Express Healthcare (Vol.11, No.1) January, 2017

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CONTENTS Vol 11. No 1, JANUARY, 2017

Chairman of the Board Viveck Goenka Sr Vice President-BPD Neil Viegas

TACKLING DOCTOR CRUNCH IN PUBLIC HEALTH

Editor Viveka Roychowdhury* Chief of Product Harit Mohanty BUREAUS Mumbai Sachin Jagdale, Usha Sharma, Raelene Kambli, Lakshmipriya Nair, Sanjiv Das, Mansha Gagneja

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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

10 Despite several efforts, India still struggles with a severe shortage of doctors, especially in the rural areas.An analysis of the current situation and ways to solve the issue | P14-16

INTERVIEWS

IT@HEALTHCARE

Consultant Chest Physician

P18: PROF DILEEP MAVALANKAR Director, IIPH Gandhinagar

SUNDARARAMAN

Manager Bhadresh Valia

Dean, School of Health System Studies, TISS

Scheduling & Coordination Ashish Anchan

P36: ATUL ANCHAN

P19: PROF T

Director, Systems Engineering, India, Symantec

STRATEGY

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P17: DR ZARIR UDWADIA

PRODUCTION General Manager BR Tipnis

CIRCULATION Circulation Team Mohan Varadkar

CARDIOLOGISTS HIGHLIGHT GROWING INCIDENCE OF HEART FAILURE IN INDIA

ON A GROWTH CURVE

LIFE

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EVOLVING TOWARDS DIGITISED HEALTHCARE

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REVOLUTIONISING HEALTH INSURANCE WITH TECHNOLOGY

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DATA-ENABLED FUTURE FOR INDIA’S PUBLIC HEALTHCARE

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WHY CLOUD IS CRUCIAL FOR HEALTHCARE?

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NABH ACCREDITATION GUIDELINES FOR PATIENTFRIENDLY HOSPITAL DESIGN

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NEERAJ LAL JOINS RAINBOW HOSPITALS

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Express Healthcare® Regd. With RNI No.MAHENG/2007/22045. Postal Regd.No.MCS/162/2016-18. Printed and Published by Vaidehi Thakar on behalf of The Indian Express (P) Limited and Printed at The Indian Express Press, Plot No.EL-208, TTC Industrial Area, Mahape, Navi Mumbai-400710 and Published at 2nd floor, Express Towers, Nariman Point, Mumbai 400021. Editor: Viveka Roychowdhury.* (Editorial & Administrative Offices: Express Towers, 1st floor, Nariman Point, Mumbai 400021) * Responsible for selection of news under the PRB Act. Copyright © 2017. 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

The politics of public health

I

ndia ended 2016 hanging onto the words of Prime Minister Modi, as he made his second national address on the eve of 2017. His first national address on November 8 ended up demonetising 86 per cent of the nation's currency and there were bets that he was due to make yet another big bang reform announcement.

Luckily, the PM had a bag of goodies for selected segments of India's population. Timed perfectly a day after the 50-day deadline post-demonetisation he started by applauding the public for supporting his move. Then went on to make a series of announcements, which were almost Budget-like in tone and content. In fact, West Bengal Chief Minister Mamata Banerjee tweeted, “The PM just took over post of Finance Minister and made pre- Budget speech... The Nation Address became the Budget Address."

But, the PM was clearly was in damage control mode, trying to counter the blow of demonetisation, at least for certain sections of society, like retired/senior citizens, farmers, small entrepreneurs and yes, women.

Healthcare professionals will be particularly pleased with his intention to improve maternal mortality rates (MMR). He announced that a current pilot project running in 53 districts, under which pregnant women who underwent institutional delivery and vaccinated their children were given financial assistance of ` 4000, would be expanded to cover the whole nation with the financial assistance increasing to ` 6000.

This may seem a small step but for a woman living in the rural or even semi urban areas of India, this is further incentive to insist on having her baby in a healthcare facility. It means a chance of better care for both the mother as well as child, not just in terms of more cash in her bank account to buy better nutrition before and after delivery but also being tracked by health workers for immunisations. This scheme will help reduce MMR in a big way, said the PM , leaving no doubt in anyone's mind that he knows the pain points of India's healthcare infrastructure and its impact on the nation's health.

This announcement may not sound like a ‘big bang’ reform like demonetisation, but PM Modi clearly has his eye on the long term. A healthier

Public health seems to have become a populist political tool, one of manysuch sops,that ruling and state parties will use to woo the electorate in the upcoming state elections as well as the all important 2019 general elections

mother stands better chance of raising a healthier child and family. An empowered mother stands a better chance of educating her children and her family.

According to the NITI Aayog, while India's total MMR reduced from 254 (deaths per per 100000 live births) in 2004-06 to 167 in 2011-13, some states are way below this benchmark. Kerala started out with 95 and ends with 61 in the same period whereas Assam remains burdened with the highest MMR, both in 2004-06 (480) and in 2011-13 (300). This data maybe dated but serves to illustrate the disparity between different states and regions.

An editorial in The Lancet, titled Universal Health Coverage—looking to the future’’, published on December 10 last year, is critical of governments, including the UK’s NHS, for being ‘complacent’ about taking responsibility for financing their health systems, and urges them not to pursue alternatives to public finance.

The Modi government has also come in for criticism, as it ‘has been disappointingly inactive in supporting UHC, and has reduced the funding of national health programmes’, though it says ‘regional initiatives are emerging and show great promise’.

As an example, the same week’s World Report describes a network of local mohalla clinics run by Delhi’s Aam Aadmi Party government, that are successfully serving populations otherwise deprived of health services.

But in a classic tussle between centre and state, the centre, (led by PM Modi’s BJP) is reportedly stalling the expansion of the mohalla clinics initiative. Public health seems to have become a populist political tool, one of many such sops, that ruling and state parties will use to woo the electorate in the upcoming state elections as well as the all important 2019 general elections.

We hope to debate such concerns in February at the second edition of our public health focused leadership summit, Healthcare Sabha. Meanwhile, the January issue, our 17th anniversary issue and a public health special, highlights some of the efforts to address these challenges.

VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com

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QUOTE

DECEMBER 2016

The initiatives we are undertaking today will have far reaching and deep impact on the health outcome of the citizens. Today, we have launched the programme where we can be collaborative and a programme that is befitting to Good Governance Day

As a turbulent year comes to a close, WHO and our global partners are helping improve the world in permanent ways Dr Margaret Chan

Check out the online version of our magazine at

www.expresshealthcare.in

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JP Nadda

Union Minister for Health & Family Welfare, at the launch of ‘SwachhSwasthSarvatra’to commemorate Good Governance Day

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Director-General, World Health Organization on WHO's achievements in 2016

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Important: Whilst care is taken prior to acceptance of advertising copy, it is not possible to verify its contents. The Indian Express (P) Ltd., cannot be held responsible for such contents, nor for any loss or damages incurred as a result of transactions with companies, associations or individuals advertising in its newspapers or publications. We therefore recommend that readers make necessary inquiries before sending any monies or entering into any agreements with advertisers or otherwise acting on an advertisement in any manner whatsoever.

MARKET PRE EVENT

Healthcare Sabha 2017: Co-creating a manifesto for a healthy India The event will be held at Visakhapatnam from February 9-12, 2017

W

ith an aim to drive a revolution and facilitate a dialogue in public health, Express Healthcare, a publication from The Indian Express Group, launched Healthcare Sabha – The National Thought Leadership Forum on Public Healthcare.

Healthcare Sabha 2017 will create a blueprint to facilitate evidence-based policy making, augment excellence in healthcare delivery and eliminate barriers to equitable access. Healthcare Sabha 2017 will work toward 'Co-creating a Manifesto for a Healthy India.'

The event will be held at Visakhapatnam from February 9-12, 2017.

Key subjects at the forum include: Pillar 1-Tackling talent crunch: Improving capacity and competence ◗ Role of PPPs in training healthcare professionals. ◗ Strategies to attract doctors to public health (especially in rural India). ◗ An assessment of the Skill India Initiative and the way forward. ◗ Creating a large pool of efficient and skilled professionals. ◗ Medical education syllabus in India: In need of a major rehaul.

Pillar 2-Developing sustainable health financing systems ◗ Galvanising healthcare via

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POST EVENTS

insurance. ◗ Govt sponsored schemes: Meant for poor, but beyond their reach. ◗ Understanding health economics: A much needed remedy for a healthy India. ◗ Infrastructure essentials: Plan for an affordable healthcare system.

Pillar 3-Ushering good governance in public health ◗ Technology for good governance in public hospitals. ◗ Revisiting our disease control strategies: Successes & failures (NCD, Anti-TB programmes etc.) ◗ Strategies to mitigate health infrastructure deficit. ◗ Uprooting corruption from healthcare: An urgent need.

Pillar 4-Ensuring access to quality health services and essential medicines ◗ Analysis of Mohalla clinics (Studying the efficacy of the model and their replicability). ◗ Universal Immunisation Coverage: Making it Mission Possible. ◗ Medicines for all: Roadmap for better accessibility and affordability. ◗ Sanitation: Is the Swachh Bharat campaign taking us closer to a Swasth Bharat? ◗ Eliminating malnutrition: Taking a multi-pronged approach.

To be held concurrently with Healthcare Sabha, the Express Public Health Awards will honour Champions, Visionaries and Game Changers in Public Healthcare.

The first edition (held from March 4-6, 2016 at Hyderabad Marriott Hotel and Convention Center) brought together significant stakeholders in public health to deliberate on cohesive, unified and innovative ways to achieve the National Health Mission’s Vision pertaining to ‘Universal Access to Equitable, Affordable and Quality Healthcare Services to All’.

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Cardiologists highlight growing incidence of heart failure in India They were speaking at a press conference held concurrently with the Annual Conference of Cardiology Society of India in Kochi recently LEADING CARDIOLOGISTS Dr Shirish Hiremath, Consultant Cardiologist & Director – Cardiac Cath Lab, Ruby Hall Clinic, Pune; Dr Mahazarin Ginwalla from Harrington Heart & Vascular Institute, University Hospitals, Cleveland; and Dr PP Mohanan, Organising Secretary, Cardiology Society of India -Kerala Chapter highlight that heart failure is a growing concern and reveal that it is a condition which affects over 60 million people worldwide. In India, approximately 4.6 million patients are living with heart failure. Speaking at a press conference held concurrently with the 68th Annual Conference of Cardiology Society of India held in Kochi from 8-11 December, 2016, the cardiologists drew attention to the fact that there are more people dying of heart failure than cancer.

The doctors also educated about the difference between heart failure and heart attacks and provides more information about the condition and its epidemiology. Heart failure is a debilitating and potentially lifethreatening condition where the heart cannot pump enough blood around the body. A heart attack is a sudden and unexpected event resulting from blockage in the arteries supplying blood to the heart muscles.

Heart failure does not develop overnight – it’s a progressive disease that starts slowly and gets worse over time.

The doctors also elaborated on the importance of effectively managing hypertension as a measure to prevent or delay the onset of heart failure. The doctors also spoke of the huge so-

Doctors unveiling the heart installation to launch Novartis’ Keep It Pumping Initiative

L-R: Dr Hiremath, Dr Ginwalla and Dr PP Mohanan addressing the media

cio-economic impact of heart failure on the patients and their families.

At the same time, they also expressed hope about growing options for treatment and management and advised early diagnosis to manage it better.

Pharma major Novartis, also launched, ‘Keep it Pumping’, an initiative dedicated to increasing understanding of heart failure. It will provide information and support to heart failure patients and their loved ones, while also raising aware-

ness among the general public.

Keep it Pumping is inviting people to help build a heart made of LEGO bricks and to donate their virtual heartbeat. These heart beats will then be combined to create a unique ‘beat of the nation’ song.

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PHD Chamber and AMTZ organise seminar It provided opportunities for foreign collaborations for technology transfers and financing for setting up units PHD CHAMBER, in association with AMTZ (Andhra MedTech Zone) recently organised a seminar on ‘Medical Electronics International collaborations & Financing for Manufacturing’ in Jaipur.

AMTZ aims to make India a self-sufficient and in fact an exporter of good quality and costeffective medical technology.

The objective of the seminar was to familiarise the industry on this opportunity which exists in fulfilling the gap which is only likely to widen as healthcare services reach out to semi-urban and rural areas. The seminar also threw up opportunities for foreign collaborations for technology transfers and financing for setting up units.

ML Gupta, Co Chairman of Rajasthan Committee, PHD Chamber addressed the delegates and briefly informed them about AMTZ. The conference was presided over by Nitin Bharadwaj, Vice-President (HR and Administration), AMTZ. He talked about the benefits of being the part of AMTZ project at Visakhapatnam, where they are offering plug-n-play infrastructure, lower cost testing services, lower capex for manufacturers, regulators and export facilitation, promotional activities through EXPO/ convention centre, finance and technology transfer services, preferential market access Circa and all other facilities commonly required in the manufacturing of medical devices etc.

Vikas Varma, Financial Advisor and Internal Auditor, AMTZ, shared AMTZ’s value

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proposition for investors. He talked about multiple fiscal incentives provided by AMTZ to companies participating in the project.

Nagaraju Devarajugattu, SM Operations, AMTZ, informed the delegates on the plot booking procedure with specifics on investment in AMTZ. He also

gave a live demo on the plot booking procedure for better understanding.

Vivek Seigell, Director, PHD Chamber, appreciated the ef-

forts being taken by Government of Andhra Pradesh and urged industry members to come upfront and be a part of the AMTZ project.

cover )

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F O C U S : P U B L I C H E A LT H

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TACKLING DOCTOR CRUNCH IN PUBLIC HEALTH

DEVELOPMENT OF HEALTH INDEX OF INDIAN STATES

STRATEGIC PURCHASING FOR UHC: ENGAGING THE PRIVATE SECTOR

EMPHASIS ON NUTRITION: A MUST FOR QUALITY MATERNAL CARE

STRENGTHENING PUBLIC HEALTH DELIVERY IN NORTH EAST

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cover )

TACKLING DOCTOR CRUNCH IN PUBLIC HEALTH Despite several efforts, India still struggles with a severe shortage of doctors, especially in the rural areas. An analysis of the current situation and ways to solve the issue

BY RAELENE KAMBLI

I

n 2013, Andrea D’souza a 35-year-old woman living in Mumbai was pregnant with her second child and required a domestic help to look after the household chores.

She approached a well-known agency located in her vicinity and hired Malati (a 20-year-old girl from a tribal village in Pakur district of Jharkhand), who had just come to Mumbai in search of a job.

In a matter of few days, Malati adjusted to city life and Andrea's family. She managed the household job efficiently; however, often complained of an

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acute stomach ache and frequent indigestion. Initially, Andrea sought help from her family doctor. But when Malati’s condition worsened, she got her admitted at Holy Family Hospital, Mumbai, where a slew of medical examinations brought to light that Malati was suffering from stage 1 stomach cancer.

Thereafter, Malati underwent a surgery and currently leads a normal life. She still continues to work with Andrea and does not wish to go back home.

When Malati narrated her story to Express Healthcare, she pointed out that her village has a

primary health centre where she often visited with her mother, but most of the time the centre remained nonfunctional due to lack of doctors and other medical staff. It takes almost one to two hours to get to the district hospital in Pakur and thereto, the situation remains the same.

She informed that doctors don't stay in the village for more than two months and often at intervals there are no doctors or nurses at all. In fact, one reason why her parents decided to send her to Mumbai was that she could work and save money to treat her stomach ache.

Malati's story is certainly not one-of-its-kind in this country. It is a stark reality of the healthcare services available in the hinterlands of India. An irony of our healthcare system is such, where the country with more than 400 medical schools that produce about 50,000 MBBS doctors every year, yet there is only one government doctor for every 11,528 people in rural areas as per the National Health Profile 2015 report by IndiaSpend in November 2016.

Similarly, data from across the country, corroborated by an array of reports from several

government agencies, NGOs working in public health, research institutes etc., have indicated that India still struggles with rural doctor shortages.

A report published by The Lancet highlighted that although the number of health facilities has risen in the past decade, workforce shortages are substantial in our country. According to the report, as of March 31, 2015, more than 8 per cent of 25,300 primary health centres in the country were without a doctor, 38 per cent were without a laboratory technician, and 22 per cent had no pharmacist. Nearly

( More than

400 50,000 medical schools produce about

MBBS doctors every year, yet there is only

ONE 11,528

government doctor for every

people in the rural areas as per the

National Health Profile 2015

Picture used for representational purpose

50 per cent of posts for female health assistants and 61 per cent for male health assistants remain vacant. In community health centres, the shortfall is huge— surgeons (83 per cent), obstetricians and gynaecologists (76 per cent), physicians (83 per cent), and paediatricians (82 per cent).

Again, the density of doctors and other healthcare workforce working in rural areas differs for state to state which was also reported by WHO is a research paper published in June 2016.

Researchers, Sudhir Anand, University of Oxford and Harvard University and Victoria

Fan, University of Hawaii at Manoa and Harvard TH Chan School of Public Health in this research paper pointed out that among the lowest 30 districts ranked by density of allopathic doctors, half are in the northeastern states and the remainder are in central states. The lowest 30 districts ranked by density of allopathic doctors with a medical qualification are found mainly in the states of Uttar Pradesh, Bihar and Madhya Pradesh.

More so, this deficit adds to the workload in district hospitals, in turn hampering the qual-

ity of care as well as contributing to increased mortality among the rural population due to lack of healthcare services.

Experts attribute this shortage to the unwillingness of medical students and specialised doctors to work in rural areas as they have better opportunities overseas. India-trained doctors account for nearly five per cent of American physicians and 11 per cent of British physicians, according to a 2005 study in the New England Journal of Medicine.

Additionally, Organisation for Economic Co-operation and Development (OECD) figures reveal that nearly 86,000 doctors from India were working in the OECD’s 35 member countries. In second place were Chinese doctors, who numbered 26,000. According to Medical Council of India between April 2013 to March 2016, 4,701 graduates from Indian medical schools moved abroad to study or work.

So what are the reasons behind this rural reluctance?

