for feedback, in the article. We encourage authors to send a short profile of professional achievements and a recent photograph, preferably in colour, high resolution with a good contrast.

Email your contribution to: viveka.r@expressindia.com Editor, Express Healthcare

KNOWLEDGE

CASE STUDY

DR JAMES CHOW Specialist in Oral and Maxillofacial (O&M) Surgery

Benefiting doctors and patients alike Stratasys in this case study elaborates how Dr James KF Chow, Specialist in Oral & Maxillofacial Surgery in dentistry, uses Stratasys printing solution to produce prototypes of patients body parts to help him explain their physical condition correctly IN THE past, doctors examined patients and made diagnoses using 2D medical scans. When the technology advanced to 3D scanning, the digital rendering remains a 2D static images on a computer screen, making accurate diagnosis to remain a challenge. The lack of a physical example also made it difficult to explain surgical procedures and risks to patients. “The more reliable way to prepare for surgeries is to create tangible 3-dimensional models. This also helps us communicate with the patient as it is easier to show them their condition with physical model,” said Dr James KF Chow, Specialist in Oral & Maxillofacial Surgery. Technology failed to reach Dr Chow’s desired standard as a medical professional – until he turned to 3D printing. Since the deployment of 3D

on. With these models, Dr Chow can walk patients through surgery in advance, helping patients understand the exact areas of treatment and every step he will take during the process. “Patients have the right to know the risk and benefit every surgery entails. With 3D printing, we can educate, reassure and instill confidence before their operations,” said Dr Chow.

Enhanced surgical precision

printing a decade ago, the technology has become an indispensable part of Dr Chow’s work. Today, he digitally scans the parts of a patient’s body that requires treatment and creates 3D printed plaster models. With the addition of

the multi-colour, multi-material Stratasys J750, he is able to choose from more than 360,000 different colour shades and multiple material properties to create highly detailed replicas of body parts or internal organs to be operated

3D printing plays a pivotal role in enhancing surgical precision. Dr Chow can produce 3D-printed guides for dental implants, which allow him to create a plan for each area that requires implants before the surgery. “Thorough preparation is key to a successful surgery. The oral cavity is full of nerve endings and 3D print-

ing greatly simplifies the preparation process for me.” With the capabilities of the Stratasys J750, each 3D printed model can represent everything from gums to nerve ending and teeth with a wide range of materials and colours. “In addition to rigid 3D models and surgical guides, the Stratasys J750 goes a step further to help us create a replica of a patient’s body part with the exact shape, nuanced colour and texture. Be it nerves, bones, muscle or blood vessels, surgeons and medical practitioners are able to visualise a patient’s condition in detail and proceed through operations with confidence, subsequently reducing complications and improving surgical outcomes,” he said.

3D Printing indispensable to the digital workflow The adoption of 3D printing not only enhances surgical quality, it simplifies Dr Chow’s workflow through integrating all the technologies needed to create a true-to-life model in house. “The scanned render on the screen is what I get off the J750. There is no need to outsource it to other vendors to produce the models,” Dr Chow said. Dr Chow is optimistic about the future of 3D printing. “The technology is set to advance and produce even more faithful models. I believe its application and adoption will continue to expand in the healthcare sector, especially in the surgical team, or medical tools production where customisation is highly valuable but resource consuming. We are confident to keep increasing our patients’ satisfaction through advanced technology such as 3D printing.”

EXPRESS HEALTHCARE

December 2016

KNOWLEDGE

RESEARCH PAPER

A proposed India-specific algorithm for management of type II diabetes Dr Anoop Mishra, Chairman, Fortis C-DOC, informs about the need for an India-specific algorithm while simultaneously highlighting the issues involved and the therapeutic treatment options in Asian Indians INDIA HAS nearly 66.8 million cases of diabetes, and these numbers are expected to rise to 120.9 million in 2035.1 So as to help clinicians choose the best option for their patients from the impressive array of available therapeutic options, various professional bodies such as the International Diabetes Federation, World Health Organization, American Diabetes Association, European Association for the Study of Diabetes, American Association of Clinical Endocrinologists, Canadian Diabetes Association, and Australian Diabetes Association have proposed algorithms and guidelines. Some previous attempts have been made in this direction in India (by the Indian Council of Medical Research, Association of Physicians of India, Research Society for Study of Diabetes in India, and other associations); however, no recent indexed publication on India-specific management guidelines is available. Need for an India-Specific Algorithm: Type II diabetes in Asian Indians is different and distinctive for various reasons. Algorithms developed and validated in developed nations may not be relevant or applicable to patients in India. It has long been recognised that type II diabetes (T2D) in Asian Indians differs significantly from that found in white Caucasians. Any treatment decision in Indians should take into account not only these differences, but also socioeconomic and cultural factors (such as

EXPRESS HEALTHCARE

December 2016

Dr Anoop Mishra, Chairman, Fortis C-DOC

dietary practices), which may render some therapeutic options less suitable in this population. The following points summarise some of the key issues that should be taken into consideration while prioritising treatment options in Asian Indians: ◗ Heterogeneity of prevalence: Urban versus rural; socio economic strata; place of residence (e.g., remote and hilly areas)2–4 ◗ Body composition: Risk of diabetes is present at lower levels of body mass index than in white Caucasians and sometimes even in lean individuals. Prevalent abdominal adiposity and non-alcoholic fatty liver disease add to the risk.5,6 ◗ Presentation of T2D: ◆Early age of onset: nearly a decade earlier than for white Caucasians7 ◆Presentation late, sometimes with complications8–11 ◆Lean patients with dia-

betes: Such patients have been reported to have more hyperglycemia and higher risk of complications. ◗ Ketosis: Although ketosis as a presenting feature of T2D is unusual, studies from Pakistan have shown that up to 14 per cent of patients with T2D have ketosis at the time of first diagnosis. Precipitating factors for ketosis include infection, major surgery, severe trauma, use of steroids, interruption of treatment, and high intake of sugar-sweetened beverages.12–15 ◗ Infections: (e.g., co-existence of tuberculosis): Patients with T2D in India often present with infections. In particular, coexistence of tuberculosis and diabetes may be more in Asian Indians than in white Caucasians.16 ◗ Metabolism: ◆Higher magnitude of insulin resistance than other races: Asian Indians have a comparatively lower insulin sensitivity index and lower

rate of glucose disposal than European-origin whites in the US, even after adjustment for both total body fat and truncal skinfold thickness. Thus, Asian Indians are more insulin resistant than Caucasians independent of generalised or truncal adiposity. 7,17 On account of this, insulin sensitisers would be useful in Indians. ◆Higher postprandial glycemia than other races: Asian Indians show higher postprandial glycemia for the same dietary carbohydrate load compared with Caucasians and other races.18,19 Hence postprandial blood glucose regulators such as aglucosidase inhibitors may be of greater value in Asian Indians. ◆Early-onset b-cell dysfunction: Asian Indians with even mild dysglycemia have reduced b-cell function, regardless of age, adiposity, insulin sensitivity, or family history of diabetes,20 and some data suggest that b-cell dysfunction appears to be more strongly associated with T2D than insulin resistance.21 ◗ Dietary factors (e.g., high carbohydrate load in diets): South Asian diets are predominantly based on starchy foods, typically consisting of high amounts of carbohydrates in the form of refined cereals.22,23 ◗ High risk of complications: Asian Indians have high risk of complications including diabetic nephropathy and cardiovascular disease.8,11 These complications of diabetes have implications for development of hypoglycemia (more in nephropathy, impacts cardiovascular disease) and may in-

fluence treatment decisions (with particular reference to sulfonylureas). ◗ Awareness: Many patients with diabetes in India, particularly in rural areas, lack awareness and knowledge regarding the disease and its management. This renders them at risk of hyperglycemia and its attendant complications, but more importantly of hypoglycemia.24,25 ◗ Socio-economic factors: Diabetes in India is still a disease of the relatively more affluent strata of society. However, there is some evidence that the epidemic is now moving into the lower socioeconomic strata as well.25 The latter category of patients is likely to experience difficulty in affording treatment with the newer therapeutic agents, especially those that are still under patent protection, as most medical expenses in India are borne out of pocket by the patient.24 It is evident from the above discussion that guidelines and algorithms developed for use in western countries may not be applicable in Asian Indians. Thus, there is a clear need for developing specific guidelines for the pharmacotherapy of T2D in this population, taking into account the characteristic phenotype of Indian patients with T2D, as well as their dietary, socio-economic and cultural patterns.18,19

Proposed therapeutic algorithm for T2D in Asian Indians Aim The proposed algorithm aims