Is it lack of healthcare infrastructure, poor working conditions for doctors in rural areas, a medical education system that lacks focus on public health, lack of government investment in public health service or is it lack of a political will to address India's most pressing public health issue?

F O C U S : P U B L I C H E A LT H

Experts give a clear picture...

Harrowing chokehold Dr Keshav Desiraju, Former Union Health Secretary, Government of India, explains, “Firstly, conditions in rural areas, especially where primary healthcare centres (PHCs) are located, are not easy. Secondly, most medical colleges are in urban areas and young doctors, even if they are from a rural background have lived in the cities for a long time and are reluctant to go back.

This is especially true among women doctors who need to also balance their family lives especially when their husbands are based elsewhere. In India this is still the way it works. Thirdly, school facilities are generally very poor in rural areas. Most doctors would, legitimately, seek schools for their children that are at least as good as the ones they went to. Fourthly, government service is no longer an attraction. There is much more money in private practice and as long as conditions in government facilities continue to be poor, private clinics will flourish. Government cadres are mismanaged, promises are not kept, favouritism and bias in postings are common, all doctors are encouraged to bring political pressure to bear on postings, etc. Moreover, in our highly hospital based system, the value is only on specialists and super specialists. A PHC needs only a doctor with an MBBS but that doctor is not content and is obsessed with getting a PG qualification because that is what the system seems to prize.”

Raising similar concerns, Dr Sunil S Raj, Director Affordable Health Technologies, Public Health Foundation of India (PHFI), says, “The main reason for this shortage is the unwillingness of medical graduates to work in rural areas mainly due to lack of facilities and relatively poorer living conditions. Moreover, medical education in the country is focussed towards providing tertiary level care rather than primary level care which is the primary need of people living in rural areas. A significant focus on specialised care during training reduces the value of primary

medical care in the eyes of a new medical graduate. Further, the government has not provided enough incentives to make rural postings more attractive to them.”

Dr Raj further quotes some insights shared by Vikram Patel, Professor of International Mental Health, London School of Hygiene & Tropical Medicine, UK, “Working in the public health sector is often a demoralising experience for doctors because their professional lives are blighted by lack of professional development opportunities, accountability, and access to even basic medical resources necessary to perform an effective role.”

“Although some steps have been taken by the government such as compulsory rural postings, linking rural postings to postgraduate admissions and monetary incentives, there is a need for more structural changes and innovative solutions,” he adds.

Dr Dileep Mavalankar, Director Indian Institute of Public Health, Gandhinagar, criticises the current health system in India that is clouded by bureaucracy. He is of the opinion that lack of political will is the biggest barrier to solve this issue.

“India is way behind in health indicators not because we have shortage of doctors or hospitals, but because we do not have the needed political will, which translates in not having a welldeveloped national and state level public health service and public health cadre. Can we imagine Indian government without Indian Administrative Service, or Indian Army without army officers trained in military skills? But as a nation, we do not bother to have a public health service, except in Tamil Nadu and partially in Maharashtra and Gujarat. India produces one of the largest number of doctors in the world every year – about 50,000 MBBS graduates, most set up private practice as government has not invested adequately in the public health services and not created enough posts of doctors in rural and remote areas. The current norm is one PHC Medical Officer for 30,000 population. In most de-

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cover ) veloped countries there is one GP or medical officer for 1000 to 2000 people. How can one medical officer look after health of 30,000 people? This norm of density of medical officer was developed by the Planning Commission in 1980s which has not been since revised,” he avers.

Certainly, Dr Mavalankar has a point. One of the major put offs for doctors posted in rural areas is the work load that they are faced with, and to add to their agony, their PHCs and community centres have poor healthcare infrastructure and at times do not even have appropriate medicines to provide to their patients.

While researching on this subject, I came across some blogs posted by doctors who have worked in rural areas and have now moved to urban cities for better prospects. I read around five to six blog posts and they all had one point in common: poor working conditions and inadequate supply of medicine. One of the doctors shared her experience working in rural village of Assam. She said that her PHC pharmacy didn't even have paracetamol. She often was harassed by Naxalite groups and lived in constant fear.

With this current state, attaining universal heath access will remain a farfetched dream for India. Not that the government hasn't taken any steps to bridge this gap; however, the measures taken so far are temporary.

Stop gap measures As per experts, in the past few decades the Ministry of Health and Family Welfare and state governments have attempted various strategies to attract doctors to rural areas, such as compulsory rural postings, linking rural postings to admission into postgraduate courses, and offering monetary incentives. Doctors trained in Indian systems of medicine such as Ayurveda, Siddha, and Unani are also being posted to government health facilities. Yet, the problem continues to exist. As a long-term measure, the health ministry in 2010 also proposed a new BSc course in community health; to train primary healthcare practi-

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tioners which was later reportedly opposed by MCI. Their point was that only MBBS doctors should be permitted to prescribe medicines under Indian law.

The proposed course was the subject of a public interest petition in the Delhi High Court in September, 2015. Later, the court suggested that the IMC Act should be amended or a new law be enacted to facilitate rural healthcare course.

In such circumstances, how can we figure out a solution?

Public health experts recommend some measures that can address this issue.

Strategies to attract doctor to rural areas Dr Prateek Rathi, Fellow Member Post Graduate Program In Public Policy Management, IIM Bangalore stresses upon providing better facilities to doctors and other public health workers as well as focus on developing PPPs for human resources development and training. “The government needs to provide better pay structure at least at par with medical education and in line with Central Government doctors. This includes time bound promotions and career progression as per recommendation by Tikku Commission, which was set up in 1992. Also, a PPP model for human resource can be a solution, wherein government finances healthcare in rural areas or is a purchaser of healthcare (by way of coupons, health insurance schemes) and the service can be provided by the public as well as private healthcare providers. The Rashtriya Swasthya Bima Yojana, a health insurance scheme for BPL population was one such step. The demand generation and financial incentives will help in laying infrastructure in rural areas. This will also help to march towards universal healthcare.” He further urges the government to revisit strategies for short-term medical courses in public health and says that India can take lessons from concepts such as bare foot doctor of China and convergence of the ASHA network which can help to cre-

AS OF MARCH 31, 2015, MORE THAN 8 PER CENT OF 25 300 PRIMARY HEALTH CENTRES IN THE COUNTRY 22 PER CENT HAD NO PHARMACIST

8 PER CENT PRIMARY HEALTH CENTRES IN THE COUNTRY WITHOUT A DOCTOR

ate a comprehensive rural healthcare institutional delivery structure.

Dr Leila Caleb Varkey, Adviser RMNCH, Centre for Catalyzing Change, New Delhi suggests, “The rural professional services need to have a common HR system and more needs to be done in terms of assistance with – children’s education, banking, transportation, holidays and perks – similar to what is done for the armed forces, railways or central PSUs where the HR department does more that just manage leave and salary.

Develop a professional cadre of State Cadre of Health Officer – that can be recruited from any of the health/life and Social sciences at Bachelors degree level and train them in clinical and community skills over a two year period (zoology, dentistry, AYUSH, nursing, pharmacy, life science, etc).”

Adding to this, Dr Desiraju advises, “A public health/family medicine orientation must be brought back into the MBBS curriculum. The government should send its new recruits to exemplary institutions such as the Jan Swasthya Sahyog, Village Ganiyari, district Bilaspur, Chhatisgarh, to understand that it is possible to do high quality medicine and render great service even in a very poor area.”

Dr Raj too has some interesting solutions that can be applied in order to address this issue.

“The top down approach of building a new cadre which can work in rural areas is important, but this will take some time to be implemented. There is a need to focus on a bottom up approach, where existing ground level service providers can be empowered to provide some basic essential services. Under the National Health Mission, there has been a significant strengthening

38 PER CENT WERE WITHOUT A LABORATORY

of health infrastructure and human resources including ASHAs and ANMs. However, the challenge with them has been a relative lack of training to the desired level, which hampers their ability to perform their task as envisaged,” he opines.

Expounding on how technology can help tide over, he cites some examples of PHFI’s technology platform which have been utilised in some rural areas of India in order to ensure quality healthcare services to people despite the shortage of medical staff.

“This is where technological innovations like PHFI’s Swasthya Slate are proving their worth. The project is being implemented in Jammu and Kashmir, where despite the effects of terrorism and internal turmoil, healthcare services have largely remained unaffected. Vulnerable populations like pregnant women and children often find it difficult to travel to a hospital to get antenatal checkups and diagnostic tests done. Thus, frontline ANM workers in the districts of Rajouri, Poonch, Doda, Ramban, Kishtwar and Leh, are now carrying a ‘Hospital on Back’ or PHFI’s Swasthya Slate kit, which is providing rural healthcare and diagnostic facilities at the doorsteps of the population in these areas”, he informs.

Recapitulating on how the slate is used, he says, “A range of 12 tests like blood sugar, blood pressure, urine, pregnancy test, foetal doppler, haemoglobin and HIV test are conducted within a span of less than 45 minutes.

Based on this, beneficiaries are given treatment or referred to the nearest PHC hospitals for treatment. This tablet also sends patient records over the cloud, which means the health directorate can, at the tap of a finger, see the demographic health dis-

ease pattern in a particular area, act on an outbreak or if need be, send reinforcement. This technology is not only providing great benefit to the patients but also helping in many other ways like referring only a selected high-risk clients to the hospitals, who have initially been found to have an abnormal diagnostic test. It also helps to empower the ANMs who are not only learning to use technology but also to conduct diagnostic tests, identify high-risk patients and referring them to higher facilities in time, filling a critical gap in training. Another advantage with this is that it can be modified to provide any population-based health services which may be needed including telemedicine, referral transport information system, pharmaceutical management etc. Some other states are using another tablet-based software ‘Anmol’ which helps to register the beneficiary and upload the history but this does not have the facility to undertake diagnostic tests, which need to be performed in a hospital separately.”

Finally...

Measures mentioned above can help us cement the cracks in small ways or big. But, the government will need to take a bigger responsibility in solving this issue. Lack of a political will is the biggest hindrance in translating these solutions into positive results. Currently, our nation stands at a crossroad where some efforts have helped us to better our health indicators, yet there is a long way to go in order to achieve the dream of a healthy India, where every citizen will have equitable access to quality healthcare. In 2017, India will therefore need to solve every single problem that serves as an obstacle towards achieving our healthcare goals. This means that political leaders and healthcare decision makers will need to work towards ending corruption and focus more on making healthcare a right of every citizen.

Is this an ambitious request to ask of our leaders? raelene.kambli@expressindia.com

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I N T E R V I E W

India’s case with TB is like that of ‘blind men and an elephant’ Dr Zarir Udwadia, Consultant Chest Physician, a speaker at the recently held TEDx Gateway, shares his views on the gaps in India's TB strategy with Viveka Roychowdhury As a chest physician, what is the most frustrating part of treating TB patients in India?

As a physician treating TB patients, there are issues pertaining to a) healthcare sector inefficiency and b) patient behaviour, that are seen as impediments. ◗Public sector or the national programme that caters to the under-served population has a dogmatic but obsolete approach rendering it not just inefficient but amplifier of our TB epidemic. Private healthcare sector is amorphous ,or at the best unorganised, leading to inappropriate management of the patients. Also, poor resource allocation and frequent drug shortages in the market causes treatment disruption of the drug in the regimen further amplifying the resistance profile of the bacteria.

For example at this very point in time two pivotal second line drugs clofazamine and kanamycin are not available in any pharmacy in Mumbai. This is irresponsible in the extreme of the pharma industry who should recognise the importance of regular treatment in this one disease. ◗It is very disturbing when patients don't follow the prescribed regimen. Those with resources at hand, go on a doctor’s shopping spree usually consulting two to three doctors and failing to follow even one. Whereas those lesser fortunate have meagre resources to even afford the prescribed treatment. Such

far fetched. The current measures taken by various high burden countries fall short to break the transmission cycle.

Most of the resources allocated are to treat the prevalent TB population with poor emphasis on prevention.

India’s performance to be specific has been abysmal with more than one quarter of the one million missing TB patients moving freely in India. India's case with TB is like that of ‘blind men and an elephant’ where we are trying to curb the epidemic without knowing its actual scale. India’s plan to study National TB prevalence, which is slated to start in 2017, will pave way for further action.

India’s performance to be specific has been abysmal with more than one quarter of the one million missing TB patients moving freely in India

inconsistent behaviour compounded with low literacy levels lead to poor follow up and treatment drop-outs, which further breeds the disease in the community.

Are you hopeful that global plans like WHO’s End TB Strategy will achieve their goals?

Currently, goals set by WHO End TB strategy appears to be

Are you satisfied with the implementation of India’s TB Mission 2020 plan? Any gaps and suggestions to plug them?

India’s report card on TB management is dismal in all quarters. The cascade of care for TB which evaluates the performance of healthcare delivery system recommends radical measures to ramp up the fight against TB. According to the latest reports 40 per cent of TB symptomatics in India never seek healthcare. Of those who seek healthcare in the public sector only 40 per cent of treated TB patients have a recurrence free survival at one year whereas only 11 per cent of treated MDR-TB patients have recurrence free survival. viveka.r@expressindia.com

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IIPH Gandhinagar has become the first public health university via Gujarat State Act passed in 2015 Prof. Dileep Mavalankar, Director, Indian Institute of Public Health (IIPH) Gandhinagar, shares his institutions’s plans to strengthen India's public health system, the need for an action plan to achieve UHC and recommendations to create a manifesto for a healthy India, in an interview with Lakshmipriya Nair What are the major objectives of IIPH? How is it equipped to achieve them?

The main objective of IIPH is to address the limited capacity in public health in India via education, training, research and advocacy as well as help improve the overall health system in the country.

There are five IIPHs now, one each in Gandhinagar, Delhi, Hyderabad, Bhubaneshwar and Shillong with a total of about 75 faculty members. Each one works with the state government and acts as a regional hub for public health training and research. All IIPHs are supported by PHFI's resources and expertise besides their own faculty and admin staff. IIPH Gandhinagar has become the first public health university via Gujarat State Act passed in 2015. It has a campus of 50 acres with a new building to teach 300 students. IIPHs offer MPH, PG Diploma in Public Health Management, Associate Fellow in Industrial Health, MSc and PhD via various campuses.

IIPHs have many national and international collaborations for research and training. They also carry out many research projects and support central and the state governments in improving public health via health system support projects.

Tell us about the initiatives which will be undertaken by

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IIPH to strengthen the public health system in India?

IIPH Gandhinagar has helped the Gujarat government to improve the design and location of new primary health centres (PHCs) and community health centres (CHCs) using an analysis by geographic information system about the coverage and need for the centres in rural and remote areas. It has helped Ahmedabad city to develop South Asia's first Heat Health Action plan to reduce mortality and morbidity during heat waves, which are increasing due to climate change. IIPHs provide policy and programme inputs as well as guidance to various state governments and the central government. IIPHs have done pilot projects in urban slums and rural areas to demonstrate how public health services can be improved.

IIPHs also train government officers to improve the health system they are in charge of.

Thus, IIPHs have contributed to improvement of the health system in many ways.

How will they help to negate or atleast lessen the current public health challenges caused by years of neglect?

The first and foremost role of IIPHs is training young professionals to take up jobs in the public health system. IIPHs also train government officers on-the-job and this contributes to further improvement of

in public health to the government with an aim to improve the situation on the ground.

IIPHs have also brought in many international experts and funds to help assess and enhance public health programmes.

There is a need for a very high level political engagement leading to national and state level mandate as well as resources and systems to provide UHC public health. They also do advocacy at various levels to strengthen the public health system. IIPHs also suggests new programmes and methods

A common complaint is that Indian healthcare institutions do not encourage research, especially in public health. How can IIPH help to reform this scenario?

All IIPH faculty are encouraged to take up research projects.

We have international collaborations and national linkages which help build our research portfolio. IIPH faculty also apply for international and national research funds and that helps to do locally relevant research in public health. All faculty are evaluated on their research contribution as part of their annual evaluation. On various fora, IIPH and PHFI also advocate the need to increase research funding and efforts as well as evidencebased policy making which, in turn, help in increasing demand for research.

What should be our action plan to achieve Universal Health Coverage (UHC)? How can academic institutes like IIPH play a constructive role in making the action plan successful?

UHC is a long term goal for any

country, including India. PHFI played a very vital role in the high level expert committee constituted by the last Planning Commission and produced a detailed report on UHC. IIPHs and PHFI have been convening meetings, making presentations at various fora and advocating UHC. They are also doing some research projects in a few states to determine the feasibility and need for UHC. What is needed to make UHC successful is a very high level political engagement leading to national and state level mandate as well as resources and systems to provide UHC. PHFI and IIPHs are committed to the goal of UHC. Please share your plans for IIPH Gandhinagar in the near future. What would be the strategies to achieve these objectives?

We are planning to start a Master of Hospital Administration (MHA) course from July 2017 besides continuing with the MPH programme. We will also start PhD in public health. As IIPHG is the first public health university in the state, in future we will start more courses related to public health such as entemology, infectious diseases, medical social work, occupational and industrial health etc. IIPHG has recently received approval from the Department of Science and Technology, Government of India to

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set up a techno-business incubator under the National Initiative for Developing and Harnessing Innovations (NIDHI) scheme. This is will be the first such incubator for technology-driven solutions in the domain of public health. Other IIPHs are also planing to start new short and long courses related to public health. We will also develop our research and health system support portfolio in future. For this, we are looking for national and international funding opportunities, donations and grants. We will also hire faculty and research staff who have the passion and commitment to develop public health in India.

I N T E R V I E W

If we create a manifesto for a healthy India, what should the fundamentals of it?

A manifesto to create a healthy India is very much needed as health and public health has to become topics of political debate and action. It should include: ◗ Increase in public funding for health from the current one per cent to three to four per cent in five years. ◗ Creation of a public health and health management service on the lines of IAS or other central services. ◗ Adoption of UHC as crucial goal over the next 15 years and development of plans and programmes to achieve it. ◗ Improving access to free generic medicines to all citizens of India, irrespective of their paying capacity. ◗ Strengthening of health directorates in each state and district health offices. ◗ Improve health planning and health statistics to ensure accountability in the health system. ◗ Take steps to decrease tobacco and alcohol use as well as reduce accidents and injuries. ◗ Develop services for mental health and chronic diseases.