KNOWLEDGE to provide a simple and easytoimplement framework for the management of T2D in Asian Indians in primary care. Scope of the algorithm The proposed algorithm deals specifically with the management of T2D in non-pregnant Asian Indian adults. As the majority of the population in India resides in rural areas with limited access to secondary and tertiary care facilities, the algorithm has been designed to be practical for use in the primary care setting. Preamble Decisions on selection of drug therapy in Asian Indians with T2D are to be made based on blood glucose profile, presence of comorbidities, age, socioeconomic and educational status, probability of developing hypoglycemia and wherewithal to tackle it, location of residence (e.g., remote areas without access to medical facilities), and overall likelihood of compliance with therapy. Search strategy A literature search was conducted in electronic databases (PubMed, Embase, and Google Scholar) up to December 2015 and was limited to articles published in English. The search terms were ‘Type II diabetes,’ ‘management algorithm,’ ‘glycosylated hemoglobin,’ ‘oral anti-diabetic agents,’

‘insulin,’ ‘India,’ and ‘Asian Indians.’ Although all articles were studied, those on management of T2D (74 articles [available upon request from the corresponding author]) were reviewed in detail. Results A summary of the proposed algorithm is given in Table 1. First-line therapy Stratification is done according to: ◆Body mass index: three categories—less than 18 kg/m2 (underweight), 18–22.9 kg/m2 (normal), and greater than or equal to 23 kg/m2 (overweight/obese) ◆Initial glycosylated hemoglobin (%) level: less than 9 per cent and greater than or equal to 9 per cent ◆Severe morbidity (severe infections, myocardial infarction, markedly high blood glucose levels with ketonuria/ ketoacidosis, marked liver or renal dysfunction, significant physical trauma) Stratification 1: Glycosylated haemoglobin less than 9 per cent (plasma blood glucose levels less than 240 mg/dL) and according to body mass index values as indicated above: ◗ Metformin is the agent of choice for all patients, except those with substantial weight loss, underweight patients,

and those who are intolerant to metformin. Metformin is to be started at a low dose and escalated to the maximum tolerable dose in those with body mass index ≥23 kg/m2 or abdominal obesity (waist circumference ≥90 cm in men and ≥80 cm in women). ◗ Sulfonylureas are to be considered as the first line of therapy in patients who are underweight or who cannot tolerate metformin. The preferred sulfonylureas are glimepiride, gliclazide, and glipizide. Sulfonylureas are an attractive therapeutic option on account of their low cost and the predominant role of β-cell dysfunction in the pathogenesis of T2D in this population.20 ◗ Alternatively, dipeptidyl peptidase-4 inhibitors may also be considered if cost is not of major concern. Stratification 2. Glycosylated haemoglobin ≥9 per cent (plasma blood glucose levels greater than or equal to 240 mg/dL): ◗ Combination therapy with two oral antidiabetic drugs should be offered to those without other major comorbidity. Sulfonylurea–metformin combination is suggested as the preferred combination for dual therapy in this setting. Dipeptidyl peptidase-4 in-

hibitor–metformin combination may be used if affordability is not an issue. ◗ Use of triple oral therapy (by adding a dipeptidyl peptidase4 inhibitor, thiazolidinedione, or a-glucosidase inhibitor) might be considered occasionally on an individual basis, taking into account levels of blood glucose, comorbidities, and overall patient’s medical and economic profiles. ◗ Insulin may be considered initially with or without oral antidiabetic drugs if blood glucose levels are very high even in the absence of ketosis. Stratification 3. Severe morbidity: ◗ Insulin should be offered as initial treatment of choice. Regular, NPH, or premix insulin can be used to initiate therapy. In severely ill patients who require hospitalisation, consideration should be given to use of multiple daily insulin injections (regular–NPH combination or basal–bolus regimen). Insulin analogs can be used with benefit if cost considerations permit. Second-line therapy The options available to the clinician after failure of firstchoice medication include the following: ◗ Addition of insulin. Insulin

therapy may be initiated with premix human insulin or with NPH insulin. Basal insulin analogs (e.g., glargine) may be used if cost considerations permit the same. ◗ Addition of second oral agent. The choice of a second oral agent depends on patient profile and previously introduced drug(s). ◆If the patient is not at target with metformin or sulfonylurea monotherapy, consider giving a combination of the two drugs. ◆Dipeptidyl peptidase-4 inhibitors can be added to the first-line agent if cost is not a major concern. These agents are likely to be helpful in addressing the early loss of b-cell function that characterises T2D in this population.20 ◆α-Glucosidase inhibitors are attractive therapeutic options as add-on drugs in Asian Indians as their mechanism of action helps in blunting the postprandial glucose spikes caused by large amounts of refined cereals in the diet.22,23 ◆In obese patients, sodium –glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor analogs are preferred agents for adding on to metformin because of their weight loss benefits. However, the cost of these agents should be considered while planning

TABLE 1. PROPOSED ALGORITHM FOR INITIATION AND INTENSIFICATION OF ANTIHYPERGLYCEMIC PHARMACOTHERAPY IN ADULT NON-PREGNANT ASIAN INDIANS WITH TYPE II DIABETES Stratification 1 (HbA1c <9 per cent and according to BMI levels)a

Stratification 2 (HbA1c ≥9 per cent or plasma blood glucose ≥240 mg/dL)a

Stratification 3 (severe morbidity)a

First-line therapy

Monotherapy with: ● Metb ● SU ● DPP 4i

●

Combination of two OADs (SU + Met,b DPP 4i + Met) ● Consider triple OAD therapy/ insulin in selected cases

●

Insulin (with or without OADs)

Second-line therapy

●

Add insulin Add second oral agent (SU,b DPP 4i,AGI, GLP1RA, SGLT2i)

●

Intensify insulin

●

Add insulin Add third oral agent (SGLT2i, GLP-1RA,AGI,TZD)

●

Add insulin Intensify insulin therapy (if already initiated)

●

Intensify insulin therapy Consider adding GLP-1RA to insulinc

Third-line therapy

●

Insulin + multiple OADs Intensify insulin (if already initiated)

●

See text for details on stratification groups. aSee text for details. bAgent/regimen of first choice. cIf not contra-indicated. AGI, α-glucosidase inhibitor; BMI, body mass index; DPP 4i, dipeptidyl peptidase-4 inhibitor; GLP-1RA, glucagon-like peptide-1 receptor agonist; HbA1c, glycosylated hemoglobin; Met, metformin; OAD, oral antihyperglycemic drug; SGLT2i, sodium–glucose cotransporter-2 inhibitor; SU, sulfonylureas; TZD, thiazolidinedione (pioglitazone).

EXPRESS HEALTHCARE

December 2016

Third-line therapy In case of failure of second-line therapy, the options include: ◗ Use of multiple oral antidiabetic drugs with insulin therapy ◗ In case the patient is already on insulin, intensification of the insulin regimen as follows: ◆Basal insulin (NPH, basal analogue) with variable mealtime bolus (regular or rapidacting analog). The high cost of insulin analogs must be considered while planning therapy. ◆Twice daily premixed insulin ◆Split-mix regimen (morning and evening combinations of regular and NPH insulin) ◆Adding glucagon-like peptide-1 agonist to insulin In every case, therapeutic lifestyle change should be recommended and encouraged to the maximum extent possible. Regular monitoring of glycemic control and frequent follow up with the healthcare team are essential. Physicians should guard against therapeutic inertia, which can increase the ‘avoidable glycemic burden’ and predispose to the development of complications. The guidelines proposed above differ from the American Diabetes Association/European Association for the Study of Diabetes guidelines, in that they provide the clinician with multiple options for first-line therapy, based on patient characteristics (body mass index, morbidities), severity of hyperglycemia, and use of second-line drugs in line with metabolic and dietary profiles of Asian Indians. Similarly, while initiating insulin, the proposed guidelines provide the flexibility of using NPH insulin, premix

EXPRESS HEALTHCARE

December 2016

insulin, or insulin analogs, in contrast to the American Diabetes Association/European Association for the Study of Diabetes guidelines, where analog insulin is specifically recommended. The guidelines proposed above have certain limitations. They are based on expert consensus and not on the results of large-scale randomised controlled trials. Second, the heterogeneity of the Asian Indian population may alter the clinical applicability of these guidelines to the entire population. There is a need for further studies to address these issues. We hope that these guidelines will stimulate further discussions and generate ideas for well-planned studies to test the usefulness and cost-effectiveness of these guidelines.

Conclusion The proposed algorithm is a simple-to-use and comprehensive framework for delivery of diabetes therapy in low cost primary care settings in India. It is nevertheless imperative that clinicians discuss all aspects of the available therapies with the patient in order to arrive at a joint decision on the best possible yet individualised therapy.

References 1. International Diabetes Federation: IDF Diabetes Atlas Sixth Edition. 2013. Update 2014. www.idf.org/sites/default/files/ Atlas-poster-2014_EN.pdf (accessed December 22, 2015). 2. Misra A, Ramchandran A, Jayawardena R, et al.: Diabetes in South Asians. Diabet Med 2014;31:1153–1162. 3. Ramachandran A, Snehalatha C, Viswanathan V, et al.:Risk of noninsulin dependent diabetes mellitus conferred by obesity and central adiposity in different ethnic groups: a comparative analysis between Asian Indians, Mexican Americans and Whites. Diabetes 1997;36:121–125. 4. Sadikot SM, Nigam A, Das S, Prasannakumar KM, et al.The burden of diabetes and impaired glucose tolerance inIndia using the WHO 1999 criteria: Prevalence of Diabetes in India Study (PODIS).Diabetes Res Clin Pract 2004;66:301–307.