What are the top priorities which should be taken into account in public healthcare. ◗ Development of appropriate human resources for serving the majority of population, most of whom face different degrees of economic and social deprivations. ◗ Increasing the level of investment from state and central government to enhance public health. ◗ Inter-sectoral convergence and action to addresses major social determinants of health, especially related to safe water, sanitation, air pollution and nutrition.

lakshmipriya.nair@expressindia.com

‘TISS’ programmes are designed to engage students in real life situation Prof T Sundararaman, Dean, School of Health System Studies, TISS, elaborates more about TISS contribution on public healthcare space, in an interaction with Sanjiv Das

Internships should focus on public health. Interns should be posted where they are engaged in more fieldwork and problem solving

What are the maladies affecting the Indian public health system? ◗ Low investment in development of public health facilities. ◗ Lack of proper regulations for the private sector.

UHC is one of our major goals. What are the steps needed to ramp up and evolve the role of the public health sector in attaining this objective?

Increase investment, build effective district-level models and scale up systematically over the next five to ten years.

Improved accountability of public health facilities and functionality is also important. Building partnerships with civil society organisations and public service minded private sector organisations are also necessary.

As the Dean of TISS, what recommendations would you like to put forth to make public health more accessible?

Our internships should focus on public health. The interns should be posted where they are engaged in more fieldwork and problem solving.

We should encourage practitioners to serve as visiting faculty or guest lecturers. We

should also encourage and provide for existing permanent faculty to go on deputations to work on implementation of public health programmes for a period of one to three years.

Course content should deal with more real life case studies which demonstrate the problem the system faces and how counter-intuitive, innovative solutions could help in problem solving.

Course content should deal with more real life case studies which demonstrate the problem the system faces and how counterintuitive, innovative solutions could help in problem solving

What has been TISS' contribution to build an effective public health system which promotes research and teaching to improve professional practice to prevent disease and promote health?

TISS already has a very robust programme for internship and field practicum. They are designed to engage students in real life situations where they are mentored both by senior practitioners as well as faculty from the school.

The school faculty also take up the implementation of a number of research projects which help to build their capacity in this area.

TISS faculty also serve on a number of policy making committees where their knowledge can be of use to guide policy. sanjiv.das@expressindia.com

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cover ) AUTHORS

INSIGHT

Development of health index of Indian states Researchers from Indian Institute of Management, Ahmedabad developed an index of Indian states based on their relative health indicator performances of their populace

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nation’s economic performance depends a lot on the heath of its populace. Not only does it improve efficiency but it is also an indicator of an all-round performance of the nation. Policy makers cannot ignore its importance in economic development as well as happiness and human development of the nation. Performance of health systems has been a major concern of policy makers in India for many years. Health has been made one of the most important dimensions of the millennium development goals set for a country. Four of the 18 development goals adopted by the General assembly of the United Nations(UN) in September 2000 relate to health and well-being of the population of the country. The focus of the Indian government is to develop a holistic care system that is universally accessible, affordable and effective’ is an indication of a national focus aligned to the UN goals.

This article is based on a study that explores the possibility of looking at the Indian states based on their relative performance on health indicators of their populace. The study involves collecting and purifying the data from reliable sources and developing an index, captures the variances across states and also gives direction for developing policies, strategies and action plans for each of the states. For a di-

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ARVIND SAHAY Professor of Marketing and International Business, Head-India Gold Policy Center, Dean (Alumni &External Relationships), IIM, Ahmedabad

PIYUSH SINHA Professor of Retailing and Marketing, IIM, Ahmedabad

TABLE - 1: VARIABLES USED IN THE STUDY Dimension Factors

Outcome

Items

Source

Year

Infant Mortality Rate

Census of India, SRS Bulletin

2009 - 13

Under 5 Mortality Rate

Census of India, SRS Bulletin

2009 - 13

Neo Natal Mortality Rate

Census of India, SRS Bulletin

2009 - 13

Maternity Mortality Rate

Census of India, SRS Bulletin

2009 - 13

Deaths due to HIV

Indiastat (2016a), Central Bureau of 2008 - 12 Health Intelligence, MoHFW, GoI

the optimum level.

Deaths due to TB

Central Bureau of Health Intelligence, MoHFW, GoI

2008 - 12

The approach

Deaths due to Pneumonia

Central Bureau of Health Intelligence, MoHFW, GoI

2008 - 12

Deaths due to Acute Diarrohrial Diseases

Central Bureau of Health Intelligence, MoHFW, GoI

2008 - 12

No. of PHCs

Indiastat (2016b), MoHFW, GoI

2008 - 12

No. of CHCs

Indiastat (2016c), MoHFW, GoI

2008 - 12

No. of SCs

Indiastat (2016d), MoHFW, GoI

2008 - 12

No. of Hospitals (Private & Public)

Family Health Plans (New India Assurance Co. Ltd., National Insurance Co. Ltd., United India Insurance Co Ltd.)

2012

No. of Registered Medical Practitioners

Indiastat (2016e ), Registrar General, 2008 - 12 Govt. of India & Bureau of Applied Economics & Statistics and Directorate of Health Services, Government of India

Mortality

Infrastructure

Input

Manpower

Utilisation

No. of Nurses in PHC’s and CHC’s Indiastat (2016f), Indian Nursing Council

2008 - 12

No. of Aganwadi Workers

Indiastat (2016g), NHRM

2008 - 12

No .of ASHA workers

IndiaStat(2016h), NHRM

2008 - 12

No. of Children Immunized

Indiastat(2016i), 2008 - 12 NationalImmunization Program, GoI Source: IIMA Study

verse country like India, it is important that the study provides a path for each of the state due to wide variation in terms of economic, geo-

graphic, social, cultural and political canvas.

The article discusses a unique outcome: Input matrix to develop insights on the rela-

tive status of states. It also indicates as to which states are performing better with lesser resources as well as those not able to utilise the resources to

DR SURABHI KOUL RA, Marketing, IIM, Ahmedbad

The study started with collecting the list of variables used by WHO to assess the health performance. These included Infant Mortality Rate (IMR), Under 5 Mortality Rate (U5MR), Neo Natal Mortality Rate (NNMR), Maternal Mortality Rate (MMR), deaths due to HIV, deaths due to TB and deaths due to malaria. It was also found that WHO also uses a list of 47 diseases under the classification of communicable and non-communicable. Taking cues from some other studies which used sanitation and vaccination as parameters, a list of diseases was prepared.

These indicators formed the outcome variables for health performance that were used to understand relative position of states.

Health is a state subject and also the states differed in their expanse and population characteristic. Each of the states also develops separate plans for themselves based on their priorities and any national agenda in line with the millennium goals. And each

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TABLE 2: STATE RANKING FOR OUTCOME

TABLE 3: STATE RANKING FOR INPUT

State Kerala Maharashtra Tamil Nadu Jammu & Kashmir Delhi Andhra Pradesh Himachal Pradesh West Bengal Gujarat Punjab Karnataka Haryana Bihar Jharkhand Chhattisgarh Orissa Madhya Pradesh Rajasthan Uttaranchal Uttar Pradesh Assam

State

Weighted Score

Rank

Uttar Pradesh

2978421

1

Bihar

1425441

2

Maharashtra

1326338

3

Weighted Score 114 162 168 204 212 239 243 247 268 275 276 295 422 423 457 473 480 485 526 558 595

Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Later, Factor analysis was conducted on these two factors to attain the weights (Factor Loadings).These weights were used to arrive at a weighted score for the states for each of the five years. Based on the weighted score for the year 2013, the final scores weights were arranged in ascending order to arrive he relative ranks of all the states as given in Table – 2.

Source: IIMA Study

state tends to use a very different level of inputs to achieve its outputs. In a resource constrained nation, and consistent with sustainable development goals, any health index needs to also capture the role of inputs along with that of outputs. A list of input variables was, therefore, also prepared which consisted of infrastructure, manpower and economic factors. Based on the discussion within the team members, another dimension of utilisation of the service was added.

The study collected data from several sources like library, reports and databases as available from websites of government departments, development organisations and research and consulting companies. The effort was to collect data on as many items as possible for each state for the last five years (2008-2013).

It was a critical step for choosing the items for further analysis.

Three factors were considered in choosing the sources and extent of data: (a) the data is available for each state, (b) it

is available for five years and (c) the source is credible and acceptable to the stakeholders.

Under these three conditions, some of the items were dropped. Diseases which had low incidences (less than 1000 per lakh population) were removed. The final list of variables used in the study is given in Table – 1. A similar method was used to select the states. In the final analysis, 21 states were chosen.

Data was collected for five years. A one year lag was considered for the outcome data.

Thus the data for input items was collected for the year 2008 – 12, whereas, data for outcome items were collected for 2009 – 13.

Analysis Two methods were applied to arrive at the scores for each of the states. In the first case, a regression analysis was used.

When regressed on input variables, the results did not indicate any clear direction. The correlation matrix indicated that only a few of the input variables were correlated to

TABLE – 4. TABLE 4: STATE RANKING FOR OUTCOME: INPUT MEASURES State

Rank

Maharashtra

1

Andhra Pradesh

1174523

4

West Bengal

1027700

5

Tamil Nadu

2

Madhya Pradesh

987946

6

Andhra Pradesh

3

Rajasthan

917712

7

West Bengal

4

Karnataka

855169

8

Gujarat

814349

9

Kerala

5

Tamil Nadu

761604

10

Jammu & Kashmir

6

Orissa

567294

11

Delhi

7

Assam

446923

12

Himachal Pradesh

8

Jharkhand

444524

13

Gujarat

9

Chhattisgarh

394401

14

Kerala

390072

15

Karnataka

10

Haryana

335357

16

Punjab

11

Punjab

326343

17

Haryana

12

Jammu & Kashmir

178169

18

Bihar

13

Delhi

156376

19

Jharkhand

14

Uttaranchal

121717

20

Himachal Pradesh

101472

21

Madhya Pradesh

15

Orissa

16

Rajasthan

17

Uttar Pradesh

18

Chhattisgarh

19

Uttaranchal

20

Assam

21

Similar to the above analysis, the normalised values of the items under parameters Infrastructure, Manpower and Utilisation were summated to attain a score of the input dimension. Further, Factor analysis was conducted on these three factors to attain the weights (Factor Loadings).

These weights were used to arrive at a weighted scores and based on the weighted score for the year 2013, the final scores weights were arranged in ascending order to arrive he relative ranks of all the states as given in Table - 3.

Source: IIMA Study

the outcome. There were also incidences of multi-collinearity.

We think that economic variables may also create a nested situation since the inputs created by the state would be a function of the budget allocated for health. Hence, this method was not pursued further.

In the second method weighted sum approach was used using factor analysis. Factor analysis helps to reduce the number of observed variables into smaller number of variables which account for the most of the variance in the observed variables. Analysis was carried out with all variables put together. The findings clearly hinted at the problem as was faced during the regression method. That is the relative position of states on notional index that combined both input and output indicators which was problematic from a diagnostic and a policy

perspective.

So, finally it was decided to carry out factor analysis separately for input and outcome variables.

The analysis was carried out in two stages. In the first stage, weights of each of the items were determined based on the factor loading of each item. Using the normalised scores and these weights, a summated weighted score was arrived for each of the input factors. A second level factor analysis was carried out using the weighted scores for each factor for that dimensions. The factor loading so arrived was used to arrive at a summated score for the input dimension.

Findings Outcome The normalised values and weights arrived from factor analysis of items of Child and Maternity Mortality rate (IMR,

The five year performance based on the outcome: input matrix and the movement of states in terms of their performance on health relative to one another can be seen in Figure – 2.

Source: IIMA Study

MMR, NMR, U5MR) a weighted summated score for the first parameter was arrived. Similarly for the values and the weights of the items of deaths due to other diseases (death due to HIV, TB, Pneumonia, and Acute Diahorrial Disease) a summated to score was obtained for the second parameter of outcome.

State ranking for outcome Later, factor analysis was conducted on these two factors to attain the weights (factor loadings). These weights were used to arrive at a weighted score for the states for each of the five years. Based on the

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cover ) weighted score for the year 2013, the final scores weights were arranged in ascending order to arrive at the relative ranks of all the states as given in Table – 2.

Input Similar to the above analysis, the normalised values of the items under parameters infrastructure, manpower and utilisation were summated to attain a score of the input dimension. Further, factor analysis was conducted on

these three factors to attain the weights (factor loadings).

These weights were used to arrive at a weighted scores and based on the weighted score for the year 2013, the final scores weights were arranged in ascending order to arrive at relative ranks of all the states as given in Table - 3.

Outcome: Input map The study found that that there is a low degree of association between the input and outcome. Hence, the two ranks

could not be compared or combined. It was decided to consider them separately. Using them as the two axes, an outcome – Input matrix was created (Figure – 1). Median of the dimensions was used to create the high and low quadrants.

Since all ranking systems across the world use outcome measure for arriving at the scores, it was given higher importance as compared to the input measures.

The input: outcome matrix divided the states in four quad-

rants. It indicated that while resources are important, implementation of the initiatives to achieve the desired outcome is equally important. It also brings out that states and their policies need to be developed as suitable for the each of the states. It is expected that such segmentation would help in developing more focussed policies as well as fine tune health policies for states and also at a level of cluster of states. The states were divided into four classes:

High performers Maharashtra, Tamil Nadu and Kerala are high performing states. These states are performing well with respect to the inputs made available or created in the state. Kerala scores highest in outcome but falls to a lower rank due to resources.

FIGURE – 1: OUTCOME: INPUT MATRIX (OUTCOME: LOWER THE BETTER; INPUT: HIGHER THE BETTER)

Middling performers Jammu and Kashmir, Delhi, Andhra Pradesh, West Bengal, Himachal Pradesh, Gujarat, Punjab, Haryana and Karnataka and lie in the low input and high outcome quadrant.

Their performance falls in the middle range.

Strugglers Source: IIMA Study

Jharkhand, Bihar, Chhattis-

FIGURE 2: MOVEMENT OF STATES OVER 2009 – 13

Source: IIMA Study

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garh, Orissa, Madhya Pradesh, Rajasthan, Uttar Pradesh, Uttaranchal and Assam are making efforts to come on the higher outcome performance.

Of these states, Uttaranchal, Assam and Orissa are the poorest in terms of the resources available to them as well as lag behind in terms of come.The states were then ranked accordingly. The final ranking of the states based on the quadrant mapping can be seen in The five year performance based on the outcome: input matrix and the movement of states in terms of their performance on health relative to one another can be seen in Figure – 2.

The way forward The Outcome: Input matrix shows us the relative status of states and also which states are performing well and which are not. There are some states which are not performing well because the resources available to them is limited. Very few states are performing well.

This study can be used by the government to analyse the current position of the states and identify focussed policies to be worked upon. It provides a snapshot of where policy attention and implementation details need to be looked at with more focus.

The current study has an enormous scope for further research in analysing the performance of the states. Since the data was not available for all the states; more updated and adequate data can be incorporated in further research.

Some new variables can be included in the outcome and input parameters depending upon the availability of the data from the secondary as well as primary sources. This report is a first step. With the existing data, we are able to make limited comments on the drivers of changes – which can provide pointers on where action is required. As we take up the next step, we will be able to bring our directions at more granular levels. The goal would be to have an annual index that is able to show how states are moving relative to one another.

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INSIGHT

Strategic purchasing for UHC: Engaging the private sector

DR RAJMOHAN PANDA Senior Public Health Specialist, Public Health Foundation of India

Dr Rajmohan Panda, Senior Public Health Specialist, Public Health Foundation of India, highlights that strategic purchasing through PPPs will minimise out-of-pocket expenditure at the point-of-care for patients while delivering good quality health services

D

eficiencies in the public sector health system in providing good quality and timely health services to the population are well documented. This has forced poor and vulnerable sections of the population to purchase health services from the private sector, perceiving it to be better and more responsive to their needs. The private sector today provide a large volume (around 70 per cent of OPD and IPD) of health services in the country but with little or no appropriate regulation.

Efforts by state health departments to reign in these sector with policy reforms has met with limited success.

The private sector is not only India most unregulated sector but also its most potent and untapped. To address the inefficiency and inequity in the health system, many state governments have undertaken health sector reforms. One of these reforms has been to collaborate with the private sector through public private partnership (PPP) to reach the poor and underserved sections of the population and to prevent large out of pocket expenditure which pushes significant numbers of people into poverty. Some of these PPP models have been through insurance mechanisms, referral transport, diagnostics, contracting out primary health services, and even high end tertiary care serv-

Consumer awareness and participation are critical elements of any partnerships especially so in PPPs where public resources are being used by the private sector to deliver services

ices like kidney dialysis centres.

However such partnerships have their share of issues and challenges. These issues are usually around the motives of the private sector, scope and objectives of partnership, policy and legal frameworks, benefits of such partnerships. These issues are mostly due to lack of technical and managerial capacity of governments and private agencies to manage and monitor such partnerships, appropriate incentives for the private sector, and explicit benefits to the poor through these arrangements.

In its simplest form, a public private partnership (PPP) is an arrangement between the public and private sectors with clear agreement on shared objectives for the delivery of public infrastructure and/ or public services by the private sector that would otherwise have been

provided through traditional public sector procurement.

The PPP approach has the potential to offer value for money and timely delivery of infrastructure when applied to projects of the right scale, risk and operational profile.

One key aspect of the PPP approach is that risk is transferred to the party that can manage it best but without a measurable outcome of the risk, the PPP can just be another instrument of ineffectiveness.

Evidence on the efficiency of such partnerships in India has been scanty. Impact and outcomes of such partnerships are difficult to measure as outcomes of healthcare delivery cannot be easily attributed to just the provision of hospital and clinical care.

In this regard it is important to examine the framework of these partnerships and the level of transparency of decision making in the execution

of these models. These PPP healthcare organisations have a leading role in health promotion in the society and their coordinated action with a set of political, social, and cultural factors can improve people’s health at minimal cost to the consumer. Since this sector is the recipient of a large part of the healthcare expenditure in the country, full attention to its performance and costs is of particular importance. Trying to implement the principles of the private sector to solve major problems in the public sector can have intended as well as unintended consequences. In fact, PPP can be a powerful political tool for improving and promoting the survival and quality of services in public hospitals too. There is a growing belief that partnership between public and private sectors can lead to increased efficiency, equality, accountability, quality and accessibility in the health system. In the health sector, the PPPs can make use of mutually competitive advantages of each other in the fields of technology, knowledge, resources, skills, and management capabilities.

Several factors have been identified for the implementation and success of executing PPP projects. Consumer awareness and participation are critical elements of any partnerships especially so in PPPs where public resources are being used by the private

sector to deliver services.

Also without effective governance and stewardship from the public partner these partnerships will not be able to deliver on that promise of good quality health services in the country. Strategic purchasing by state health departments will minimise outof-pocket expenditure at the point-of-care for patients while delivering good quality health services. At scale such models can help in achieving universal health coverage (UHC) and help in covering the last mile.

This will also be in tune with the government’s move to a cashless economy as all transactions by such partnerships will be in digital mode. Effective governance and institutionalising such models with regular monitoring and evaluation will help to dispel notions that the private sector in PPP is only interested in profiteering. Harnessing private resources for public goods is a challenging task, however we have to move beyond the idea that the public and private sectors are always at odds. It is the responsibility of the government to lay the groundwork for private equity to productively invest in things like health. We must remember that the best partnerships aren’t dependent on only a mere common goal but on a shared path of equality, desire, and a great deal of commitment.

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cover ) INSIGHT

Emphasis on nutrition: A must for quality maternal care Karin Lapping, Director,Alive & Thrive Program and Dr Shalini Singh Deputy Director General, Division of Reproductive Biology and Maternal Health, ICMR, advocate multi-sectoral alignment on maternal nutrition specific initiatives as a measure for India to achieve its maternal health goals DESPITE SIGNIFICANT global political attention on maternal health and the increased adoption of maternity services, the MDGs for maternal health have not been achieved, and many women continue to remain at risk.

The gaps in progress in maternal care are particularly significant where maternal nutrition is concerned, largely due to undernutrition and its associated causes such as early marriage and child birth, gender norms and misinformed health practices associated with social beliefs.

The loss of health and productivity is multiplied manifold as the impact of poor nutrition is inter-generational, affecting future cohorts of men and women in a vicious cycle.

Given the extensive and growing reach of Maternal Newborn Child Health (MNCH) programmes, it makes sense to place and prioritise proven maternal nutrition interventions at the core of public maternal care services.

For instance, calcium and iron folic acid (IFA) supplementation are two key nutrition interventions that help address high blood pressure disorders and post-partum hemorrhage – the two leading causes of maternal deaths.

International evidence shows that prenatal and antenatal iron and folic acid supplementation not only reduces the risk of postpartum haemorrhage but also preterm labour and infection post-delivery.

Indian studies have also indi-

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cated that Calcium supplementation reduces the occurrence of high blood pressure related conditions like preeclampsia and preterm delivery in first time pregnant women with low daily dietary calcium intake.

Another key nutrition intervention is improving sub-optimal diets, which is an underlying cause of poor pregnancy outcomes. It is critical for communities to be sensitised about the importance of life-saving early breastfeeding practices and MNCH programmes must include this in the counselling given to pregnant women.

Optimal breastfeeding, in addition to being the leading intervention for child survival, also has additional benefits for women in helping prevent maternal cancer deaths and short birth intervals.

Global maternal nutrition guidelines have been issued

by WHO and many countries including India have probreastfeeding and maternal nutrition policies in place due to the large and growing evidence of its significant health impacts. Over the past few years, India has also developed programme guidelines for addressing some of the emerging maternal nutrition concerns such as a revised strategy for IFA supplementation, calcium supplementation and deworming during pregnancy.

However, coverage of these nutrition interventions, which are critical in bridging the

access gap and addressing the slow progress in maternal health, remains low. Although improvement in antenatal care has been seen in states like Bihar, where Tetanus Toxoid during pregnancy is almost 90 per cent, IFA coverage however remains less than 15 per cent. High coverage of interventions like Tetanus Toxoid suggests it is possible to reach these women with adequate nutrition interventions as well.

The gaps in connect between health workers and pregnant women is a big missed opportunity for delivering nutrition. The same MNCH system, which is effective in delivering critical health-focused interventions, can also deliver a small package of proven nutrition interventions for maximising health outcomes for mothers and newborns. Nutrition can be delivered even where the availability or use of formal health services is weak, as no highly qualified specialists or diagnostics or cold chain and drugs are needed and counselling can be delivered at home or in the community.

The National Family Health Survey 4 (2014) shows that timely initiation of breastfeeding was only 34.5 per cent in Madhya Pradesh, 34.9 per cent in Bihar and 40 per cent in Andhra Pradesh, whereas the institutional delivery rates were 81 per cent, 63.8 per cent and 96.5 per cent respectively. The challenge clearly lies in setting nu-

trition priorities within MNCH services with the assistance of nutrition scientists and practitioners to plan for adequate nutrition coverage and quality. Additionally, monitoring indicators need to prioritise coverage for select critical nutrition interventions like initiation of early and exclusive breastfeeding.

For India, a focus on maternal nutrition aligns well with shifts in patterns of overall maternal health outcomes – from maternal mortality alone to mortality, morbidity and disability, and the rise in nutrition related conditions such as diabetes, heart disease, hypertension and other chronic illnesses linked to maternal health outcomes. The delivery of even one set of nutrition interventions can positively affect a diversity of poor outcomes. With almost 30 million women becoming pregnant in India annually and the delivery of 27 million babies each year, placing greater emphasis on nutrition interventions during pregnancy care in MNCH programmes deserves greater attention.

Multi-sectoral alignment on maternal nutrition-specific initiatives is important for India to achieve its maternal health goals. For instance, ensuring coordinated action among the public, decision makers and programme managers across relevant ministries like the Ministry of Health & Family Welfare and Ministries of Women & Child

Development and Drinking Water & Sanitation in addressing maternal undernutrition will go a long way in achieving India’s overall health and nutrition outcomes, including its SDG goals in maternal health.

Government and community interventions across India and South East Asia have already yielded positive results in this regard. Vietnam, for example, has shown an improvement in exclusive breastfeeding levels from 19 per cent to 58 per cent through a primary healthcare-based Ministry of Health (MoH) programme.

Bangladesh recently demonstrated a rapid increase in the consumption of iron folic acid and calcium tablets among pregnant women, and the adoption of a more diversified diet through intensified monitoring and working with family and community influentials. In India, recent formative research in Bihar and UP also shows that husbands and mothers-in-law can be engaged by frontline workers to ensure the procurement and consumption of nutrient supplements and locally available nutritious foods for pregnant women.

We have already seen that our health system can deliver services by improving antenatal care (ANC), institutional delivery and routine immunisation coverage. There is no reason why maternal nutrition interventions should continue to be left behind.

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INSIGHT

Strengthening public health delivery in North East Dr Priscilla C Ngaihte, Public Health Specialist, Public Health Foundation of India and SumMinLun Vualnam, Independent Researcher, Developmental Studies,Tata Institute of Social Sciences, give an idea on public health scenario in the region which has lacked not only in world class infrastructures, but also basic facilities

DR PRISCILLA C NGAIHTE Public Health Specialist, Public Health Foundation of India

SUMMINLUN VUALNAM Independent Researcher, Developmental Studies, Tata Institute of Social Sciences

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ight to health is fundamental to human being, states the World Health Organisation.

It further states that the right to health consists of two components viz. freedom and entitlements. Freedom as in the right to control one’s health and body and to be free for interference and entitlement includes the right to a system of health protection that gives everyone an equal opportunity to enjoy the highest attainable level of health. The constitution of India under Article 21 provides the right to life and personal liberty. The Supreme Court on its various court rulings has interpreted Article 21 as not just the act of physical breathing or animalistic existence but the right to a dignified life. This interpretation includes the right to proper healthcare and thus makes the government legally responsible for the health care of its citizen.

The North-East region of India has always been one of the most under-developed regions of India. Despite the availability of natural resources, the region has lacked the infrastructure needed to fully utilise these resources. Apart from the hilly terrain, the insurgency infested nature of the region has kept private investors away from the region. The local businessmen have also

chosen to stay out of large business venture due to the uncertainty of the region and the risk involved in such uncertain conditions. It has become the sole task of the government to cater to the development needs of the region until it is able to solve the political problems that has clouded the region since independence. A striking observation to all economist and other academicians, however, is that despite its

low GDP and its economy mostly dependent on agriculture and its allied activities, the area has performed comparatively well in its Human Development Index (HDI).

Most academicians have attributed this to the tribal cultural and traditions as the region is predominantly occupied by tribals. Nonetheless, this does not mean that the region has achieved the desired standard of human development. It still has a

long way to go, especially in public health which has lacked not only in world class infrastructures, but also basic facilities of healthcare.

The recently concluded ‘North-East Health Care Summit’ organised by Public Health Foundation of India (PHFI) and Federation of Indian Chambers of Commerce and Industry (FICCI) at Guwahati highlighted the status of healthcare sector in North East region. The sum-

mit was attended by leading healthcare professionals, government health departments and other stakeholders as well as academicians and over 200 doctors. The main highlight of the summit is the lack of infrastructures and the shorthanded nature of the available infrastructure in the region. There are shortages of reputed medical, paramedic and nursing institutions as well as equipment to treat advanced

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cover ) diseases such as cancer. The requirement of health facilities exceeds the sanctioned post. In Sikkim and Assam, the Community Health Centres available fell 50 per cent and 37 per cent short of the required needs respectively.

Also, Tripura fell 17 per cent short of the required needs of primary health centres.

Apart from the lack of world class infrastructure, the summit also highlighted the shortage of skilled manpower such as supervisors, doctors, specialist, female health workers, HRH professionals etc. in the region. A 100 per cent shortage in Lady Health Visitor (LHV) and health assistant in Tripura and Assam respectively is notable. Other basic reinforcing facilities such as electricity, proper connectivity, clean drinking water which are required for healthcare services are also lagging behind.

Another added problem to infrastructure and manpower shortage is the problem of access to the sparsely available healthcare facilities. The geographical terrain is one such hindrance to access. The north eastern states being mostly hilly area and majority of the population living in the rural areas access to healthcare facilities most of which are made available in the cities, thus a majority of the population are cut off from accessing quality healthcare. For example, as highlighted in the summit report, the highest cancer mortality in India is seen in the North Eastern states while 40 per cent of the cancer centres are in the metros, 85 per cent are in the private sector (inherently out of the reach of the poor patients) and 50-60 per cent trained oncologist reside in the metros. To add to this problem of concentration of medical facilities at the metros and cities, the connectivity to rural areas is in a very bad shape. Most of the rural corners are cut off from the towns and cities during monsoon due to landslide and other natural calamities thus further

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worsening the situation. It is during the monsoon season that various communicable diseases are more prevalent.

Thus, the life and death of the rural populace are sometimes kept at the mercy of the climatic condition. The summit also highlighted lack of funding from the government leading to financial crunch as one of the major setbacks to healthcare in the region.

To tackle these institu-

private players in the arena.

The summit has rightly identified the bottlenecks in the region but the policy suggested to tackle the problem has been a concern. The entry of private players will only create a market condition while the only aim of these capitalists is profit making. As David Harvey said, the first objective of capitalism is profit making and not serving the needs of the public. Capitalist

The government must ensure that private healthcare institutions and facilities are made available to the masses.

The government will need an iron arm in regulating such institutions and not fall to corporate pressures.

An alternative to this problem and which I think that India as a welfare state should be doing is to increase its expenditure in the healthcare sector. Health as men-

Strengthening of healthcare in India and in the North Eastern region is dependent on how far the government is ready to extend its arms for the welfare of the people tional, infrastructural, access and human resource shortage problems, the summit proposed various policies for strengthening public health and healthcare facilities in the region. The summit has its eye on modernising the health infrastructure in the region and making available world class infrastructure at its disposal. It has discussed the need for formulating policies that will suit to the needs and resources available in the region, to overcome bureaucratic red tapeism in getting clearances in the healthcare sector. The main suggestion to the problems while not forgetting the need for setting up more PHCs, training more health personnel and penetrating the rural and border areas was the introduction of PPP model in the healthcare sector. The need to create a more viable environment for the entry of private players in healthcare sector in the region and inviting more investment from them for setting up world class hospitals, institutions and other healthcare facilities were some of the other suggestions.

It is no doubt that the aim of achieving a world class medical infrastructure and facilities can be done in no time with the involvement of

only create needs and they thrive from making profits from the needs of the people and not providing the need of the people. It can be argued that most of the developed countries have handed over the health sector to the private companies and in the hands of market while various players compete. One thing to be noted is that the foundation has been set in those countries for such competition such that they are able to avail healthcare facilities as they have enough income to do so. The condition is not the same in India and especially in the North East where more than 30 per cent of its population is under poverty and more than 75 per cent are employed in the unorganised sector. Leaving such an important sector in the hands of the market will only create more problems to the question of access. While the infrastructure and facilities might be improving, it will only be accessible to a few high income groups excluding the poor and low income groups from the system. Rural and border areas will be left out by these players due to the question of profitability. It thus defeats its purpose of making healthcare more easily accessible.

tioned earlier is a basic human right and it should be the obliged duty of the government that an individual is entitled to this right. In providing basic healthcare to its citizen, the government not only fulfills its duty but also build up its economy in the long run by providing itself with a healthy workforce.

This would be a great advantage to the country in trying to achieve its millennium development goals and will push the country in its strive for a global economic power. There might be argument that India have spent enough of its resources on the healthcare sector and that it is unable to spend more of its resources.

It is however seen that India’s expenditure on healthcare as a proportion to GDP is one of the lowest amongst the middle income countries. Also, there are countries which have a lower GDP than India but performed much better than India in terms of providing healthcare.

With minimal investment by the government in such a crucial sector, healthcare facilities and infrastructure will be sub-standard. To boost this sector, more government attention in terms of increased flow of monetary assistance, is required. And the

first and prior focus should be in terms of penetrating healthcare facilities in the rural areas. This can be done by setting up more healthcare centres in rural areas and making sure that healthcare professionals are available in these areas. A development from the grass root is necessary so that the objective of greater access can be achieved. Modern and advanced equipment which are out of the reach of majority of the population will not help in improving the health condition of the region. To actually strengthen public health and healthcare facilities in the region, it needs to be ensured that the facilities are made available to the intended beneficiaries. Another step to make healthcare accessible to the people is to improve the available hospitals and healthcare centres. When hospitals face shortage of healthcare professionals such doctors, specialists, nurses and other basic equipment, patients have no choice but to approach other private hospitals where in many cases, the poor are unable to afford such expenditure. This can be addressed though setting up of more government hospitals, medical institution and medical research centres to address the specific medical needs of the region.

Public hospitals should be equipped with the latest equipment, have adequate healthcare professionals and managers etc. A sector as crucial as this cannot be left in the hands of the private sector and it should be the duty of the government to ensure that its citizens are entitled to this basic right of health. A private sector which aims of squeezing out maximum profit from the people thought its primitive system of exploitation cannot be trusted with the life and death of the people. Strengthening of healthcare in India and in the North Eastern region is dependent on how far the government is ready to extend its arms for the welfare of the people.

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INSIGHT

Humanitarian action and public health in India

LEENA MENGHANEY South Asia Regional Coordinator, MSF’s Access Campaign

Leena Menghaney, South Asia Regional Coordinator, MSF’s Access Campaign, explains how the Nobel Peace Prize winning organisation’s work on developing treatment models for DR-TB, kala azar, malaria and HIV co-infection with other diseases has encouraged India’s Ministry of Health to re-evaluate policies which impact access to quality treatment in these disease areas

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octors Without Borders / Médecins Sans Frontières (MSF) medical humanitarian projects in India started in 1999, the same year the organisation was awarded the Nobel Peace Prize in recognition of its ‘pioneering humanitarian work on several continents.’

Since then, I have been witness to MSF teams in India providing medical assistance during natural disasters, bringing medical aid to people in areas where access to healthcare is limited or non-existent, treating patients for neglected diseases such as malaria, kala azar and drug-resistant TB and training thousands of medical and nonmedical personnel to work in resource-constrained settings across several states.

MSF’s medical teams in India work in places that many people across the world have never heard of. These places are in difficult terrains and remote settings where MSF medical teams make healthcare accessible to the affected and vulnerable population. This may sometimes translate into working independently as the sole treatment provider or working in collaboration with state authorities and institutions affiliated to the Union Ministry of Health.

Keeping patients’ priorities central to its humanitarian work – particularly excluded and vulnerable populations – and constantly improving medical protocols has led to a very important contribution to pub-

Pic used for representational purpose only

lic health in India.

In the last decade, MSF has saved hundreds of thousands of lives in India and helped millions more with its work to address drug resistance – whether to chloroquine in the treatment of malaria or to the drugs used to treat tuberculosis or HIV. MSF has persevered to bring medical innovation to remote and resource-poor settings in India, introducing rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT) for malaria and

working with research institutions to build evidence on the effectiveness of Liposomal Amphotericin B (LAmB) in the treatment of kala azar. The organisation has also acted early in recognising, diagnosing and treating cases of extensively drug-resistant tuberculosis (XDR-TB) and challenging patent and regulatory barriers to protect and encourage the introduction of low-cost generic fixed-dose combinations for HIV and direct-acting antivirals for hepatitis C.

Led by its motto that everyone should have access to healthcare, the humanitarian organisation has gone a step ahead by collecting evidence and developing treatment models for DR-TB, kala azar, malaria and HIV co-infection with other diseases – encouraging the Ministry of Health to re-evaluate policies which impact access to quality treatment in these disease areas. Patient needs remain at the core of MSF’s work and its contribution to public health in India.

While MSF carries out its medical humanitarian work in India it also considers the country a very important player in global health with its generic and vaccine industry, technical and scientific capacity, vast pool of skilled human resources, leadership in a number of international forums and growing financial clout as one of the fastest growing economies.