66.8 120.9

cases of diabetes numbers are expected to rise to

million

therapy. ◆Thiazolidinedione. Pioglitazone should be offered in the low dose (7.5–15 mg/day), wherever possible. 26,27 Furthermore, this drug improves insulin sensitivity, cardiovascular and inflammatory risk markers, and vascular response more in Asian Indians than in white Caucasians.24 ◆Patients with severe infections or other comorbidities as defined above should be treated with insulin.

million

KNOWLEDGE

in 2035

5. Misra A, Shrivastava U: Obesity and dyslipidemia in South Asians. Nutrients 2013;5:2708–2733. 6. Misra A, Khurana L: Obesity and the metabolic syndrome in developing countries. J Clin Endocrinol Metab 2008; 93(11 Suppl 1):S9–S30. 7. Misra A, Khurana L: Obesity related non-communicable diseases: South Asians vs. White Caucasians. Int J Obes 2011;35:167–187. 8. Chowdhury TA, Lasker SS: Complications and cardiovascular risk factors in South Asians and Europeans with early-onset type 2 diabetes. QJM 2002;95:241–246. 9. Bellary S, O’Hare JP, Raymond NT, et al.: Enhanced diabetes care to patients of south Asian ethnic origin (the United Kingdom Asian Diabetes Study): a cluster randomised controlled trial. Lancet 2008 24;371:1769–1776. 10. Raymond NT, Varadhan L, Reynold DR, et al.: Higher prevalence of retinopathy in diabetic patients of South Asian ethnicity compared with white Europeans in the community: a cross-sectional study. Diabetes

Care 2009;32: 410–415. 11. Earle KK, Porter KA, Ostberg J, et al.: Variation in the progression of diabetic nephropathy according to racial origin. Nephrol Dial Transplant 2001;16:286–290. 12. Jabbar A, Farooqui K, Habib A, et al.: Clinical characteristics and outcomes of diabetic ketoacidosis in Pakistani adults with Type 2 diabetes mellitus Diabet Med 2004;21: 920–923. 13. Jeon CY, Murray MB: Diabetes mellitus increases the risk of active tuberculosis: a systematic review of 13 observational studies. PLoS Med 2008;15:e152. 14. Stop TB Department and Department of Chronic Diseases and Health Promotion World Health Organization, International Union Against Tuberculosis and Lung Disease: Collaborative Framework for Care and Control of Tuberculosis and Diabetes. 2011. http://whqlibdoc.who.int/publications/2011/9789241502252_e ng.pdf (accessed December 4, 2015). 15. Pearson F: Diabetes and tuberculosis: how strong is the association and what is the public health impact? [PhD thesis]. Newcastle, United Kingdom: Institute of Health and Society, Faculty of Medical Sciences, Newcastle University, June 2013. https://theses.ncl.ac.uk/dspace/ bitstream/10443/ 2029/1/Pearson,%20F.%2013.pdf (accessed December 9, 2015). 16. Viswanathan V, Kumpatla S, Aravindalochanan V, et al.: Prevalence of diabetes and prediabetes and associated risk factors among tuberculosis patients in India. PLoS One 2012;7:e41367. 17. Kooner JS, Saleheen D, Sim X, et al.: Genome-wide association study in individuals of South Asian ancestry identifies six new type 2 diabetes susceptibility loci. Nat Genet 2011;43:984–989. 18. Misra A: Ethnic-specific criteria for classification of body mass index: a perspective for Asian Indians and American Diabetes Association Position Statement. Diabetes Technol Ther 2015;17:667–671. 19. Shrivastava U, Misra A: Need for ethnic-specific guidelines for prevention, diagnosis,

and management of type 2 diabetes in South Asians. Diabetes Technol Ther 2015;17:435–439. 20. Staimez LR, Weber MB, Ranjani H, et al.: Evidence of reduced b-cell function in Asian Indians with mild dysglycemia. Diabetes Care 2013;36:2772–2778. 21. Mohan V, Amutha A, Ranjani H, et al.: Associations of bcell function and insulin resistance with youth-onset type 2 diabetes and prediabetes among Asian Indians. Diabetes Technol Ther 2013;15:315–322. 22. Misra A, Sharma R, Gulati S, et al.: Consensus dietary guidelines for healthy living and prevention of obesity, the metabolic syndrome, diabetes, and related disorders in Asian Indians. Diabetes Technol Ther 2011;13:683–694. 23. Joshi SR, Bhansali A, Bajaj S, et al.: Results from a dietary survey in an Indian T2DM population: a STARCH study. BMJ Open 2014;4:e005138. 24. Shrivastava U, Misra A, Gupta R, et al.: Socioeconomic factors relating to diabetes and its management in India. J Diabetes 2016;8:12–23. 25. Deepa M, Bhansali A, Anjana RM, et al.: Knowledge and awareness of diabetes in urban and rural India: the Indian Council of Medical Research India Diabetes Study (Phase I): Indian Council of Medical Research India Diabetes 4. Indian J Endocrinol Metab 2014;18:379–385. 26. Raji A, Gerhard-Herman MD, Williams JS, et al.: Effect of pioglitazone on insulin sensitivity, vascular function and cardiovascular inflammatory markers in insulinresistant nondiabetic Asian Indians. Diabet Med 2006;3: 537–543. 27. Rajagopalan S, Dutta P, Hota D, et al.: Effect of low dose pioglitazone on glycemic control and insulin resistance in Type 2 diabetes: a randomized, double blind, clinical trial. Diabetes Res Clin Pract 2015;109:e32–e35. (This review has not been financed by any pharmaceutical company, and the members of the India Diabetes Management Algorithm Proposal Group declare no conflict of interest)

IT@HEALTHCARE I N T E R V I E W

VR Labs trending in healthcare Virtual reality is not only limited to gaming, this innovation is a leading trend in healthcare. The Centre for Advanced Design in Engineering Training (CADET) VR Lab in Deakin University, Australia, facilitates automatic virtual environment with a computer-aided design which gives hands-on experience to training junior doctors and midwives in a virtual world. Professor Guy Littlefair, Pro Vice-Chancellor Industry Development at Deakin University, reveals more in an interaction with Prathiba Raju What made you set up the first VR Lab? What are its unique features? CADETâ&#x20AC;&#x2122;s Virtual Reality (VR) Lab is the first-of-its-kind in the world. This is due to facilitate a cave automatic virtual environment (CAVE), a computer-aided design (CAD) wall and a large-scale haptic device in one facility. This means a participant, for example, a trainee doctor or a midwife is able to walk around through virtual objects in a virtual world, and imagine products and treat them. The VR CAVE was set up to support research and teaching opportunities in design. More recently, we have realised the potential of utilising the facility for human factors-based research and training of industry operatives facing hazardous or unusual situations â&#x20AC;&#x201C; fire fighters; ambulance staff; construction workers, etc. Moving from traditional theory-based model of

learning inside a static lecture theatre, your programme offers virtual learning. How will it help the students? The move from traditional lecture-based delivery to more of a problem or designbased curriculum allows students to create their own learning opportunities and not rely constantly on the expert to guide them. This, in so many ways, mirrors what real life is outside of the confines of the university. What other innovative programmes in healthcare are you focusing on like the midwifery programme? We are using a deployable and haptically-enabled VR system for training of midwives on virtual situations. Again, this allows the students to be exposed to experiences which otherwise they would only encounter for real or may actually not encounter until in the child delivery situation which is clearly far from ideal.

VR Labs enables training on all the difficult case studies which could otherwise take years of clinical exposure to cover it Do you think the VR Labs would be an apt fit for a country like India, with such low doctor to patient ratio? How will it help? In terms of training, VR Labs would be an absolute fit. It enables training junior doctors on all difficult case studies which could otherwise take years of clinical exposure to cover off on. Deakin University already has tie-ups with Hyderabadbased engineering firm Cyient. Are you looking out for similar tie-ups with medical colleges? Is there anything on the pipeline? Deakin is a comprehensive and progressive university with a

long history of supporting India. Presently, we are working on the development of collaborative research and development projects with a number of universities, industries and research organisations. How useful would 3D bio technology be in the medical field? In many ways, this will be the future of pharmaceutical development and deployment in the future. There is tremendous potential and we are likely to see significant disruption in the coming years. What are the milestones that the medical fraternity will witness via 3D bio printing?