But domestically healthcare is increasingly seen as an area of profit making with many arguing that it is best left to market dynamics and private players.

However, privatised healthcare in India and its market dynamics constantly exclude the vulnerable, marginalised and difficult to reach populations, a practice that Indian policy makers can ill afford to ignore.

Focusing on patient needs, vulnerable communities and excluded populations is not just about addressing inequality and economic hardship. It plays a central role in addressing public heath challenges and epidemics, something that MSF has experienced firsthand in India.

The ultimate onus to ensure an inclusive healthcare system that provides quality, accessible and affordable treatment lies with the government. With a growing public health burden in the area of drug-resistant infections, communicable and noncommunicable diseases, health policy making in India needs to start placing patient needs before profits.

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Mass communications strategies for public health

NICK HAWKINS MD, EMEA at Everbridge

Nick Hawkins, MD, EMEA at Everbridge, elaborates how mass notification platforms, can be used to communicate directly with vulnerable people to reduce the flu death toll

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he definition of a crisis can alter dramatically dependent on the stakeholders involved. The magnitude of a crisis in healthcare is unpredictable and can evolve quickly. Efficient management of an emergency can be the difference between life and death.

What should healthcare communications professionals look for in an emergency notifications provider?

Healthcare professionals will seek a solution that prepares for the unexpected and helps to prevent the contamination of diseases prior to epidemic status. In India for example, the health ministry, reported 70 deaths from the dengue virus since January.

Additionally, more than 14,650 cases of the chikungunya virus have been detected and more than 800,000 cases and 119 deaths from malaria.

A mass notifications solution helps communicate with vulnerable citizens and advise on best practice health guidelines.

Central to the success of critical communications platforms are two key functions.

The first is the capability to deliver messages using a variety of different methods – known as multi-modal communications. This is particularly important in developing countries where smartphones and email may not be widely used. The second is effective two-way communication, which is the ability for recipients to respond to emergency notifications

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quickly and easily, acknowledge receipt and confirm actions or declare status.

Importance of multi-modality No communications channel can ever be 100 per cent reliable 100 per cent of the time, so multi-modality transforms the speed at which people receive the message. Multi-

ample, the Government of India could communicate with regions at risk of malaria, offering advice around mosquito net availability and sharing local hospital information.

An example of when multimodal communications would have been effective was during the March 2016 terror attacks in Brussels. Belgium’s response to the attacks was complicated

Emergency services resorted to emails, iPad messages and a radio communications system called Astrid which medical staff found too complicated and time consuming. Lt. Col. Eric Mergny who coordinated the medical response at Brussels Airport said that Astrid limited his communications to the point where he was unable to check which lo-

Central to the success of critical communications platforms are two key functions. The first is the capability to deliver messages using a variety of different methods – known as multi-modal communications.The second is effective two-way communication, which is the ability for recipients to respond to emergency notifications quickly and easily, acknowledge receipt and confirm actions or declare status modality facilitates communication via more than 100 different communication devices and contact paths including email, SMS, VoIP calls, social media alerts and mobile app notifications, amongst many others. It is even possible to integrate critical communications platforms with tannoy systems or digital signage to deliver a more effective and holistic communications strategy.

Multi-modality also enables multiple methods of delivering vital preventative information during widespread breakouts of disease. For ex-

by a communications blackout, understaffing and a series of false alarms. During the attack, the mobile phone network went offline, making standard mobile communication impossible. The team at Brussels Airport made its public Wi-Fi discoverable and free, allowing anyone with a Wi-Fi enabled device to connect, send and receive messages. Without access to a variety of communication channels, those in the midst of the attack would have been unable to contact friends, family and colleagues to let them know they were safe or in need of assistance.

cal hospitals had the capacity to take patients. This led to the miscommunication that hospitals were full. An advanced multi-modal communications platform could have eliminated confusion and streamlined responses to limit fatalities.

Two-way or no-way Just as multi-modality ensures that it is easier to receive a message, two way communications makes it simpler to confirm a response. In a critical emergency, every second counts, so organisations can use communications platforms to cre-

ate and deliver bespoke templates that require a simple push button responses. In doing so, the level of response to critical notifications can increase significantly.

For instance, if a crisis breaks out in New Delhi, local hospitals can send a notification to staff in the vicinity to find out if they are available to help. The message will have the option to reply with “I am available” or “I am not available” with one-button press, enabling a clearer picture of staff availability within minutes.

Combined, these two functions enable organisations to respond smarter and faster to those in need. In situations where multi-modal communications and response templates are deployed together, response rates to incidents increase from around 20 per cent of recipients to more than 90 per cent.

Another important requirement in healthcare is patient confidentiality.

Healthcare professionals must seek a solution which can provide secure modes of communication to eliminate compliance concerns. Critical communications platforms such as Everbridge offer a variety of secure messaging applications to encourage collaboration between on-call teams whilst ensuring patient privacy is a priority.

How can a critical communications platform help to stop the spread of disease?

Mass notification platforms

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such as the Everbridge platform can be used to communicate directly with vulnerable people and reduce further contamination of disease. For example, during flu season the communications technology can send targeted messages to diabetes sufferers and the elderly to remind them to book a flu vaccine and deliver updated information around flu symptoms and treatments.

This process can be implemented for any type of disease in any country. In 2016, the Zika Virus caused global hysteria and very little was done to communicate simple prevention methods. Critical communications technology can be used to eliminate fear and advise on best practise against contamination such as using mosquito repellent and removing stagnant water from public areas.

Deploying a critical communications platform Businesses have traditionally been early adopters of critical communications platforms but there has been increasing interest and support amongst emergency services. One of the UK’s leading Ambulance Trusts recently deployed the Everbridge critical communications platform.

South Western Ambulance Service NHS Foundation Trust South Western Ambulance Service NHS Foundation Trust in the UK provides emergency and urgent care services across 20 per cent of England. The trust employs more than 4,000 staff members, responsible for 96 ambulance stations, three clinical control rooms, six air ambulance bases and two hazard response teams.

Everbridge’s mass notification system enabled the trust’s emergency response teams to notify and alert key stakeholders of major incidents. The availability of multi-modal delivery has increased staff notification responses by 138 per cent, whilst text-to-speech functionality has reduced

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staff response times from more than 60 minutes to less than four, helping to increase the trust’s visibility of major incidents—ensuring its resources are deployed quickly and efficiently.

Oliver Tovey, Resilience

Officer at the Trust, discovered that by routing all its communications through the Everbridge platform, the Trust would save £70,000 to £80,000 a year. "That's a cost-saving that equates to five or six extra ambulances

on the road," he commented.

Conclusion With a rise in the number of critical events worldwide, emergency services need the tools to locate and communicate with staff, in a timely,

measurable manner, even when traditional routes of communication are unavailable. Healthcare must plan for the unexpected. With a critical communications platform costs can be significantly reduced and lives can be saved.

STRATEGY ANALYSIS

On a growth curve An analysis of the medical devices market in India to examine the current landscape and identify the key growth agents. By Lakshmipriya Nair

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conomic progress, growing demand for quality healthcare among consumers and a surge in lifestyle diseases, among other factors, are transforming the dynamics in Indian healthcare. Yet, the country continues to battle several challenges in its attempt to ensure the three ‘As’ - affordability, accessibility and availability - crucial determinants of a functioning healthcare system.

In such a scenario, from increasing access and reducing disease burdens to early diagnosis, improved clinical outcomes and shorter recovery times, the role of medical devices in the care continuum is constantly enhancing at a rapid pace. As Pavan Choudary, Director General, Medical Technology Association of India (MTaI) highlights, “The medical devices industry is the smallest of the wheels, contributing to about seven to eight per cent of the healthcare spend in India. However, it is the most critical contributor to the improvement of healthcare outcomes in India.”

Hence, in a review of the medical devices market in India, we examine the current landscape, identify key growth agents and look at the efficacy and efficiency of the measures implemented to reform the sector.

In the present day The medical devices market in India is still in the nascent stages of its growth. Despite featuring among the top 20 markets for medical devices, and being the fourth largest in Asia after Japan, China and South Korea, India’s share in the global devices market is fairly small. A

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report by the SKP Consulting Group reveals that the Indian medical devices industry accounts for just over 1.3 per cent of the global medical devices market of $335 billion.

It comprises four segments – consumables and implants, diagnostic imaging, instruments and appliances and patient aids and others. Multinational firms dominate the high-end segments offering more value in terms of technology, price and quality while domestic players have more prominence in the low-priced, high-volume segments.

Himanshu Baid, MD, Poly Medicure informs, “It is estimated that there are about 800 manufacturers present in India. Majority of them are SMEs and MSMEs – approximately 65 per cent have an annual turnover of less than `10 crores. Only two per cent of them have an annual turnover of ` 500+ crores.”

A complex regulatory framework, fragmented domestic industry, inadequate healthcare spending and a disproportionate dependency on imports have long plagued the Indian medical devices market and hindered its progress. The above mentioned report also highlights that India’s per capita spend on medical devices is the lowest among BRIC nations. Choudary points out, “The per capita spend of $3 (2014) is significantly lower than not just the developed countries but also the other emerging economies, with Brazil at per capita spend of $28, Russia at $43, China at $178 per capita.” Probir Das, Chairman - FICCI Medical Device Forum further clarifies, “Its (India’s) very low per capita consumption of medical

cent of the total population).”

In addition, health insurance penetration is also set to rise from the current 300 million people to 655 million by 2020, as per the same report which also highlights that the share of spend on healthcare as a percentage of total household spend is expected to increase from seven per cent in 2005 to 13 per cent in 2025.

Policy reforms: The government, in the recent years, has brought in several changes at the policy and regulatory level.

Some of the noteworthy ones have been: ◗ 100 per cent FDI in medical devices under automatic route Picture used for representational purpose ◗ ‘Make in India’ initiative to promote indigenous manufacdevices is indicative of the fact Changing demographics: An turers and encourage foreign that the market still remains increasing burden of communi- players to set shop in India largely underpenetrated.” cable and non-communicable ◗ Harmonising standards with Moreover, it is also an industry diseases, ageing population, in- international ones to assure which is hugely import-reliant. creasing need for diagnostic quality, safety and efficacy of Over 70 per cent of the coun- services etc. are some of the medical equipment try’s total demand are served major reasons for a growing ◗ Announcement of New through imports and only medical devices market. Das Medical Device Rules 2016 Some of these measures around 30 per cent of devices explains, “It has a huge potenare indigenously manufactured tial for growth in India from the have already started bearing demographic and disease bur- fruit. The Deloitte NATHealth devices.

But, all that is set to change. den points of view as medical report reveals, “The inflow of As per a study by research and devices play a very significant FDI in medical devices was ~$ consulting firm GlobalData, the role in diagnosis, therapy, and 90 million between December Indian medical devices market even point of care forms of 2014 to August 2015, post the government permitting 100 per will witness remarkable healthcare service.”

Fuelled by economic cent FDI under the automatic progress, escalating from $10.4 billion in 2014 to touch $17.6 bil- progress, rising education lev- route. Several MNCs have been lion by 2020. A double digit els and urbanisation, there is increasing their manufacturing growth of 15 per cent CAGR is an increase in the paying ca- footprint and locating research being predicted for the indus- pacity if citizens in the country. centres in India to serve both try, much higher than the This, in turn, has led to an in- the Indian and global markets. growth rate of the global med- crease in the demand for quality Increased funding and investical devices market which is healthcare services. A report ments have also reflected in pegged at a CAGR of around released by Deloitte and other supply side changes in NATHealth reveals, “The size healthcare delivery in India.” four to six per cent.

The industry has lauded But, what are the factors of the population earning more which will usher in this trans- than $5,000 per annum is esti- these efforts and believe that formation? Industry experts mated to increase to around they will accelerate growth in 450 million (~28 per cent of the the sector. share their views. total population) in 2025 from Choudary states, “A colossal Agents of change the current 145 million (~12 per growth in the sector has been

made possible due to free cross border flow of technologies, healthcare worker training, market development, and progressive recent measures like the announcement of 100 per cent FDI in medical devices industry. Just the latter has led to the FDI jumping from $60 million per annum to $160 million per annum.”

Similarly, Das opines, “Of late a much clear understanding is beginning to prevail in the Government of India and there are efforts to identify medical devices separately from drugs. Along these lines, a legacy of regulatory issues are also likely to be put on path of resolution with the introduction of a digital regulatory approval system called ‘e Sugam’ and the announcement of New Medical Device Rules 2016.” He further states, “As focus on med tech emerges in policy decisions it is likely that the supply side will be reinforced with ease of doing business reforms, fast regulatory approvals, infrastructure development to support Make in India.”

Supporting the move to have a separate law for medical devices in the form of New Medical Device Rules 2016, Baid opines, “This will definitely be a game changer as medical devices industry will get a separate recognition from drugs and the regulations will be in line with global best practices.”

The Make in India campaign, launched with the intention of making India a global manufacturing hub, has also resonated well with the healthcare industry players. It has also opened up avenues to reduce our dependency on imports. Presently, India imports approximately ` 23000 crores worth of medical devices. A research paper released by Deloitte and NATHEALTH on the current landscape in medical devices industry and the imperatives to optimise the opportunities thrown up by ‘Make in India' initiative, highlights, “With 70 per cent of the demand for medical devices being met through imports, the import bill will be significant for both growth trajectories — organic and inorganic growth of the medical devices industry in In-

dia. Apart from reducing the import bill, ‘Make in India’ has the potential to attract investments, generate revenues for the exchequer, earn foreign exchange earnings through increased exports and generate direct and indirect employment.”

Medical devices parks: Another significant move from the government to boost the sector has been the decision to set up medical devices parks in Tamil Nadu and Gujarat. Dr HG Koshia, Commissioner, Food & Drugs Control Administration, Gujarat, says, “Medical devices parks are required to boost the medical device industry and provide common facilities within the park. The medical device market is very huge and we are importing large quantities of medical devices and equipment. However, if this emerging sector is supported by the Government, India has the capability to produce world class medical devices at affordable prices.” He states further, “India will be self sufficient in medical devices and equipment and save huge foreign exchange. It will also generate employment under the Make in India vision.”

Baid also reiterates the same vies and says, “The medical device parks will encourage local manufacturing and reduce the country’s dependence on imports. The proposed parks with in-house manufacturing units and facility for consolidated raw material procurement will help reduce cost.” He further states, “These parks offers common facilities like testing, power and effluent treatment plants. Besides, there will be common utilities and services such as storage, testing laboratories, IPR management, import and export facilitation centres and regulatory offices. Low cost rentals and revenue-support services for companies are also being considered. As per various estimates, once these parks become operational, they can bring down the cost of production of devices by at least 30 per cent.”

Rajiv Nath, Forum Coordinator, AIMED, advises, “The parks are needed to aid manufacturing of medical devices in

India and address India's import dependency of 70 per cent.

The parks you are referring to are not of today but repackaged park related projects languishing for over 10 years in Tamil Nadu (project lead by HLL) and Gujarat (project by DoP and Gujarat government).

These parks will remain green parks until manufacturing of medical devices in India becomes not only viable but profitable. What's needed is course correction and reversal of earlier policies that made India import dependent.”

Overcoming obstacles Thus, the Government of India’s ‘Make in India’ initiative, new entrants in the sector, increased investments, and the hope of amendments in the current regulatory scenario are spurring growth in the sec-

T he Indian medical devices market is set to grow at 15 per cent CAGR, higher than the growth rate of the global market tor at an accelerated rate. But achieving its true potential would be no cake walk. Despite many steps taken to reform the sector, certain challenges continue to exist and threaten the sector's progress.

As Choudary highlights, “In the current market, demand is predominantly driven by the major cities while penetration in smaller towns and rural areas has remained low due to the lack of accessibility, awareness, availability and affordability. There are also many challenges faced by the industry in terms of ambiguity in defining medical devices, regulations, lack of dedicated labs for product development, lack of financial incentives and skilled manpower.”

However, the industry players also recommend some more measures to mitigate the challenges and sustain the growth story.

Das lists down his suggestions to tackle the challenges and states, “While the broader policy mechanisms work in tandem, industry and government need to work closely on the following aspects: ◗ Focus on R&D and Innovation as India’s strengths in overall cost competitiveness globally- has seen key success stories like GE, Philips, Medtronic, Boston Scientific, Stryker, among others creating a large base for R&D and product development in India. ◗ Exports - Value creation and enhancing exportability in product segments where India is fairly self-sufficient in manufacturing (consumables and surgical etc. ) ◗ Matchmaking of India’s inherent strengths to sectoral MII demands. ◗ Enhancing India’s competitiveness / attractiveness as a manufacturing destination in comparison to China, Ireland, Malaysia, Costa Rica etc. ◗ Enhancing market size to boost attractiveness – by awareness, public health spend etc.

He also suggests, “The primary and secondary healthcare machinery of our country needs to be updated with skilling, awareness of possible medical pathways, technology solutions and scaled implementation of projects through PPP and other models which are inclusive. The medtech industry plays a large role in building awareness and know how among healthcare providers through trainings and extended supply chains especially in critical care segments. This effort also needs to be further augmented with support from state health directorates and civil hospitals, PHCs, SHCs in all states.”

Nath also has a set of recommendations to make. He says, “The market is growing at approximately 15 per cent but it's got the potential to grow faster once these (devices) can be made in India. That's not only a huge opportunity for import substitution but also an

opportunity to make India one of the top five manufacturing hubs of medical devices. A huge potential is awaiting to be unleashed - what's required are conducive policies and a supporting ecosystem- we are not asking for subsidies but a revenue support model to help reduce our cost of manufacturing and make India competitive by performance, value delivery and then by price.”

Choudary offers a different perspective, “Currently, in the field of medical devices, the main question to ask is not whether India should go for medical device manufacturing or not, but, 'What will attract manufacturing in medical devices to India? Protectionism or Incentivisation?' Protectionism, surely has played a role in spurring manufacturing in some sectors in some countries. But it does not come without side effects. And it does not work for all sectors.

Manufacturing in India could work for those medical devices where a high level of import substitution of an acceptable quality has been obtained or can be obtained quickly by virtue of the technological and financial ecosystems being already place, for example, in some cannulae, IV sets, stop cocks, extension lines etc. But, where import substitution is still far away, increasing import duties, the protectionist measure usually employed, is just taxing consumers to subsidise domestic production which is bad economics.”

He further elaborates, “When we look at these factors above, one concludes that it will be a process of incentivisation, R&D, skill development, greater health expenditure or better insurance coverage, which will benefit the cause of Make in India.”

Going forward Thus, while the sector is on a progress path, there is a long way to go before India establishes itself as a medical devices hub. The need of the hour is that all the stakeholders come together, step up and, make coordinated and concerted efforts to help the sector achieve its true growth potential. lakshmipriya.nair@expressindia.com

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IT@HEALTHCARE KNOWLEDGE EXCHANGE

EVOLVING TOWARDS DIGITISED HEALTHCARE A power-packed discussion with healthcare CEOs, hosted by Microsoft, brought out some concrete submissions on how technology will play a critical role in enabling healthcare.

By Prathiba Raju

T

ech giant Microsoft, along with E x p r e s s Healthcare, recently organised a round table with select healthcare CEOs on the ‘Digital Transformation in Healthcare.’ The prime focus of the select meeting was on how digitisation could help deliver superior services amid growing patient demand for better a experience.

The two hour-long discussion was chaired by Jean-Philippe Courtois (JPC), Executive Vice President and President, Microsoft Global Sales, Marketing and Operations, who gave a broad overview of Microsoft's mission to make healthcare more accessible and affordable for people across the region, using technologies like Artificial Intelligence (AI) and Cortana.

Initiating the discussion, moderator of the roundtable session, Dr Rana Mehta, Leader-Healthcare, PwC India commented that

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the digital revolution is actually expected to happen across the continuum of care and asked how the private sector viewed this trend as the digital revolution sets in.

Briefing about private sector’s view on digital revolution in healthcare space, Sangita Reddy, Joint MD, Apollo Hospitals, said,”In India, one needs to look at multiple factors like scaling, innovation, access, financing and efficiency. A combination of all these factors are driven by IT at different levels. They cannot replace hospitals but will definitely have an influence.”

Further drawing an analogy between healthcare and the telecom space, Reddy informed that the infrastructure facilities put up and the investment made by the telecom sector are seeing benefits by big players like Google and Amazon. The value realisation out of the original infrastructure is getting realised. Similarly, pharmaceutical companies and hospital providers must seri-

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ously look at how they can connect the ‘Überisation and WhatAppisation’ of healthcare, alluding to the increasing number of apps in the healthcare space.

Ajay Bakshi, CEO, Manipal Hospital opined that hospitals are the fulcrum of the healthcare ecosystem as patients trust the doctor. Thus, the patient will approach a hospital with his health issues rather than a telecom company, even if they provide the latest technology.

“So hospitals have to find a way to reach out to the community instead of looking for other companies like doctor appointment booking sites to tell us what we have to do,” he added.

Agreeing with Bakshi and drawing attention towards patient care and safety, Rajit Mehta, CEO, Max Healthcare, said, “Patient care safety is the most neglected aspect in healthcare. I'm struggling to find a technology where we could enforce a simple measure like hand hygiene in hospitals. Interestingly, in South

Korea there is a gadget where the ICU door does not open until you use a hand sanitiser. Here, nobody has actually looked at what kind of digital technology is needed in healthcare, they just assume. We need a private ecosystem to handle health variables and monitoring.”

Touching upon Artificial Intelligence (AI), one of the core areas in healthcare digitisation and how the doctors see it's role, Bakshi informed that neuroscience is learning more from computer science and it is a two-way dialogue. He also accepted that computers bring in a lot of power. He stressed that digital technology should be more involved in the decision making part of medicine practice, not the motor, physical or surgery part of the procedure and affirmed that it will take another decade for robots to take the place of surgeons.

“The decision making part of the medicine will migrate away from the doctor to the machine even as early as 2022, 2023 since

KEY TAKEAWAYS FOR HOSPITALS ON THE PATH TO DIGITISATION ◗ Follow one common billing format be it CGHS or ECHS.A simplified commercial terminology should be followed. ◗ Move into the bandwidth of SNOMED CT, (A Systematized Nomenclature of Medicine -- Clinical Terms) which is free for both private and government hospitals: ◗ Common PHR empowering the patients storing the summary of the patients and building the option for continuum care. ◗ Hospitals should agree to the STG with insurance companies as it will change and help creating minimum standards of care. ◗ Equivalent to NABH which is an infrastructure play, there needs to be a process play.As there is a complete lack of business model for scaling up.This is because hospitals are cutting down on quality ◗ Hospitals should think about different levels of digitisation as per the capability, be it common HIS platform or imbibing AI. Hospitals should decide the where and how of digitisation. ◗ Microsoft looks at enabling doctors for tomorrow and brainstorming on how to engage with and help them make the digital transformation smoothly ◗ Increasing the digital capacity and enabling doctors with AI so that the decision making for doctors becomes easy. ◗ Invest in systems and technologies to make hospitals cyber secure

Rajit Mehta

Ajay Bakshi

Jean-Philippe Courtois

Sangita Reddy

Anant Maheshwari

Ravindra Karanjekar

Naresh Kapoor

Shankar Narang

Manpreet Sohal

Dr Devlina Chakravarty

digitsation is moving at an exponential space,” he said.

Detailing about the role of AI in healthcare, Courtois informed that AI reinvents and automates healthcare. It also holds far greater promise which helps humans and machines to work together.

Further he said, “It is not just collecting and passing signals but we capture people’s emotions and symptoms. We see

incredible potential in using AI as it has the capability of protecting privacy, transparency and security.”

Agreeing with this premise, Naresh Kapoor, CEO, BLK Super Specialty Hospital also pointed out that AI has a role to play not only in large hospitals and metro cities, but should also be replicated in rural areas. However, he indicated that the challenge is to

send the doctors to work in smaller towns at the district level.

Moving forward, Dr Ravindra Karanjekar, Group CEO, Jupiter Hospitals spoke on the scalability of digital technologies and how government as well as district hospitals can utilise them. He said, “All district and government hospitals are not equipped to get access to software. With

hospitals at varied capacities, scalability of digitisation would differ and will be done incrementally. I believe digitisation has the power to change healthcare, though it will take some time.”

Quoting an example of Microsoft’s work in connecting people at the grass root level, Courtois shared an example how a Singapore-based organisation, Ring.MD connects mil-

lions of patients and enables quality healthcare across Asia.

“It has a virtual healthcare platform, connecting doctors with over 10 million people across Asia and it also utilises the power of the Microsoft Azure cloud platform and makes healthcare more accessible and affordable for people across the region, using technologies like Skype, bots and Cortana. Such collaborations

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IT@HEALTHCARE of technologies will help in connecting faster way to people and provide healthcare access,” explained Courtois.

Giving a perspective on how IT is adapted in other sectors and what would be the learning for healthcare, Anant Maheshwari, President, Microsoft India, informed that there is a tremendous transformation after the Digital India initiative, as rural India and the Tier-IV and V cities are getting digitally transformed.

“Microsoft is witnessing the digital transformation happening in rural areas of the country. We have partnered with the governments of Maharashtra and Andhra Pradesh where the whole combination of the Common Services Centers (CSCs) and tele-medicine is getting digital health across to the villages. A CSC in village helps not only healthcare but it becomes a common place where you get other important facilities like death certificate, and birth certificate,” Maheshwari explained.

Shankar Narang, COO, Paras Hospitals, spoke about the variations in the healthcare market in smaller places like Darbhanga, 150 km northeast from Patna. He said the technology can be a supporter to a extent at such smaller towns but it can also be a obstructor as its acquisition is not cheap. He firmly felt, “We need to adopt a standardised technology across hospitals.”

Narang also mentioned that medical colleges should introduce topics like AI and Watson medical systems in their syllabus so medical graduates learn them early and later disseminate the same as doctors.

In response, Courtois hinted that Microsoft would like to explore further such suggestions in terms of imparting practical training skills for doctors and specified that these are some of interesting ideas to ponder.

Manpreet Sohal, CEO, Global Hospitals, Mumbai and Hyderabad suggested that Microsoft can explore setting up eICUs in small hospitals, as most small cities cannot get access to ICUs and mentioned

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that it is a huge potential to scale up.

Raising concerns about the e-waste produced in hospitals, Dr Devlina Chakravarty, CEO,

Artemis Hospital, informed that though more hospitals are moving towards a totally paperless environment each passing year, the amount of e-

waste and hardware is increasing and is a big concern. “Virtualisation could help but at what level is a big question. Hence, so a tech

giant like Microsoft which is driving digitisation, should consider this aspect as well and address this issue,” Chakravarty said.

The healthcare CEOs also expressed their concerns and quizzed Microsoft experts for solutions on the security aspects of increasing digitisation, drawing attention to the threat of hacking and data breaches.

“This is one of the areas where Microsoft invests the most,” averred Courtois “Starting with iPhones, OS system, it goes all the way to the cloud and to the services and apps where people interact and download from. We understand and build incredible, in-depth security features and get billions of connections through our enterprise business collected directory.

Microsoft has all the ability to prevent and see the signals of the malware coming and it is able to take practical action against at it. So, we have an end- to- end solution and ability to issue the signal’s real time. The users can then monitor, detect, protect well on time of a cyber attack.”

Further giving the details on cyber security, Maheshwari informed that the concept of prevention is outdated.

Explaining, he said that there are only two kinds of organisations: one who knows they are hacked and do something about it and the other who doesn't know if they have been hacked. He added that the detection and then the response is very important and cited Microsoft's decadelong experience in cracking cyber crime, leveraged by

Microsoft has recently opened Core 7 cyber security engagement centres for defence agencies in Sansad Marg in New Delhi

Interpol. He also mentioned that Microsoft has recently opened Core 7 cyber security engagement centres for defence agencies in Sansad Marg in New Delhi.

Summing up the session, Reddy said, “There is immense data available but the country needs data aggre-

gation and integration. It needs the vision to integrate and put everything together. A tech giant like Microsoft can lead and tell us how it can be done. An integrated mission with a group of like- minded people and a consortium can bring in transformation.” prathiba.raju@expressindia.com

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

Important medical devices are almost never updated with the latest security patches One medical record is 10 times the value of credit card details in the underground market. This makes data breaches and medical identity theft a worrisome issue for both hospitals and patients. Atul Anchan, Director, Systems Engineering, India, Symantec tells Viveka Roychowdhury what makes this sector so vulnerable and outlines some cyber security strategies

Symantec’s Internet Security Threat Report (ISTR) Vol. 21 highlighted that globally, the largest number of breaches took place within the health

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services sub-sector, which actually comprised 39 per cent of all breaches in 2015.

Why is this sector so vulnerable to such attacks?

The healthcare industry is going digital with massive amounts of patient data stored and shared among organisations. But the bad news

is that attackers now target this sensitive and often personal information. According to the Symantec’s Internet Security Threat Report 2016 (ISTR), 78

million patient records were exposed last year in a major data breach at Anthem, the second largest healthcare provider in the US. This is no big surprise given that huge volumes of marketable and sellable data, lagging security, remote services, medical devices, special requirements to share and protect personal data. With the growing complexities of attacks, and interest of cyber criminals, security is slowly becoming the most top concern for the healthcare industry worldwide.

Recently, Symantec also highlighted that the healthcare industry is vulnerable to attacks such as Gatak Trojan.

The majority of Gatak infections (62 per cent) occur on enterprise computers.

Analysis of recent enterprise attacks indicates that the healthcare sector is by far the most affected by Gatak. Of the top 20 most affected organisations (organisations with the most infected computers), 40 per cent were in the healthcare sector. In the past, the insurance sector was also heavily targeted by the group.

How does the attack occur?

IT@HEALTHCARE Are there certain devices that are more vulnerable?

Internet-connected things are multiplying rapidly. Symantec saw many proof-of-concept and real-world attacks in 2015, identifying serious vulnerabilities in medical devices and more. These smart devices are increasingly attractive targets for online criminals. As a result, they are investing in more sophisticated attacks that are effective at stealing valuable personal data or extorting money from victims (ransomware). Many of the systems that are used in hospitals run on well-known software’s such as Windows and Linux. Sadly though, these extremely important devices are almost never updated with the latest security patches. The healthcare industry has long seen the risks as these devices had previously been infected by malware such as Zeus, Citadel, Conficker, and more. In fact, some (computer) virus infections have shut down entire hospital departments, required rerouting of emergency patients, or had similar implications on care delivery.

What could be the possible impact of this breach/ theft of personal health data like health records, etc, in monetary terms etc?

When a health system suffers a data breach, it can cause serious and irreversible damage to patients, employees, third-party partners, the business and the trusted relationship between patients and their care providers. The trouble is, health data and other sensitive information stored in health provider systems by nature needs to be shared with other entities. For example, in the course of treatment, protected health information (PHI) can travel between medical and finance departments, other practices, family members and third party entities such as insurance companies and home health agencies. All the while, health systems are legally bound to protect confidential information while coordinating care and payment. Symantec’s ISTR highlighted that in 2014,

one medical record can fetch $50 in the underground economy, which is 10 times the value of a credit card numbers.

Further, medical identity theft victims have had to pay an average of $13,500 to resolve the issue.

What are the steps healthcare organisations in India need to take to prevent such breaches? Globally, are there any best practices that consumers (patients, caregivers) can put in place to protect their health data?

How can India's public health authorities proactively prepare for such cyber attacks?

encryption: Allows users to monitor and protect confidential information wherever it is stored and however it is used. In the healthcare sector, described content matching technology looks for matches on regular expressions or patterns. DLP allows scanning network to share files, databases and other enterprise data repositories identifies and protects confidential unstructured data.

This also allows a single webbased console to let its users define data loss policies, review and remediate incidents, and perform system administration across all endpoints, mobile devices, cloud-based services,

cloud, or mobile app with builtin integrations ◗ Ensuring device security: Security across endpoints, ranging from desktops to Internet of Things (IoT)enabled medical devices is critical. At the most basic level, organisations need to have the right security solutions for various endpoints- from AV and anti-malware, to IoT security.

What is Symantec's protection strategy, risk management strategy for such attacks? Any instances, case studies of its implementation in healthcare organisations.

When a health system suffers a data breach, it can cause serious and irreversible damage to patients, employees, third-party partners, the business and the trusted relationship between patients and their care providers Sensitive information is stored at all levels of healthcare organisations, and there’s so much new, unstructured data being generated every day that it can be difficult for IT administrators to know where it all resides and how and by whom it is being used. Judging by the rising number of data breaches—and ransomware attacks resulting in hospital shutdowns—health systems are seriously lagging when it comes to safeguarding patient records and other sensitive data.

Symantec suggests below to stay protected: ◗ Manage and protect sensitive data, on-premises or in the cloud: The healthcare industry is moving towards cloud, which has obvious benefits, including cost savings and scalability. Security and complexity concerns have slowed adoption in the industry and Symantec offers a broad portfolio of security solutions designed to help healthcare IT manage and protect sensitive data, whether on-premises or in the cloud. ◗ Data loss prevention and

and on-premises network and storage systems. ◗ DLP Cloud Service for Email: Allows users to quickly transition to the cloud and securely adopt software-as-aservice applications, such as Office 365 or Gmail. Cloud Service for Email provides realtime protection with automated response actions such as message blocking, redirection, and encryption capabilities. This allows users to know how to prioritise real incidents with accurate monitoring and analysis, and respond faster with one-click responses and automated workflow. ◗ Validation and ID protection: Ensures that only authorised users can securely access clinical and IT systems.

This enables a stronger multifactor and risk-based tokenless authentication that eliminates up to 80 per cent of breaches. VIP enhances all the existing static passwords by positively identifying users with a dynamic second factor of authentication that cannot be predicted or stolen. VIP can adapt to nearly any network,

globally and in India?

2015 was the changeover year for the healthcare industry with more targeted attacks. While many hospitals have mature cyber security programmes in place, various others are still struggling with the basic goals like implementing encryption to protect data on lost or stolen mobile devices, laptops, or data carriers. By and large, the healthcare industry is not prepared to face today’s cybersecurity risks, be it hospitals, pharmaceutical or biotech companies, medical device manufacturers, health insurers, national health agencies, or employers.

Additionally, with emerging technologies such as the IoT, the industry faces concerns as expressed in our blog post, dated June 24, 2015 titled, “Hospitals Breached via Medical Devices?” and how consumer health IoT devices can be susceptible to data loss.

Within the healthcare industry, there are medical devices that use off-the-shelf (OTS) software found vulnerable to viruses, malware and other threats.

With security experts facing a rapidly changing threat environment, one thing is clear: existing solutions are not the efficient answer. Advanced attacks are on the rise and security professionals using a myriad of individual point products to stop them are at a great loss. To address this, Symantec recently introduced Symantec Advanced Threat Protection (ATP), the first solution that allows enterprises to uncover, prioritise and remediate advanced threats and zero day attacks much faster, that too without adding any new endpoint agents to thwart these threats. Further, organisations not only need to plan proactively but also be ready with reactive measures, among which a major step would be insurance of assets and intellectual property (IP).

Symantec is also partnering with IoT manufacturers in healthcare to address cyber security risks through its IoT technology portfolio that includes Device Security with Symantec's Embedded Critical System Protection, IoT Roots of Trust and Device Certificates and Code Signing Certificates and Secure App Services. Our future plans will help enterprises address IoT security include introducing new technologies, such as an IoT portal for managing all IoT security from a single interface, and security analytics for proactively detecting anomalies that might indicate stealthy attacks on IoT networks. In fact, Englewood Hospital and Medical Center (EHMC) in Norton America wanted an efficient, costeffective option for IT security monitoring and management that matched its high standard of clinical excellence. After rigorous, six-month analysis of options, EHMC signed a threeyear Symantec Managed Security Services (MSS) contract. The IT team felt Symantec understood the healthcare space. The decision frees EHMC internal security staff for higher-value work and takes advantages of the expertise Symantec gains from its 24×7 global security monitoring operations. viveka.r@expressindia.com

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IT@HEALTHCARE

INSIGHT

Revolutionising health insurance with technology

MUNISH DAGA, CEO, CEO, Remedinet Technologies

Munish Daga, CEO, Remedinet Technologies, expounds on the scope and possibilities of digital platforms for healthcare insurance in India Cashless for health insurance

DESPITE THE technological evolution of the healthcare sector over the past two decades, health insurance in India continues to grapple with the same difficulties such as lack of adoption and complex utilisation. As a result, the adoption numbers struggle to make it past a disappointing percentage figure in a country with the second largest population in the world. On the flip side, the situation in which the health insurance industry currently finds itself, also presents tremendous opportunities to evolve, possibility to scale, and scope to become profitable.