Producing scaffolds to allow tissue cells to be grown to reproduce human parts, will be one of the milestones. How will digital fabrication help in implants of human organs? What would be its future? In years to come, human implants will invariably and inevitably be produced through digital manufacturing means. This will improve the lives of millions of people and ensure that society will benefit as a direct consequence. The future seems to be very exciting as engineering, science and medicine mesh together. prathiba.raju@expressindia.com

EXPRESS HEALTHCARE

December 2016

STRATEGY I N T E R V I E W

â&#x20AC;&#x2DC;Our idea is to build healthier cities for Indiaâ&#x20AC;&#x2122; eClinicalWorks is very enthusiastic about the growing healthcare sector in India. Therefore, it plans to expand its business in this region. Sameer Bhat - Vice President & Co-Founder and Aakash Shah, Director Sales National and International Market, eClinicalWorks share their experiences working in the Indian healthcare technology market and the company's business plans for 2017 in conversation with Raelene Kambli How do you see digital technology transforming the healthcare space? Sameer Bhat: We are witnessing an impressive progression of technology. Today, affordable and sustainable models of healthcare delivery are necessary and the expansion of technology into the healthcare sector is essential to establish a solid foundation for patient and population health. Moreover, the healthcare sector is poised to embrace cloud computing in a big way in the coming decade, as organisations see many benefits that can be realised with Cloud computing; on-demand service, reliability, scalability, and security are all available in the cloud, delivering the resources needed at the right time, at the right place, and at the right price. eClinicalWorks has implemented innovative solutions to many hospitals in India, delivering high quality healthcare services through a robust technology backbone.

The enterprise of healthcare is expanding its footprints catalysed by a wide variety of innovative products and services spearheaded by healthcare start ups in India -Sameer Bhat

EXPRESS HEALTHCARE

December 2016

We are getting ready to launch our mobile application platform in India and will see this product in general release in mid-2017 -Aakash Shah

What is more impressive about the Indian healthcare sector? Sameer Bhat: The enterprise of healthcare is expanding its footprints catalysed by a wide variety of innovative products and services spearheaded by healthcare start ups in India. Tell us about your company's success in India? Aakash Shah: eClinicalWorks has more than 4,000 employ-

STRATEGY

ees worldwide with clients in the US, Europe, and India. With its headquarters in Massachusetts, with five regional offices throughout the US, eClinicalWorks has three offices in India, and an office in the UK and Dubai, UAE. Founded in 1999, the company continues to be independent, private, and entrepreneurial. We have seen an increasing need for innovative healthcare technology in India and began offering a hospital inpatient solution in 2014. The past two years have been highly successful for eClinicalWorks in India, with approximately 90 hospitals adopting the eClinicalWorks Hospital Management Information System. These hospitals range in size from 50 to 2000 beds. Several are focused on specialities such as eye care, dental care, cardiology and oncology. Different hospitals have different requirements when it comes to EMR solutions. How easy or difficult is it to design a solution according to corporate needs? Aakash Shah :Like any corporate attempting to enter a new market, eClinicalWorks encountered various barriers and our products matured gradually. Nevertheless, with creative thinking and leveraging new technologies, our team overcame the obstacles and delivered a product that integrates functions in the hospital inpatient environment, improving efficiency, streamlining workflows, and facilitating delivery of high-quality care. We have also found that deploying a strong implementation team and establishing a collaborative relationship with open communication with the client’s staff goes a long way to ensuring an optimal experience for all. Have you experienced any kind of reluctance from the hospital staff in adopting technology? Aakash Shah :Yes, it is human nature to resist change. This holds true when adopting new technology as well, whether

The healthcare sector is poised to embrace cloud computing in a big way in the coming decade, as organisations see the many benefits that can be realised with Cloud computing; on-demand service, reliability, scalability, and security are all available in the cloud, delivering the resources needed at the right time, at the right place, and at the right price you live in the US, India, or anywhere in the world. When people have grown accustomed to a certain process, most have found it difficult to convince them that new technology can be beneficial. However, over the years, we realised that the new generation of system users are comfortable with technology, and in fact, expect to have high quality technology solutions available to them in the workplace. This holds true in the medical field and we have experienced a positive attitude change toward technology. The ‘Digital India’ campaign is certainly resulting in higher levels of adoption of the technology. Improvements in infrastructure have increased Internet access and digital literacy have encouraged many to embrace the new technologies. Have any of your clients got back to you with positive feedback or case studies that reflect increase in efficiency at their hospitals? Aakash Shah: Efficiency has been experienced in all aspects of the integrated healthcare delivery system as adoption rates are high and we have received positive feedback about overall improvements in efficiency and patient care. For example, clients have realised improvements in various workflows and the delivery of high-quality care. Prior to the adoption of eClinicalWorks, we identified flaws and gaps within their workflows. Now,

the dashboards are helping the organisations to view utilisation productivity measures, none of which can be achieved within paper-based system. The Hospital Management System is a web-based product that spans the clinical, administrative and financial areas of an integrated healthcare delivery system. The system also provides the tools to build and manage formularies. As a result, a physician can prescribe medications electronically, allowing the patient to pick up directly from the pharmacy of their choice. What kind of solutions are more in demand? Aakash Shah :We offer many advanced technology solutions, each of which meets specific needs in the delivery of healthcare. Mobile platforms, web portals, cloud-based platform, and telemedicine services are gaining in popularity. Interestingly, we’ve realised that telemedicine solution is not only being used in rural areas, but also gaining steam within the urban landscape. These patients are tech-savvy and are able and willing to engage with their doctors using telemedicine and appreciate the convenience of care. Do these technologies increase cost of healthcare services? Aakash Shah : eClinicalWorks focuses on reducing medical costs at all levels, whether it involves procurements within the hospital for medical

equipment, medication stock, or providing excellent, efficient care to patients. Attention is also directed towards bringing transparency to the medical record documentation and billing process. Establishing and maintaining a high level of transparency is an efficient method to reduce the overall cost of healthcare. It also diminishes medical errors, provides quality care to patients, and streamlines operational and administrative efficiencies. eClinicalWorks provides the hospital with a highly functional and customisable customer portal and mobile application for patients who are white labelled. These tools bring added value to the patients and enhance the patient experience which improves the brand image of the hospital. I would like to know your opinion about the healthcare start-up trend in India. Sameer Bhat: Healthcare Information Technology (HIT) is gaining traction throughout the world and has an ever-expanding footprint, fuelled by innovations in products and services. Healthcare IT startups in India are industry leaders in bringing new technologies to market. Do you think it’s a bubble? Aakash Shah : No, I do not believe that this trend is a bubble by any means. It is part of the trade cycle that happens

within every industry at some point. In fact, I think healthcare is the last major segment of the Indian economy that is being transformed by technology. Personally, I feel that healthcare in India has a long way to go. Start ups that have the will to survive will go a long way. Secondly, start ups can become a huge source of support to the mainstream healthcare providers in improving the state of healthcare in India. What are your plans for the next quarter and 2017? Aakash Shah : Our plans are very clear. We will provide a step-by-step adoption approach to hospitals with 50 or more beds. First, we will provide them with a hospital information system that helps automate various functions within the respective departments that are now labour-intensive manual processes. Secondly, we provide a patient engagement platform that allows doctors to communicate securely and easily with their patients via mobile or portal platforms. And thirdly, we establish a technology foundation for population health that uses artificial intelligence for predictive analytics research. This will improve quality of care and result in a population of healthier citizens. The overall goal is to build smart, healthy cities in India. What is your biggest challenge in operating in India? Aakash Shah : The biggest challenge is overcoming fear of change. This natural reluctance to try new things is difficult to overcome but with time and perseverance, we will continue to make inroads and see increased user acceptance of the new technologies. Any product launch for 2017? Aakash Shah :We are getting ready to launch our mobile application platform in India and will see this product in general release in mid-2017. raelene.kambli@expressindia.com

EXPRESS HEALTHCARE

December 2016

STRATEGY I N T E R V I E W

‘Affordable pricing strategy is our USP’ Suresh Vazirani, Founder, Transasia Bio-Medicals shares his views on the Indian In Vitrodiagnostic market (IVD) and talks about how his company has successfully earned a major market share within the emerging IVD markets of the world, in a conversation with Raelene Kambli Give us an overview of the Indian IVD market? The Indian IVD is still nascent and has picked up momentum in the last few years. Even today, only 30 per cent of India’s population go for blood tests. This shows that there is a huge opportunity for the IVD segment in India. Also, the focus for these players should be on prevention of diseases. Do you see a lack of access to diagnostic services in the rural areas? There is a huge gap in terms of availability of diagnostic services in the rural areas. People have to travel upto 100-200 kms to get to a diagnostic centre. Therefore, there is a need to venture into these smaller markets to create more access. We at Transasia have entered towns and soon hope to enter the rural areas as well. Where does India stand in comparison to other emerging markets? If you compare India with the other emerging markets such as Russia, Brazil and South Africa, the spending on diagnostics is lowest in India. We stand at the bottom 10 per cent as our per capita spending on diagnostic is less as compared with other countries. As I mentioned earlier, 70 per cent of the population still does not spend on diagnostic test. Is affordability a problem that holds back people to seek diagnostic services? Yes. Affordability is the biggest barrier for people to seek these services. Another factor that is detrimental is the mindset of not prioritising health.