The emergency of the situation, in several cases has not only served as a business opportunity, but also led to the adoption of digital frameworks as foundational pillars that ensure last mile delivery of health insurance for the policyholder.

The Gap Back tracking to the gaps in the health insurance industry, one of the key problems that is making health insurance utilisation complicated for the policyholder is the lack of coherence between the provider – the hospitals and the payer – the insurance company/third party administrator (TPA). Owing to the current claim exchange process, the policyholder has little or no information or awareness regarding the status of their claim when the policy is being utilised. Worse yet, lack of a standardised

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and transparent process to adjudicate claims adversely affects the patient’s experience of utilising their health insurance policy at the time of hospitalisation.

Digitising health insurance In line with a fast-catching trend – transacting cashless for anything from day-to-day expenses to larger transactions, e-commerce and online payments have made it possible to avail of services and products at the click of a button. Such online payment systems are linked seamlessly with banks and the customer’s

bank account to process these transactions in real-time.

To make this more relatable, imagine if the current ecommerce industry were to function manually where every time we place an order online, an individual sees the details of the order, prints it, goes to the warehouse or the vendor with the print out, checks the availability of the product, goes back to the computer, and sends the customer a response. Also, take into account if there are any changes, or unavailability of product, and the fact that the individual processing the order has to update the cus-

tomer regarding the placed order every step of the way.

There is no way the e-commerce industry would have scaled to this extent had it depended on human intervention. But this is the reality for health insurance today. The health insurance desk at the hospital sends and e-mail or FAX to the payer with the policyholders information and treatment details, the payer receives such claims from thousand other hospitals, responds to the hospital with queries, the hospital responds again over e-mail or FAX, and the time-consuming cycle continues.

While significant strides are yet to be made with respect to digitisation, cashless health insurance is being increasingly adopted by corporates for their employees, as well as health insurers are increasingly encouraging cashless health insurance by providing policies that can enable policyholders to use their policies cashless at empanelled hospitals. But to make cashless health insurance truly cashless, standard, and universal for all, the flexibility and transparency that digital platforms have to offer need to be leveraged to make health insurance simplified for the policyholder.

Employing a strong technology foundation will make the entire health insurance process electronic, paperless, transparent, and real-time, and thereby efficient for the hospital, the payer, and the end customer as well. Cashless health insurance mandates pre-authorisation of the claim before the treatment begins.

To have claims pre-approved in real-time, only a platform that enables electronic data capture and exchange, with direct integration with hospital HIS and/or drop-down menus that will allow the insurance desk at the hospital to share information with the insurer at the click of a few buttons will be able to scale and match the needs of growing healthcare and health insurance needs.

Take for example health insurance claims processing in the US. Nearly 80 per cent of

IT@HEALTHCARE

OPINION

Data-enabled future for India’s public healthcare

ANGSHUMAN SARKAR Principal Consultant, ThoughtWorks

Angshuman Sarkar, Principal Consultant, ThoughtWorks, opines that at an individual level, India lacks patient history for most of her citizens, impeding their right to effective healthcare. At the national level, there is a profound lack of reliable health-related data for informed decision making IN ONE of my trips to a local public health centre, I overheard a member of the National Health Mission (NHM) staff preparing a disease profile report showing reduced instances of diabetes in her area. Thankfully, in this case, the practitioner’s good sense prevailed.

While the claim itself is impossible to be true, even after accounting for migration and deaths, this report is a perfect synecdoche of India’s health reporting system.

Health information in India is sparse, anecdotal, and often unsuitable for supporting policy decisions. At its best, reporting is done mostly through disparate surveys such as National Family Health Survey (NFHS), District Level Health Survey (DLHS) and Annual Health Survey (AHS). These surveys happen in two to six year intervals, with a lag of 9-22 months in publication of the data from end of collection. As per a recent World Health Organisation (WHO) review, about 90 per cent of the questions in these surveys focus on maternal and child health, and reproductive health,1 even as India’s disease burden has significantly shifted towards non-communicable diseases.

The biggest obstacle to a standard, accurate and updated health information system is the complexity of our health services delivery. For the purpose of this article, let’s only consider the public healthcare system, which the majority of Indian population rely on. At the lowest levels are the community

health centers (CHCs) and primary health centres (PHCs), augmented by sub-centers and community health workers (CHWs). Data from this level is foundational for surveillance and monitoring health events for the purpose of planning, implementing, and evaluating public health interventions.

Currently, information gathering and recording at this level is either through memory or on paper. In the rare cases where it is digitised, it is unusable at higher levels for individual patient care, because systems are not standardised, not interoperable, and unsuitable for local analysis.

At the secondary level, there are sub-divisional and district level hospitals. In this level clini-

cal reporting is expected — enabling the timely spotting of health trends and to take appropriate corrective actions in the area. However, most hospitals don’t maintain any Electronic Health Record (EHR) and don’t share patient information with PHCs or referral hospitals, leading to repeated examination and tests adding to patients’ burden, and to the chaos of data analysis.

At the tertiary healthcare level, the problems are more complex. In the rare cases where hospitals use EHRs, they can’t refer to the information from PHCs and district hospitals. They end up being purely reliant on a patient’s description of treatment management (or repeating the diagnosis, tests

and evaluations yet again).

This multi-tier disconnected structure of public health care delivery and systems make the assimilation and analysis of patient information a Herculean task.

To complete this task, and to build a universal, integrated, holistic health information system, eHealth needs to be imagined like e-Governance — with the citizen at the centre and all government services around her.

Similarly, we need to build a system that works to leverage the patients’ clinical history to provide them with quality healthcare that they should be entitled to, without needing them to be the bearer of information.

Last year’s concept note by the National eHealth Authority

(NeHA) outlines the basic needs and structures of a national digital health initiative.

“For building an interconnected e-Health system across public and private hospitals within a state or nationally, it is imperative that they should have consistent standards for identity management, data entry, messaging, data encryption, retrieval, reporting etc.”

On the other hand, government contribution to healthcare is little over one per cent of GDP - less than half of that spent by comparable sized economy of Brazil. We have one doctor per 1400 patients - lower than Pakistan! While the natural need is to increase spending on healthcare, any national level initiative should be affordable to remain sustainable — affordable to build, maintain, and scale, while working uninterruptedly in lowresource and moderate connectivity environments.

Our neighbour Bangladesh has made great strides in this regard. With clear foresight, and strong political will, Bangladesh has ventured to build a centralised Health Information Exchange (HIE) that assimilates data from the field and facilitates integration across levels of healthcare delivery, throughout the country. This enables seamless sharing of patient information for better continuity of care — such as mother-child care, HIV care and TB care. Systems at various levels will synchronise their catchment patient information from the HIE — allowing patient records to be readily avail-

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able for reference for clinical care and local analysis. Each level becomes a hub for the lower levels.

Information will continuously be processed from the central HIE, aggregated and sent to the national reporting system, for measuring and evaluating progress on an almost real-time basis — enabling measurement of effectiveness, bringing transparency and accountability. This is currently running as a pilot programme in one district, and it is intended to scale across the country.

With universal health coverage in mind, everyone (programmes, initiatives) working in public health space is expected to integrate with the HIE. Any system being developed would need to share patient information with the national Shared Health Record (SHR), and/or share aggregated data with the national reporting system. In the

While the natural need is to increase spending on healthcare, any national level initiative should be affordable to remain sustainable — affordable to build, maintain and scale, while working uninterruptedly in low-resource and moderate connectivity environments long run, hope is that private healthcare providers will also see benefit and join the HIE. In several ways, India is similar to Bangladesh — the delivery system is similar, majority of the population is dependent on the public health system, and the staff and practitioners prefer a system in their local context.

Bangladesh’s model may be of relevance and provide useful insight for adaptation in India.

While the scale of an integrated health information system for 1.3

billion people (Bangladesh’ population is less than that of Uttar Pradesh) is a challenge in itself, it is amplified by health being a state subject in our country.

To establish a federated yet integrated ecosystem, India may consider a hub-and-spoke model — each state having its own HIE interconnected to the national HIE. This way, the patient’s information can be accessed from wherever, whenever needed.

Aadhaar can be leveraged for identification and patient con-

sent to information sharing.

Such a journey will be tough and ongoing, and India appears to be on its path. The 2015 draft National Health Policy has raised hopes of many as it alludes to ensuring health as a fundamental right. A digital health strategy — coming together of policy and regulations, technologies and standards and of economics and of operation — will help strengthen this ambitious mission.

While introducing technol-

ogy, special care needs to taken to ensure patient confidentiality and safety. Devising standards (EHR, interoperability, etc.) or defining guidelines for data protection are not enough; India must outline clear regulations, compliance and build means of monitoring and evaluation and accountability. For instance, in Bangladesh, doctors sign in and out using biometric fingerprint scanners at the points of care, which is then uploaded to the Ministry of Health.

Healthcare should work best for those who need it most. To protect that, we need to ensure that digital India does not widen the digital divide and make technology in healthcare unreachable for the poor! There is a long and arduous journey ahead, and policy makers, care providers, legal experts, technologists in public and private need to work together towards making health care equitable.

Revolutionising health insurance... the claims are processed automatically or what is also known as straight-through processing, where claims are processed without manual interventions (according to America’s Health Insurance Plans, a national trade association). The same associate has also recorded a significant reduction in the cost involved where the cost came down from $4 to $1 per claim.

Leveraging technology in similar manner to make the claims process digital and efficient in India will make the transaction transparent for the end consumer where they can be looped into process by notifying them about their claims’ status every step of the way. In the Indian context, there are a few examples of public healthcare schemes and private health insurers that have embraced electronic platforms to process cashless health insurance claims. While such initiatives have laid the foundation for digitalisation, they indicate the scope and possibilities of digital platforms for healthcare

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insurance in India.

Chief Minister's Comprehensive Health Insurance Scheme – Tamil Nadu (CMCHISTN): Launched in 2011, CMCHISTN covers 1.32 crore families in the state, with a cashless health insurance policy at 800+ hospitals for pre-defined conditions. The scheme runs on an electronic platform where all data is captured and stored electronically.

The patient can walk in only with their policy ID at an empanelled hospital to avail cashless treatment. Patient’s eligibility and pre-authorisation take place in real-time where in the payer is immediately notified of the patient’s arrival through an electronic platform. The patient experiences a completely paperless health insurance claims process where the entire claims cycle is transparent and efficient, and serves their purpose.

In the case of private health insurers, there quite few notable ones that have taken the leap to transform their back-end infrastructure into digital platforms

that allow them to seamlessly exchange claims information with the hospital electronically and in real-time. This has tremendously benefited cashless health insurance policy holders where the overall turnaround time has decreased significantly, leading to quicker discharges, optimum bed utilisation and significant improvements in customer satisfaction.

Let’s not forget outpatient healthcare needs With these first steps taken and efforts made to simplify the process for the end consumer, there are still many milestones that the sector needs to cross. While health insurance will catch up with other sectors that employ completely cashless and paperless systems for transactions, in the current context there is a need to leverage digital platforms to address outpatient health insurance that accounts for a far larger chunk of healthcare needs than inpatient/hospital-

isation healthcare needs. In developed markets outpatient health insurance market size is 3 to 3.5 times bigger than the inpatient market.

The same technological infrastructures that are slowly gaining prominence can be used as a foundation for a framework upon which an enhanced platform is built to bring in other players of the primary and secondary healthcare ecosystem such as pharmacies and diagnostics. Such a platform will make it possible to deliver outpatient health insurance for an individual who walks into a clinic for an ailment such as a fever or physical injuries that don’t require hospitalisation but can be covered under health insurance.

With a truly mature and tested electronic platform, health insurance in India can evolve to cater to healthcare needs such as dental and ophthalmic treatments, making universal health insurance possible for every single healthcare need.

Does health insurance have a choice?

Landmark rulings such as demonetisation from the recent past have forced the society to transact digitally and transact cashless. It has pushed the economy to become cashless and made it difficult to transact in cash. For universal health insurance, cashless policies coupled with a strong digital transaction framework, can make universal health insurance possible, especially where it is absolutely needed.

Furthermore, digital transactions also lend themselves to a host of other improvements for the healthcare sector such as automation and standardisation of the claim process from end-to-end, preventive healthcare management, better product pricing, and much more. At the centre of these enhancements is an efficient and transparent claims exchange for both, the payer and the provider, and a reliable, customer-friendly process for the policyholder.

IT@HEALTHCARE

INSIGHT

Role of ICT in healthcare

GEETANJALI SAHA Student, PGDM – Healthcare Management, Goa Institute of Management

Geetanjali Saha, Student, PGDM – Healthcare Management, Goa Institute of Management shares her views on the evolving role of ICT in Indian healthcare and its potential to reform the sector INDIA, has a current population of 1.25 billion. By 2050, it is expected to reach 1.6 billion.

So, the public health planners of the country have a big challenge to cater to. The performance of the health sector is suboptimal because of an increased burden of factors like political instability, underdevelopment, weak institutions, scarcity of resources, inadequately developed social sectors and evident social inequalities. However, with an increase in population, healthcare service resources will not increase in the same proportion. There are big geographical disparities in health and wellbeing of the population along with demographic and epidemiological transitions that take place. This demands nonstop spatio-temporal adjustments in plans and readjustment in allocation of healthcare resources. Though the government has made huge budget expenditures under ambitious schemes like NRHM, accessibility to low-cost healthcare is poor. Technology has a huge potential to grow capacity in this sector due to low-cost innovation, low-priced mobile phones and more ‘inclusive’ solutions that fill crucial gaps in health information and access.

To tackle these challenges, the process of health planning needs to evolve by the use of ICT in healthcare delivery and distribution and public health decision making at every level.

This will ensure delivery of right health services to right people at the right place as well as on right time. ICT has the capacity to influence all aspects of the health sector. For instance, in public health, management of information and communication processes are very crucial and are assisted or limited by

the availability of information.

Of late, the use of ICT has seen a remarkable growth.

In India, e-governance has been institutionalised, the use of ICT has become a norm for several government departments. ICT helps patients become more involved in their own care. This becomes more significant in managing chronic conditions such as asthma, diabetes, heart disease etc. People in remote areas sacrifice a day’s work and wages in order to get to a doctor for minor ailments. In such cases, primary healthcare costs can be reduced by be facilitating innovation in telemedicine.

Telemedicine can also streamline processes and decrease administrative overheads, thereby leading to creation of new, hightech markets and jobs. It is also being used for education, research and data management.

Though India has the benefit of a strong IT force as well as indigenous satellite communication technology along with trained human resources, still the application of telemedicine is at quite a nascent stage, particularly in the public health sector. However, with increased efforts, telemedicine could play a pivotal role in delivering specialised healthcare to the remotest corners of the country.

Telemedicine can provide the advantages of tele-diagnosis in the areas of pathology, cardiology, radiology and dermatology.

It can also essentially lead to operationalisation of CME programmes.

There are various advantages of incorporating ICT in healthcare such as better access to total and accurate EHR that collect information to improve diagnoses, prevent errors and thus save precious response times. It also leads to greater

patients’ engagement in their own healthcare. Further, it improves population-based knowledge in a country such as India. ICT ushers in an augmented administrative efficiency in a nation where the public health infrastructure is in absolute mess. For instance, administrative tasks such as filling forms, processing billing requests represent an important fraction of healthcare costs. Health IT can help to streamline these tasks and thus substantially reduce costs, as well as decrease the number of personal visits to doctors. ICT in healthcare can assist remote consultation, diagnosis and treatment through telemedicine.

Examples of successes India has witnessed varying success across states with the application of ICT in healthcare.

This is because of different levels of engagement by way of latest technologies.

An important example is the use of Personal Digital Assistants (PDA), a pilot based project, by ANMs who are important links in the primary healthcare system as seen by the NRHM. This has decreased paperwork and increased data accuracy by making it certain that the data is available in electronic form, even in rural areas with restricted broadband connectivity. The PDA sends out data through wireless communication networks which can later be entered into a larger database using the internet.

In Tamil Nadu, to bolster information practices in primary healthcare with the objective to improve processes concerning healthcare delivery for the rural community, HIS saw an efficient and effective

launch. This system develops the capacity of health staff to work on computers which in turn leads to better governance of the health sector and enhances delivery of healthcare to the community.

A health programme, ‘Aarogyam’ was launched in UP as an end-to-end community-based digital health mapping project.

It allows citizens residing anywhere in India, using any telecom network, to access their health profile information. The programme provides a health database for a future healthcare strategy. Under NRHM, there is the Mother and Child Tracking System (MCTS) where the project focusses on keeping a track of each pregnant woman, from registration to post-natal care.

GVK EMRI is another example. It handles medical emergencies through the ‘108 Emergency Service.’ It is a free service that is delivered through emergency call response centres. It has ambulances across Goa, Andhra Pradesh, Uttarakhand, Gujarat, Tamil Nadu, Assam, Karnataka, Madhya Pradesh, Meghalaya, Chhattisgarh and Himachal Pradesh.

Healthcare services in these states have remarkably improved, especially in remote areas, w.r.t. the response times and number of cases treated.

Challenges and opportunities In India, public health IT systems exist in silos. Several state health departments make their own IT solutions to fulfill their programme reporting needs. As a result, the systems do not aid in integrated decision making.

Therefore, it results in a lack of standardisation in architecture, data standards, disease and service codes.