EXPRESS HEALTHCARE

December 2016

What is your opinion about the private sector collaborating with the government to provider diagnostic services at a lower cost? PPP in diagnostic services have already started taking ground. States like Andhra Pradesh, Maharashtra have already entered into a PPP with private players to provider diagnostic services at affordable prices. Yet, there is a long way to go for these models to function in a sustainable manner.

it is necessary to ‘Make for India, rather than ‘Make in India’ for the rest of the world. What is your vision for this industry? I wish that every Indian should have access to quality and free diagnostic services. Also, the focus of our healthcare system should shift from curative to preventive only then can our economy grow stronger. Any other challenges that are detrimental to your the sector’s growth? High tax structures is the biggest barrier to the growth of the sector. Total tax component comes to around 25 per cent, out of the which the high component is Excise Duty which is 12 per cent and VAT 12.5 per cent. Moreover, the inverted duty structure on manufacturing sector punishes us. Therefore, we pay higher duty than our competitors.

What has been TRANSASIA Bio-medicals’ market share in India and other emerging markets? In India, we have around 25 per cent of the market share. We are present in around 100 countries. Are there any competitors in the global market? Our competitors in India and in the global markets are Roche, Abbott, Siemens. In India, the competition becomes lesser as this is our home ground and we have a strong base here, that is why we lead the race here. But I believe it is just a matter of time and we will be able to lead in other countries as well. You have carved a niche for yourself among the emerging markets. What has been your winning strategy in a competitive environment, especially in an industry dominated by foreign players? Affordable pricing strategy is our USP. We develop products which are reliable, affordable and innovative. This strategy has helped us to capture the

I wish that every Indian should have access to quality and free diagnostic services desired market share in India. Right pricing is key to capture market share in other emerging markets as well. You have been a strong advocate for the ‘Make in India’ campaign. So what opportunities do you see for domestic manufacturing players within the IVD segment? I believe that the only way to extend our services to poor patients in India is by making diagnostic services affordable

and by manufacturing within the country. Therefore, ‘Make in India’ is the key. The actual idea behind the ‘Make in India’ campaign was to attract global companies to set shop here and increase investments in India, right? That's not happening yet in the IVD sector in India. Can we say that the campaign is not working for diagnostic players? Yes, it is not yet working for diagnostic players. But in India

Will GST have an impact on the IVD sector at large? How will it impact individual business like yours? It is said the GST will bring down the tax burden, but we will only have to wait and watch how this will play out in the long run. Just as India’s pharma sector is globally known as the generic pharma market of the world, do you see our domestic IVD market leaving such an imprint on the globe? Yes I see immense scope. However, domestic IVD players will first need to have a strong base in India only then they should venture into other market. raelene.kambli@expressindia.com

TRADE & TRENDS I N T E R V I E W

‘We are changing the landscape for procurement and supplies space in medical institutions’ Medikabazaar aims to build the largest medtech and disposables supplies platform and have been progressing steadily since its launch in April 2015. Vivek Tiwari, Director and CEO, Boston Ivy Healthcare Solutions, in an interaction with Express Healthcare reveals more Tell us about your start-up. What challenges did you face while setting up of Medikabazaar and how did you overcome them? Medikabazaar, a tech-enabled pioneering concept, is aimed to address a large segment of medical procurement and supplies. Medikabazaar empowers medical institution to deal with complex problem of procurement and regular purchases including supply chain and logistics planning. Medikabazaar is a complete ecosystem of medical supplies addressing the major challenges in awareness, availability, ambiguity and affordability. Medical procurement and supplies include a complete range of products from medical gloves, cotton to high-end medical devices and equipment etc. We are changing the landscape for ‘procurement and supplies’ space in medical institutions and aim to build the largest medtech and disposables supplies platform. Our journey started a year ago in April 2015, where we commercialised our operations, and have been progressing steadily since then. The founder is Vivek Tiwari an alumni of IIM Calcutta. Medikabazaar is both B2B (for hospital supplies) and B2C (for home healthcare medical devices and aids). The websites are www.medikabazaar.biz (B2B); www.medikabazaar.com (B2C) Our business portal is pioneering in the segment and caters to the procurement and supply chain efficiency needs of medical institutions. In order to sustain higher growth and operational

excellence, medical institutions need to achieve higher efficiency for remarkable outcomes. In order to achieve better healthcare delivery model; optimising the cost and efficiency of medical procurement is of paramount importance. The challenges were manifold, since it is primarily a B2B concept. The initial challenge came in with the fact that there is no established B2B supply platform in India. Most of business to business solution enterprises are just for information and advertisement purpose. We had to organise a massive campaign in medical institutions through direct contacts, digital medium etc to inform them on this concept, the concept was well accepted due to the acceptance of problems from users in the identified area. What made you come up with the idea to set up Medikabazaar? The business model was conceived out of my past experience in managing a chain of multi-location tertiary care clinics. I worked as the Chief Operating Officer primarily looking after clinics roll out and operations. A digital procurement platform for medical supplies was non-existent and it was a humongous task to engage multiple vendors and ask for price quotes, negotiation for purchases etc and there always existed a bigger challenge in getting the right price from a reliable vendor and there was no vendor who was covering an array of medical supplies. I envisioned that the need to set up an innovative medical supplies

VivekTiwari

platform was of paramount importance as healthcare facilities were being set up in tier II and III cities. The supplies were always a problem due to nonavailability of last mile vendors / reliable suppliers in tier II and III cities. As a result of this, hospitals and medical institutions ended up falling prey to the unorganised and inefficient procurement system in the medical fraternity. These identified problems resulted into an idea which could solve all these complex operational issues. How did you build your core team (co-founders and initial employees)? The operations started with a team of five members including the founder. Keeping the initial phase of business in mind, smaller operational verticals in the area of finance, sales and business development were formed. The Co-Founder and Chief Financial Officer, Ketan Malkan (an established accounting professional with more than 30 years experience) played a vital

role in drawing up the financial and accounting roadmap for the venture. Three key employees were appointed for the development in Mumbai, Ahmedabad and Kolkata and a product specialist was appointed in Mumbai. IT was initially outsourced to a vendor but later we started building internal IT development and administration capability with the hiring of few IT engineers. With all the initial teething problems, we realised that at the beginning of the venture, it is important to have a team of known, reliable and experienced people. Some of the team members were taken on personal references to avoid any trials etc. Give us a background of your team members and advisors. ◗ Vivek Tiwari (MBA, IIM Calcutta), Founder and Chief Executive Officer - Worked with two healthcare service start-ups in tertiary care earlier. Notable achievements being forming and managing a JV with Japanese Leading equipment manufacturer (Nipro India Corporation) and German leading equipment manufacturer (Fresenius Medical Care) and setting up 13+ tertiary care renal dialysis centres and also learning the economics and challenges of setting up a tertiary healthcare unit. Successfully worked on value engineering the initial setup cost and reducing it to less than 50 per cent of the total cost with equipment lease and hospital revenue sharing model. I was also offered and signed up an invest-

ment term sheet in my last venture. Strategic tie up with LOK Corporation, a global regulatory and marketing organisation for medical devices and equipment. Actively engaged with various medical devices congresses and conferences globally as a delegate speaker. Tiwari is an alumnus of IIM Calcutta. ◗Dr Rupam Tiwari (B.Sc IT, B.A Litt, MBA, Ph. D, Red is a certified engineer) Co-founder and Chief Technology Officer An astute learner and keen observer of IT-related development and changes. Rupam has completed her doctorate studies in the field of management with a complete hands on knowledge and experience in managing complex IT domain. She graduated in IT with distinction and also completed her masters in Systems & Operations Management before pursuing and completing her doctoral studies. ◗Ketan Malkan (B.Com), Cofounder - An entrepreneur, a visionary who has more than 30 years of work experience in managing diverse business areas including healthcare, gems and jewellery, trading and manufacturing etc. Belonging to a moderate Gujarati family, Malkanis a self-made businessman with astute management skills and participative management capabilities. His core competence include managing accounting and finance vertical of business. Prior to this venture, he has set up and managed a medical devices distribution company with a five fold business growth in four years ◗Daniel Cloutier, Advisory Member, CEO – Lok Corporation : Daniel Cloutier is a vet-

EXPRESS HEALTHCARE

December 2016

TRADE & TRENDS eran in medical devices sector, having represented CASMED (US medical devices co) as their International Sales Director. He has been instrumental in setting up LOK Corporation, a global medical devices market access and regulatory body. Daniel is actively engaged with more than 50 global medical devices companies for their regulatory compliance, clinical trial and market access. ◗Adi Ickowicz, Founder & CEO, MedicSense Limited, Israel - With more than twenty years of experience, Adi specialises in developing company-tailored clinical and regulatory strategies, meet technical and regulatory demands for medical products, Ickowicz’s previous experience includes managing clinical and regulatory affairs departments in both well-established and

start-up companies. One thing that sets you apart from your competitors and what's your revenue model? Medikabazaar provides a comprehensive solution to procurement problem, this includes the following; ◗Product identification ◗Comparison ◗Recommendation ◗Instant quotations for approvals ◗Instant buying options ◗Requirement catalogue buildup ◗Historical Statements ◗Loan or short term/ long-term finances (instant approvals and sanction) – we are working on this ◗Price alerts ◗Request a call back option ◗Refurbished and old medical equipment - Medika recycle In a nutshell, we are a

complete ecosystem of medical supplies. How do you procure funds? Currently, we are self funded and a bootstrapped enterprise and were profitable in the first year of our operation. Give us a brief on the working of your products? We work as a B2B and B2C marketplaces for medical supplies, the core product creates a bridge between medical manufacturers and medical institutions, hospitals, medical professionals as well as individual customers. Medikabazaar remains the interface of this arrangement, manufacturers or suppliers keep on getting the orders but customers’ info is well protected and Medikabazaar remains as the selling interface.

What are your future plans? Since we already tested our business model, we are looking to raise $5 million for scalability and future growth. What makes you different from your competitors? Medikabazaar is the complete ecosystem of medical supplies, starting from sourcing and procurement to awareness and availability. Last mile delivery options to arranging finance for purchases (with the help of credit rating agencies and financial institutions) options for the smaller institutions linked within our portal to facilitate B2B trading. It works on pin code-based GIS system so that order delivery can happen in shortest possible time. We are tied up with many manufacturers exclusively with many innovative medical technology companies looking at launching

their products through our portal. In the shortest possible time, we are engaged with many leading medical institutions in tier-I, tier-II and tier-III cities. We also have Medikastar reward points for managing subscription-based reward programme for regular buyers. What are the barriers to entry and Intellectual property in the business? We have been able to identify key barriers to entry in our business model; primarily these are registration with hospitals, exclusivity in supplies as well as exclusive contracts with sellers. We are working on getting some more barriers to ensure a stronger foothold of Medikabazaar in the business. Contact details www.medikabazaar.biz www.medikabazaar.com

Kenzai: Robust healthcare business solutions provider The objective is to handhold clients and help them comply and improve their capability across the pharma value chain GUJARAT, HAS attained a critical and focal role from bulk drugs to formulations and ancillary’s etc in Indian pharmaceutical sector. It is poised to capture global opportunities and become a global pharma hub. Many leading pharma companies have its headquarters and Gujarat accounts for 40 per cent of the total Indian pharma business. Some other highlights worth mentioning is: ◗ 5,585 manufacturing licenses, home to 40 per cent of CRO in the country ◗ 40 per cent of machinery for pharma sector is manufactured in Gujarat ◗ Largest manufacturer of IV sets in India ◗ 70 per cent of cardiac stents and 50 per cent of intraocular lenses manufactured in Gujarat ◗ 58 per cent of orthopaedic im-

EXPRESS HEALTHCARE

December 2016

plants are manufactured in Gujarat ◗ Home to 40 per cent of India’s CRAMS companies ◗ Presence of more than 50 biotechnology companies and 66 support organisations All these accounts for employment for around 75,000 people. This number is increasing by 20 per cent to 25 per cent each year with increase in business, laying of new manufacturing plants and introduction of new start up pharma companies. Pharma companies in order to continue to have the competitive advantage and grab greater share or role in the global scene, must ensure processes which are world class, quality of output matching global standards, manpower quality/productivity which is one of the best in the

country and comply with all regulatory / statutory norms. Here exists a lot of gaps, as companies in its pursuit to cater to the market demand has missed in certain areas, though not intentionally but possibly due to lack of knowledge and absence of adequate experience. This is the wide spectrum and gap which opens up a new area of opportunity for knowledge base work and support. Kenzai a new entity based in Ahmedabad has identified these key areas and has set out to offer robust solutions by bridging the gap that exists due to lack of adequate knowledge and experience. Kenzai’s objective is to handhold clients and help them comply and improve their capability across the pharma value chain which

could be at the organisation level, marketing, human resource, operations, strategic or to adopt to new way of marketing i.e. digital. Kenzai partners are pharma professionals with less five decades of executive experience in leading MNC’s / Indian companies of Mumbai and Ahmedabad. Both the partners have worked through the pharma sector i.e. from medical representative to business head positions and have handled multiple therapies during their journey. Kenzai intends to bring in this change in Gujarat pharma space and help their partners / associates to scale new heights in business by making them compliant, competitive and future global ready. P Pradeep Kumar, Managing Partner, Kenzai says, “Adopting

to processes and binding the business through knowledge and experience is the key element to differentiate in the marketplace today”. Kenzai’s strong value added offerings will certainly help pharma company’s move ahead with confidence alongwith that, influence the lives of manpower employed by equipping them with better work practises and skills.” Kenzai thus stands committed to “Robust Healthcare solutions to Healthcare” as quoted by Dr Dipankar Dutta, Managing Partner, Kenzai. Contact details Kenzai A-118, First Floor, SOBO Center, South Bopal, Ahmedabad – 380058 Tel: 9820997809, 9909907343 Email: ask@kenzai.in

TRADE & TRENDS

Meditek Engineers: Reforming healthcare,inspiring life Ranging from five function motorised intensive care beds to operation theatre trolleys, the company has solutions for every need of the hospital MEDITEK ENGINEERS is a privately-owned company led by a competent team with many years of experience in providing excellent service to both public and private hospitals. Meditek was established to provide unrivalled service and support for all medical equipment. The company has highly trained and multiskilled staff to bring a range of services to suit every situation. First generation entrepreneur Anil Phirke realised the need of quality production of medical equipment and established Meditek Engineers in the year 1989. Meditek Engineers is an ISO 9001:2008 and ISO 13485 certified company engaged in the business of manufacturing and marketing full range of medical beds and furniture. Ranging from five function motorised intensive care beds to operation theatre trolleys, the company has solutions for every need of the hospital. Headquartered in Mumbai, Meditek Engineers' display showroom and manufacturing plant are in Ambernath near Mumbai and spans a pan India presence. With exceedingly superior hospital solutions, the company has its international presence in the African countries.

The management The managing body of Meditek Engineering is a team of experienced domain experts. With a passion to deliver superior results, they complement each other well. The team’s proficiency encompasses all the factors, necessary for the governance of a successful hospital equipment manufacturing company.

A state-of-the-art manufacturing facility Being a solution provider for hospital equipment and allied components, from ‘Concept to Delivery’ Meditek Engineers' engineering and design centre is self sufficient in technology for conceptualising, developing, testing and manufacturing of related products. The company is proud to have developed a setup that is absolutely well-equipped and state-of-the-art as per global standards. It offers a turnkey medical device manufacturing service that spans the entire supply chain from component procurement to distribution, all within a quality controlled environment. It starts with working with you to generate, develop and refine your product concept to ensure all of the requirements for a commercially and technologically viable product are met. Meditek takes pride in its full-fledged in-house manufacturing facilities such as ◗ Hydraulic shearing. ◗ Bending and pipe bending machine. ◗ Seven tank pre-treatment plant for metal surface treatment. ◗ Automatic conveyorised polyester epoxy powder coating plant. ◗ Modern Assembly and Welding set up with test laboratory. The excellence thus acquired is aptly reflected in the performance and quality offerings of the company. It has developed a unique range of advanced products required for the healthcare industry, making it the most cost-effective manufacturer of the given product range.

ICU Special Care

Convenience of usage and ease of operations are equally important for the medical practitioners and patients. These beds provide them to the optimum level and make the patients stay comfortable.

1101A – Five function ICCU bed (Manual) With split type safety side rail (set of four), polymer moulded head and foot board ◗ Easily removable polymer moulded head and foot boards for easy access to the patients ◗ Approx. 60mm X 30mm CRCA rectangular tube frame ◗ Four section perforated

CRCA sheet top stainless steel telescopic IV rod ◗ Four non rusting 125mm dia. Polyurethane casters two with brakes and two without brakes pre-treated and powder coated

1102A – Three function ICU bed (Fixed height) Manual with new design SS collapsible side rail, polymer moulded head and foot board. ◗ 60mm X30mm Approx. CRCA rectangular tube frame. ◗ Four section perforated CRCA sheet top. ◗ Three separate screws for backrest, knee rest and trendelenburg and reverse trendelen-

burg position by individual SS folding handles. ◗ Four 125mm-dia non rusting castor wheel two with brake. ◗ SS telescopic IV rods. ◗ Urine bag holder. ◗ Pre-treated and epoxy powder coated. Contact details Meditek Engineers W-13(A) Additional MIDC, Near Hotel Krishna Palace, Pipiline Road, Ambernath(E) 421506,Thane, Maharashtra Cell# 9820855328 email: sales@meditekengineers.com

EXPRESS HEALTHCARE

December 2016

TRADE & TRENDS

Carestream receives Certificate of Merit Carestream believes that service delivery is critical to customer success

breakdowns ◗ Self-serviceable product to increase the up-time of equipment ◗ NPS – Net promoter score to bring the customers’ voice into the company ◗ Ensuring shortest possible spare parts delivery time ◗ Establishing customer care centre ◗ Attending customer concerns in the shortest possible time ◗ Customer champions recognition programme “We are both honoured and humbled by this Certificate of Merit for Best Customer Service in Healthcare. We would like to dedicate this honour to our customers who have stood by us over many years. We wish to renew our pledge to strive as hard as possible to provide them even better service in the years to come,” said Sushant Kinra, MD, Carestream Health India. The Healthcare Leadership Awards is a premium forum bringing elite hospitals, diagnostic centres, medical equipment manufacturers, pharmaceutical companies, etc. all together under one roof. The programme offers top healthcare professionals, agencies and consultants a conducive environment for recognising and rewarding excellence.

CARESTREAM HEALTH India, worldwide provider of dental and medical imaging systems, has recently received the Certificate of Merit for Best Customer Service at the ABP News Healthcare Leadership Awards ceremony. Organised by the World Marketing Congress in association with ABP News, the award function was held in Mumbai. The ABP Healthcare Leadership Awards are given to the best healthcare organisations for the outstanding work done by them in healthcare. Carestream provides an extraordinary customer service experience by effectively leveraging our people, processes and tools. The company believes that service delivery is critical to customer success. In order to deliver service excellence efficiently and cost-effectively, three elements must be successfully combined: people, processes and tools. Some of the key initiatives undertaken to achieve service excellence by Carestream are as follows: ◗ The centre of excellence setup – remote resolution of

Carestream launches first wireless detector Showcases its CARESTREAM DRX Plus, CARESTREAM DRX Core and DRX 2530C detectors at the Radiological Society of North America conference Carestream transformed radiology imaging with the launch of its first wireless detector while the company’s newest detector families demonstrate its proven commitment to innovation. Carestream showcased its CARESTREAM DRX Plus, CARESTREAM DRX Core and DRX 2530C detectors at the Radiological Society of North America conference (Booth #4704).

EXPRESS HEALTHCARE

December 2016

“Detectors that deliver access to high-quality digital images in seconds and offer wireless communication of images have revolutionised radiology workflows across the globe,” said Jianqing Bennett, President of Digital Medical Solutions, Carestream. “In response to customer feedback, Carestream has continuously expanded its detector portfolio with small-format and largeformat detectors, as well as

newer families of DRX Plus and DRX Core detectors.” CARESTREAM DRX Plus detectors (video link) in 35 x 43 cm and 43 x 43 cm sizes offer a choice of gadolinium (GOS) or higher-resolution cesium (CsI). These detectors are available in the US and Canada as well as many countries in Europe, Asia and Latin America. DRX Plus detectors offer rapid image capture to help users achieve a streamlined

workflow and deliver excellent DQE (detective quantum efficiency) to enhance image quality and lower dose. In addition, DRX Plus detectors can be submerged in one meter of water for 30 minutes without failure, which achieves IPX Level 57 rating for liquid resistance to the IEC standard 60529. A reduced weight and thinner profile allow even easier handling. Carestream has modified the Bucky in its DRX-Evolution Plus and DRX-Ascend systems to accept the larger-format DRX Plus 4343 detectors, which also can be used with the CARESTREAM DRX-Revolution Mobile X-ray System. Carestream also offers a small-format DRX 2530C cesium detector designed for use with paediatric and NICU patients as well as for tabletop imaging. Carestream is now shipping its new DRX Core detectors designed to make high-quality DR imaging affordable for smaller imaging centres and hospitals, as well as urgent care facilities,

specialty clinics and mobile imaging service providers. The DRX Core portfolio includes wireless gadolinium and cesium detectors in 35 x 43 cm and 43 x 43 cm sizes—as well as fixed 43 x 43 cm detectors with both scintillators. DRX Core detectors can be used with Carestream’s DRXAscend System, DRX-Mobile Retrofit Kits and its new Motion Mobile X-ray System. Up to two DRX Core detectors can be registered with each system at any time. Facilities can have a combination of eight DRX detectors registered with DIRECTVIEW Software on each imaging system for simultaneous use. DRX Core detectors deliver a preview image in three seconds and full-resolution display in 12 seconds. They use the same battery as DRX Plus and DRX-1 detectors and can be used with Carestream’s DIRECTVIEW software or Image Suite software. Contact details www.carestream.in

BUSINESS AVENUES

EXPRESS HEALTHCARE

JMS Medi Tape

MADE IN JAPAN

Hypo-allergenic

Air and moisture permeable microporous paper backing No irritating special acrylic polymer adhesive agent

Why JMS Meditape ? • Excellent adhesion to skin • Special bio-compatible polymer adhesive Safe, do not cause skin irritation • Air permeable and breathable • Water repellent, do not come off even wetting or bathing.

JMS Infusion Set PRECISION FLOW RATE 20 DROP / ML • Special design V-Clamp Accurate and regulated flow control over time. • Latex free injection port, safe, protects against latex allergy. • Soft unique drip chamber, facilitates accurate fluid level adjustment. • ISO 8536-4 Compliant Spike, conical design with a graduated shoulder structure allowing for easy closure piercing.

JMS Blood Transfusion Set SPECIAL DESIGN DOUBLE DRIP CHAMBER

Benefits of JMS Double Drip Chamber • The double drip chamber consists of the upper chamber with a blood filter and the lower chamber with a drip orifice. • This configuration assures full utilization of the filter of the upper chamber for better filtration and easy observation or drops at the lower chamber. • Large polyester mesh filter of pore (1 85 or 211 u) is suspended in the upper drip chamber for smooth blood flow and maximum. Marketed in India By :

Hemant Surgical Industries Ltd. 502, 6th Floor, ECSTASY, City of Joy Commercial Complex, J.S.D. Road , Mulund (W), Mumbai -400 080.Tel. : 022 - 2203 0935/36, 2591 2747/5289 E-mail : info@hemantsurgical.com, sales@hemantsurgical.com

DISTRIBUTORS REQUIRED for other products details please visit our website www.hemantsurgical.com Please feel free to contact us Mob. : 9619484952, 9619484154

... Serving for Better Life Care EXPRESS HEALTHCARE

December 2016

BUSINESS AVENUES

December 2016

EXPRESS HEALTHCARE

BUSINESS AVENUES

EXPRESS HEALTHCARE

December 2016

BUSINESS AVENUES

EXPRESS HEALTHCARE

BARIATRICS At Ease!

MAGNALED TRU WITH CAMERA

ISO 9001:2008 Certified Company

December 2016

EXPRESS HEALTHCARE

BUSINESS AVENUES

EXPRESS HEALTHCARE

December 2016

BUSINESS AVENUES

December 2016

EXPRESS HEALTHCARE

BUSINESS AVENUES

EXPRESS HEALTHCARE

December 2016

BUSINESS AVENUES

EXPRESS HEALTHCARE Advertise in

Business Avenues Please Contact: ■ Mumbai: Douglas Menezes 91-9821580403 ■ Ahmedabad: Nirav Mistry 91-9586424033 ■ Delhi: Ambuj Kumar 91-9999070900 ■ Chennai/Bangalore: Mathen Mathew / Amit Tiwari 91-9840826366 / 91-8095502597 ■ Hyderabad: E.Mujahid 91-9849039936 ■ Kolkata: Ajanta 91-9831182580

December 2016

EXPRESS HEALTHCARE

BUSINESS AVENUES

EXPRESS HEALTHCARE

OXYGEN CONCENTRATOR Precision Engineering Technology from Germany FEATURES: • Generate High Purity of Oxygen 5 Lit / min. • Whisper silent (35dB (A)) • Simple operation • Microprocessor-controlled • Easily accessible ﬁlter and fuses • USB – interface • Modern design, easy to carry • New, innovative measuring sensor • Integrated ﬂow adjustment • Maintenance Free Long Life • Prompt after sales service • Economical Price

AERO

Made in Germany

PISTON COMPRESSOR NEBULIZER

For breathing or respiratory problems Aero nebulizer is your best companion FEATURES: • • • • • • • • Marketed in India By :

Strong Durable body Light Weight & Compact Easy to carry Ideal for all ages Effective Medication Delivery Latex free Prompt after sales service Economical Price DISTRIBUTORS REQUIRED for other products details please visit our website www.hemantsurgical.com Please feel free to contact us Mob. : 9619484952, 9619484154

... Serving for Better Life Care EXPRESS HEALTHCARE

December 2016

BUSINESS AVENUES

December 2016

EXPRESS HEALTHCARE

LIFE PEOPLE

Dissecting Dr Rakesh Sinha’s strategy to success Raelene Kambli explores Dr Rakesh Sinha’s growth trajectory and how he demonstrates that a clinical expert can take on different roles and yet continue to excel in their signature skill

ow can one truly define success in medical practice? Often people measure success with the happiness they get by doing their jobs, or by the joy that others feel as a result of their work. Going by various books, success is defined as a state where a person achieves money and power. Psychologists simply describe success as a state of self-satisfaction. Well, the fact reminds that

success is a crucial element of happiness and can be interpreted in several ways. When it comes to determining success for a medical practitioner, it is often associated with clinical excellence. Nevertheless, as the practice of medicine continues to evolve, the role of a practitioner keeps changing and so does the definition of success amplifies. India has several examples of healthcare leaders who as-

certain that success in medical practice today is much more than just clinical excellence. It is about providing value-based care to patients for which practitioners need to understand the co-relation between medicine and management. Let’s look at the lives of influential leaders in Indian healthcare such as, Dr Prathap Reddy, Dr Devi Shetty, Dr Ramakant Panda, Dr Naresh Trehan, late Dr L H Hiranandani, Dr A

Velumani and so on. They all have not just achieved clinical excellence but have graduated to be entrepreneurs, philanthropists, motivational speakers, etc., and still continued to shine in their medical practice. Taking up different roles is not a cake walk. But these leaders, by beating all odds in their path to glory, prove that this isn’t impossible too. They display qualities of agility, perseverance, courage, immense voli-

tion to grow, a clear mind and above all a risk taking attitude. Their definition of success is to have a continued purpose in life. A purpose to save many lives and to make a difference. This drives them to take on different roles, explore new avenues or surmount newer heights. All this is done with just one intention that is to become a healthcare influencer and to earn a name that the world will cherish for a very

EXPRESS HEALTHCARE

December 2016

LIFE long time, isn’t it? This is evident from the fact that patients actively seek for their medical advice even if it means a long waiting time or travelling to another city. This becomes their Unique Selling Preposition (USP) which is the most important element of brand building. The reason I speak of these leaders as inspiration is because they teach us great lessons on self development, success and above all building the brand called 'The doctor'. My recent interaction with one such leader was an eyeopener.

A management pill for doctors Dr Rakesh Sinha, a gynaecological endoscopic surgeon, teacher, trainer, an entrepreneur, a motivational speaker and now an author firmly believes in the concept of self development to make a great fortune. Quoting the words of Jim Rohn he says,“If you work hard on your job, you will make a living. But if you work hard on your self, you will make a fortune. This approach has made a tremendous difference in my life. The rewards of self development are far more than just being a great surgeon.” When asked about why a surgeon is so keen being a motivational speaker and a management guru, he shares, “There is a human potential movement happening globally and I am trying to make people aware of their potential.” Quoting from the words of Benjiman Franklin, Dr Sinha says, “Most of us live like ‘Sundials in the Shade’ who haven't yet explored their true potential. We are all capable of doing something great, but rarely understand our true potentials and therefore settle down for less.” I quiet agree with Dr Sinha on this aspect. John Maxwell, a leadership trainer from Florida describing ways to unleash the extraordinary potential within individuals writes, “Basic physics describes two kinds of energy at play given any situation — potential and kinetic energy. Potential energy refers to the energy that an object could have as it sits at the top of the

EXPRESS HEALTHCARE

December 2016

Dr Sinha uses management lessons to enhance his medical practice on a day-to-day basis. He says that management is key to every healthcare organisation, in order to provide value-based care to their patients hill. Due to gravity, the snowball has the potential to move down the hill. As the snowball rolls, it exerts kinetic energy.” Maxwell calls this the energy of motion. He says, “All it takes is a little push and the object starts rolling. There may be resistance along the way, but the momentum is enough to keep it moving.” With this illustration Maxwell draws parallels to human nature towards stretching themselves to do more. Similarly, Dr Sinha uses management lessons to enhance his medical practice on a day-to-day basis. He says that management is key to every healthcare organisation, in order to provide value-based care to their patients. Giving an example for the same he says that, healthcare organisations usually invest heavily on advertising to attract patients. Rather, they need to invest in their physicians and nursing staff. “Investing in people gives great returns on investment (ROI). This is one of the most important lesson which the healthcare providers need to learn which is why, I keep reiterating on the importance of self development.” Certainly, Dr Sinha has a case in point that reflects that a right strategy adopted towards self development and brand building will lead to success. Here is his game plan.

Records - one, for having removed the largest fibroid weighing 3.4 kgs laparoscopically and second for having taken out the largest uterus weighing 4.1 kgs laparoscopically.

A teacher’s role is important for progress During those days, Dr Sinha also established a chain of specialised surgery centres for women called Beams Hospitals. It is now called Womens Hospital. While expanding his business and continuing to update his skills from laparoscopy to robotics, he trained several gynaecologists and surgical endoscopic surgeons from India and abroad. He did it in order to share the knowledge he gained and to continue the learning process within himself. He has been a faculty for training workshops in Endoscopic Surgery in London, Singapore, Malaysia, Indonesia and Kenya and has delivered lectures, presented papers, keynote addresses and orations at the UK, the US, Holland, Kenya, Singapore, Germany, Italy, Malaysia and Canada besides India. Undertaking a teaching role did not hinder Dr Sinha, as laparoscopic fibroid surgery is his signature skill. Therefore, even when Dr Sinha attended workshops and training programmes, he juggled with time to perform endoscopic surgeries in more than 55 cities in India.

A doctor par excellence Dr Sinha believes that it is important to pick up a niche area and build expertise around it. In his career path he exactly did the same. He chose to gain clinical excellence in the field of gynaecological laparoscopy and kept updating his knowledge in this area. Through this he achieved two Guinness World

Re-inventing himself as a success mentor “Humans have 25947 genes. Those are the number of excuses that people can make for not utilising their full potential. But if, you turn them around they can become 25947 opportunities,” says an optimistic Dr Sinha. With this mindset, he

continued to grow in his endless capacities. He went on to become four time international marathon runner having completed 42.195 kms each time. Further on, he pursued an internationally certificate to be a motivational speaker and a licentiate practitioner for Neurolinguistic Programming (NLP). Moreover, Dr Sinha has also done a special training in Anthropomaximology, a study of understanding higher human potential. All these noteworthy accomplishments have earned him goodwill in India as well abroad. With this acclaim, he has been featured on Jack Canfield’s Success Profiles. The latest addition to his portfolio is the book where he intends to dissect the science of being successful.

It is imperative to attain these achievements, happiness, legacy and significance in areas of profession, personal, family and spiritual life. Likewise, he stresses upon the fact that we need to challenge mediocracy and rise above. “Despite our genetic make-up, everybody can succeed, if we have the inner urge to do something worthwhile. But above all, the most important ingredient to success is the character of integrity that defines the path you choose for prosperity,” he asserts. Well, the book makes an interesting read. It tells us exactly what the practice of medicine can teach us about success. He also lays emphasis on the fact that science aims to become a coach to handhold people through their success journey.

Anatomy of Success in a nutshell

Learning lessons

Two and a half minutes, 150 seconds that is the time limit given to him to a save a live. How does Dr Sinha manage this short time frame to make a life-death decision? The book begins with a gripping episode of past experiences that explains what medicine can teach about success on a day-today basis. Dr Sinha narrates incidences that teach him how important it is to take risk, to unlearn when needed so that one can learn new things, to have a strong will power and undeterred focus to continue on the path to progress and so on. He further discusses success as a combination of three parts: what you are born with, or Biology; what you learn along the way, or Learning; and your deep desire to succeed, or Cognition. Apart from this, Dr Sinha also advices to maintain a balance in every area of our lives.

Dr Sinha’s success mantra is indeed praiseworthy. He directs us to chase our dreams with great zeal. His growth trajectory also demonstrates that a clinical expert can take on different roles and yet continue to excel in their signature skill. However, it is also important to stay grounded and not be distracted, not feel tired and above all, maintain a balance in the four main areas of life. Quoting the words of Dr A Velumani, when he addressed CXOs from the healthcare sector about his life’s journey at Healthcare Senate 2016, “Step out of your comfort zones and explore new areas of growth as only those who have the courage to take risks and venture into the unknown would be successful. In life, there is security and there is prosperity, but there is nothing called secured prosperity”. raelene.kambli@expressindia.com

REGD. WITH RNI NO. MAHENG/2007/22045, POSTAL REGD. NO. MCS/162/2016 – 18, PUBLISHED ON 8TH EVERY MONTH, POSTED ON 9TH, 10TH, 11TH EVERY MONTH, POSTED AT MUMBAI PATRIKA CHANNEL SORTING OFFICE, MUMBAI – 400001

Coming Soon.... Be a Part India’s First Chain Of Budgeted Hospital

If You Are 50-100 Bedded Hospital & Want To Come Under Corporate Umbrella Of Caremed Contact Us.