It is evident that significant challenges and opportunities exist in India. These include growing healthcare needs of an aging population, a shift towards community-based care, costly technologies, need for improved quality and accessibility and the longing of people to be better and directly involved in decisions concerning their health. Information related to health plays an important role in determining the ways of meeting these challenges.

The Indian healthcare sector provides ample opportunities for low-cost innovation and the application of technology to improve health outcomes.

These opportunities exist due to brick-and-mortar infrastructure gaps, training of ICT-illiterate health professionals, capacity building and lack of primary healthcare staff.

Hence, ICT can play an essential role to improve healthcare for individuals as well as communities. ICT can help bridge the information gaps that have surfaced in the health sector in developing countries like India by providing novel and efficient ways of accessing, communicating and storing information. The gaps between health professionals and the communities served by them can be addressed by implementing ICT in healthcare. Further, with the development of databases and similar applications, ICT has the potential to improve health system efficiencies and thus prevent medical errors.

A smart, careful and contextual integration of ICT in delivery of healthcare service should be a prioritised strategy to aid complex health needs of a country with than a billion people.

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Why cloud is crucial for healthcare?

Suresh Venkatachari, Chairman, 8K Miles Software Services elaborates on the manifold advantages of the cloud in offering healthcare firms a secure, agile and cost-effective environment TRADITIONALLY THE healthcare industry has been technology-agnostic as it used to rely on conventional IT systems. The aversion to adopt new means of technology in order to streamline operations and systems has for long stymied the process of upgradation in the healthcare field.

The basic idea of centralising data in one organised and accessible place has long eluded the healthcare sector.

While revolutionising the very foundation of patient care, adoption of cloud will help the healthcare industry find new avenues to aggregate and consolidate patient data.

Physicians and clinicians will be empowered to make better decisions.

According to a study by research firm MarketsandMarkets, the global healthcare cloud computing market is expected to reach $9.48 billion by 2020 from $3.73 Billion in 2015 at a CAGR of 20.5 per cent.

Over the years, healthcare players will increasingly move to cloud in order to cut down on healthcare costs and better the quality of healthcare services. Critical healthcare applications can be hosted on cloud platform in order to increase their accessibility and availability. Apart from that, the following hardware, software and data can also be moved to cloud: email, electronic Protected Health Information (ePHI), picture archiving and communication systems,

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pharmacy information systems, radiology information systems, laboratory information systems, disaster recovery systems, databases and backup data.

Why healthcare organisations should move to cloud?

The advantages are manifold.

Cloud-based applications can easily scale up or down in accordance with changes in demand. Cloud allows utmost flexibility as well as accessibility. It lets healthcare firms to a secure, agile, and cost-effec-

tive environment.

One of the foremost advantages is with regard to the costs involved. Healthcare organisations can reduce IT costs to a great extent by adopting cloud.

Cloud-based software requires lesser resources for development and testing, meaning that fewer resources for maintenance and more robust solutions at a lesser cost. The estimate is that over a period of 10 years, cloud-based applications cost 50 per cent lesser than traditional in-house hosted appli-

cations.

A majority of cloud users have seen considerable cost reduction as a result of using cloud-based software and infrastructure. It requires only less development and testing resources, which will cut down on the expenditure for support and maintenance of applications. Studies have shown that cloud-based software can bring down costs by 50 per cent as compared to traditional software applications.

Healthcare firms can save

SURESH VENKATACHARI Chairman, 8K Miles Software Services

time also. Whereas cloudbased software get ready for use within six months, inhouse hosted apps will take one to three years to be developed and well tested before deployment.

Cloud also makes data accessibility to doctors who can diagnose and analyse the patients without spending too much time.

Another great advantage is improved efficiency. With cloud organisations need not spend too much on infrastructure. With early access to wide range of data, businesses can gather valuable insights about the performance of systems and plan their future strategy accordingly. Healthcare firms, hospitals and doctors can focus on their core objective – giving the best possible treatment and service to patient – while the cloud service providers take care of their IT needs.

Cloud-based software can be accessed 24x7 from anywhere by any authorized personnel. Apart from that, it is easier to recover from loss in case of natural disasters because of its distributed architecture. The cloud’s resiliency and high availability make it a cost-effective alternative to on-site hosted solutions.

There have been security concerns about cloud computing for a while. Such apprehensions were shared not only by pharma companies but also by other segments also. But today, such fears are allayed by the fact that cloud-hosted data is far more secure than data hosted on site and it is quite accessible. Cloud computing allows applications to run independently of hardware through a virtual environment running out of secure data centers. This allows employees to access same docu-

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Future of cloud In the days to come, cloudbased computing will remain as one of the topmost agendas with doctors, hospital managements, and patients seek costefficiency, security, and access to information.

As of now cloud is being used to manage business applications to attain financial efficiencies. The relevance of cloud is bound to increase in the days to come as we are heading to an era of virtual care and tele-medicine. IDC predicts that virtual care will become normal by 2018 with the possibility of estimated 70 per cent of routine doctor visits can be effectively managed through telemedicine. It is also predicted that by 2018, Internet of things (IoT) and big data

will be the deciding factors in almost 80 per cent of patient service interaction. This will effectively improve quality, value and timeliness. In order to a achieve all these, the healthcare segment needs to adopt healthcare cloud in a big way. Such an adoption is essential to achieve a flexible and highly scalable communications architecture.

This leads to several predictions about emerging trends.

The challenge before healthcare IT professionals is to make the organisation less reliant on capital-intensive technology investments and ensure flexible and scalable solutions. In order to ensure improved outcomes, healthcare companies ensure cash flow-generating activities which in turn will deliver results. The core advantage of cloud computing is that it lets healthcare organisations

stay focused on their core competency – that is the healthcare service – instead of worrying over other infrastructural hassles such as data centers, and the required professionals to maintain them.

The global healthcare cloud computing market is expected to reach

$

9.48 3.73

by 2020 from

$

billion billion

ments and apps anywhere, breaking barriers of geography and converting any place into a virtual 'office'.

in 2015 at a

CAGR OF 20.5 %

Future trends The healthcare industry is increasingly relying on cloud-based computing so that its players will remain collaborative, flexible, and target-focused.

Talking about the trends, in the days to come there will be more patient-clinician interaction on account of cloud. With care increasingly being delivered through wearable technology, mobile, alerts, and other new-age digital means, we can predict more fruitful and effective interactions between physicians and patients.

Another possible trend

will be the availability of real-time clinical records. Clarity and transparency will become a reality as both patients and healthcare professionals can access real-time data and health records, allowing the stakeholders to adopt a holistic picture.

Cloud can bring about a virtual health information exchange with democratisation of data. Soon we can expect a scenario where individuals will start taking ownership of their own health and data and start connecting their experiences with government organisations, educational institutions, etc.

These are only a few of the many benefits that cloud computing offers to the healthcare players. There are a lot more a cloud-based technology can contribute in improving a healthcare player’s long-term return on investment and scale operations.

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NABH accreditation guidelines for patient-friendly hospital design

DEEPAK VENKATESH AGARKHED General Manager –Engineering, Facilities & Quality

Deepak Venkatesh Agarkhed, General Manager –Engineering, Facilities & Quality, highlights the importance of designing hospital infrastructure as per NABH guidelines THE HOSPITAL X-Ray room wall was redone during hospital construction phase as room wall thickness was not 9 inch. A new air-conditioning unit added at pharmacy as temperature was more than 25o. NABH assessment pointed out that there is no child play area in hospital during assessment.

The above examples point out deficiencies in hospital infrastructure. The biggest challenge for any operating hospital to secure accreditation is modification in infrastructure.

The hospital project planning team normally takes inputs from various stakeholders like architects, service consultants and user team but tend to miss out on design considerations on NABH compliance with respect to infrastructure. In few cases the hospital planners try to justify their stand on facility requirement to hospital by using NABH as guidelines which may or may not be true.

As mentioned in the NABH website, accreditation results in high quality of care and patient safety. Adoption of NABH standards related to infrastructure will help hospitals to achieve an environment conducive for patient safety.

It is advised to go through the accreditation standards as part of hospital design and implement infrastruture requirements during the hospital construction phase.

The necessary infrastructural requirements in NABH accreditation guidelines are divided in three categories.

■ Statutory requirements: There are some mandatory re-

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quirements for accreditation of a hospital. NABH team invariably reviews all documents pertaining to legal compliances during their audit. ◗ The areas of imaging services like X-Ray, CT scanner unit should adhere to Atomic Energy Research Board norms.

The AERB website provides the details on facility planning. ◗ The blood bank should have 100 sq m for operations of blood bank, 50 sq m for preparation of blood components and 10 sq m for Apheresis are to be considered ■ Explicit requirements based on standard interpretation: These requirements are given

in the NABH guidebook as interpretation of standards and often accessed by NABH assessors to provide scores of particular standards. ◗ The space for each clinical service should be based on either national (like IPHS) or international standards, except in cases where directives of government agencies like AERB are laid out. ◗ The laboratory area, CSSD and rehabilitative service infrastructure should have adequate space to meet the defined scope of services. ◗ Patient rooms should consider the following ● The optimal space between two patient beds should be one to two meter.

● There should be clean utility area in wards and ICU to keep medicines in clean, safe and secure environment.

There should be a utility room in patient care areas to keep all types of wastes. ● A negative pressure isolation room should be provided for airborne cases like measles. ◗ Patient safety alarms i.e. both visual and auditory like nurse call bells, medical gas alarm units should be installed at designated locations in hospitals.

Fall prevention measures for elderly like anti-skid tiles and grab bars, ramps with railings for disabled should be provided for safe & secure environment to vulnerable patient group.

The handicap toilets for physi-

cally challenged people should be available. ◗ The paediatric service should be child friendly and should include playroom for children, breast feeding room. The CCTV camera should be installed in paediatric services to present child/neonate abduction. ◗ The space of worship for patients and their relatives is to be provided. ◗ The operating theatre should have facilities for pre-op holding, separate changing rooms for males and females, handwashing area, operating rooms, waiting area for relatives, storage area, collection area for waste and linen and recovery room. The layout of the theatre should be such that the mix of sterile and unsterile patients does not happen or if it is not possible the mix is reduced to the bare minimum. The operating theatre should have dedicated AHU and three stage/two stage air filter depending on type of OT. ◗ The ambulance parking should have demarcated space and access for is to There should be communication system between hospital and ambulance. ◗ The central storage area for medical supplies and consumables should be as per manufacturer’s guidelines with provision to keep high risk medicines like narcotics and hazardous materials in safe manner. ◗ The hospital kitchen should kept away from the traffic.

There should be a separate storage area to keep cleaning supplies away from food. The re should be a dedicated food preparation area provided in

hospital kitchen. ◗ Hazardous material storage, central waste collection area for keeping biomedical wastes should be provided. ◗ The engineering plant should have sufficient spaces for alternate sources like DG, compressor or vacuum plants. ◗Infrastructure for fire emergencies like fire water tanks, fire exit routes etc. should be planned as per NBC norms depending on the height of the hospital building.

◗ The following signages as mentioned below should available. ● Bi-lingual signages about clinical services provided by the hospital. The services not provided should also be clearly indicated. ● Bi-lingual signage display of patients’ rights and responsibilities in strategic locations like entrance/lobby of hospital, registration, billing, OPD and IPD area. ● Safety signage for imaging

services, as required by regulatory authorities. ● Bi-lingual fire signage like fire exit/no smoking etc. as per the requirement by statutory bodies should be provided. ● Hand washing signage as per WHO guidelines near hand washing area.

■ Implicit requirement based on standard interpretation: ◗ The provision of curtains in all examination rooms in OPD,

treatment rooms to ensure patients’ privacy and dignity. ◗ The patients in a temporary holding area should have provision of oxygen, suction provision and a few electrical sockets. ◗ Energy efficiency measures should be in corporated into infrastructure design like low power consumption LED lights, solar energy utilisation, rain water harvesting pits, variable frequency drives for AHU,

water and electrical meters at various locations and creation of landscaping gardens.

Modern day patients expectations from hospitals go beyond clinical outcomes and comprise various aspects including hospital infrastuture.

Hence, hospital infrastructure planning and execution with due consideration on accreditation points should no longer be considered as a wish list. It must be a mandatory part of any hospital design.

PRODUCT

HSIL launches Hindware Rimless WC HSIL HAS recently launched the Hindware Rimless WC to ensure efficiency in cleaning and maintenance, not only guaranteeing that hygiene standards are maintained, but also saving time in hightraffic environments. Ushering in a new era in flush technology, the rimless WC’s as the name suggests, have no rim.

In practice, having no rim means there’s simply nowhere for germs to hide and bacteria to build up, providing a 100 per cent clean and bacteria free environment. It is also the only WC brand in India which is recommended by the Indian Medical Academy of Preventive Health (IAMPH). In contrast to any conventional toilet, a rimless WC has multiple flushing points along the rim of the pan allowing the entire surface area of the pan to be cleaned easily.

Element Rimless WP

These WC also conserve water due to their exceptional flushing performance.

This enables one to save water with every flush, as the water gushing out is more powerful and more direct, thereby ensuring superior environment-friendly performance.

The Hindware rimless WC’s offers clean simple lines and contemporary styling suitable for any bathroom. These WC’s are a worthwhile, lasting investment that combines a timeless aesthetic to ensure its relevance for years to come.

The rimless WC is targeted at hospitals, hotels and offices and residential complexes The Hindware Rimless collection of WC’s has three different product offerings currently and two more products will be launched soon.

Lara Rimless WP

Enigma Rimless WP

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KNOWLEDGE I N T E R V I E W

‘About one in 10 of the people admitted to a hospital will contract a HAI’ Shailendra Trivedi, Director Channel Management & Operations at R&M India explains the importance of secure cabling solutions in reducing HAIs and R&M's offerings in this sphere, in an interview with Raelene Kambli Can you shed some light on the hospital acquired infections (HAI) scenario in India? How grave is the problem?

Hospital Acquired infections are contracted because of an infection or toxin that exists in a certain location of the hospital.

People now use nosocomial infections interchangeably with terms like healthcare associated infections (HAIs) and hospital-acquired infections. An HAI is an infection which was not present before someone underwent medical care.

One of the most common wards where HAIs occur is the intensive care unit (ICU), where doctors treat serious diseases. Research says that about one in 10 of the people admitted to a hospital will contract a HAI. They’re also associated with significant morbidity, mortality and hospital costs.

As medical care becomes more complex and antibiotic resistance increases, the cases of HAIs will grow. The good news is that HAIs can be prevented in a lot of healthcare situations with the right product solutions.

How does R&M contribute in reducing the HAI rate within hospitals?

The responsibility of HAI prevention lies with the healthcare facility. Hospitals and healthcare staff should follow recommended guidelines for sterilisation and disinfection.

Taking steps to prevent HAIs can decrease risk of contracting them by 70 per cent or more.

R&MhealthLine solutions have special additives that are permanently incorporated into

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plastic materials to inhibit the growth of bacteria and reduce the risk of cross contamination.

All parts of the cabling that are accessible to patients have antibacterial properties tested in accordance to ISO 22196. This test demonstrates protection against two bacterial strains, Staphylococcus aureus and Escherichia coli through cabling located near the patient’s bed.

This can assist in reducing the potential for cross contamination of disease causing bacteria.

Tell us about the need for secure cabling solutions within hospitals in India?

Clinics need extremely powerful networks with brilliant performance for fast transport of enormous quantities of data – for example those generated by imaging processes, virtualisation or storage systems. Structured cabling should ideally be capable of supporting a transmission performance of 10 Gigabit Ethernet (10 GbE). This high-frequency data transmission protocol demands network components of a special quality.

In addition, shielding against electromagnetic interference may often be required in clinic buildings to ensure data transmission without any time lag. Care has to be taken that the operation of large medical devices or interference from a wide variety of radio systems will not affect signal quality. As a leading specialist in shielded copper cabling, R&M provides high-performance systems which are exactly right for healthcare facilities. The two product families, Cat. 6A and Cat. 6A EL, offer unbeatable performance and complete protection

Clinics can extend their IT risk management to the field of hygiene by installing R&MhealthLine products for bits and bytes. The advanced insulation displacement contact technology in R&M’s copper modules also ensures long-lasting protection against corrosion and vibration for wire contacts.

How effective will antibacterial cabling be in preventing HAIs? On its own, a reliable network is not enough when there is a risk of cross contamination between

patients due to contact with cables and outlets. According to World Health Organization (WHO) around 16 million people die every year from infections contracted in hospitals.

R&M wants to make a contribution to reducing risks of this kind and to promoting health in clinics. The latest development is the R&MhealthLine antibacterial range. This is the first consistent and complete solution for cabling systems in patient rooms and comparable, highly-frequented areas of use. Clinics can extend their IT risk management to the field of hygiene by installing R&MhealthLine products.

What are the challenges faced by hospitals in choosing cabling solutions?

Even clinic areas with harsh and damp ambient conditions or with rigorous hygiene requirements (cleaning) can be reliably connected to the network using resilient R&M solutions for protection classes IP54 and IP67. Areas of use are laboratories and operating rooms, ambulances, supply stations for gases, fluids and refrigerants, or outdoors with access control and video monitoring.

The Splash Line retrofittable rubber grommet provides protection against splashing water and dust. It makes a simple RJ45 connector into a protection class IP54 connection. Splash Line can withstand cleaning agents and disinfectants. The IP67 type 6 plastic grommet ensures even higher protection. It protects connectors against mechanical loads such as shocks and im-

pacts. Grid clamps prevent connectors and cables from being pulled out in error. It is especially suitable for moveable equipment. The IP67 type 6 grommet is particularly suitable for waterproof connection of mobile devices to LAN sockets using cables.

What are the parameters for selecting such solutions?

There are unique protection and security requirements in the area around large diagnostic devices, in laboratories, and above all, in operating rooms. IT availability plays a key role here. The IEC 60601-1-1 standard (room category II) demands galvanic separation of medical equipment from the network to protect patients against overvoltage and to ensure devices operate reliably.

The maintenance-free R&MsafeLine network isolation module from R&M takes care of galvanic separation in the outlet. This product saves costly solutions in medical equipment and increases the reliability of data transmission. This innovative product provides device independent operation, complies with the standards, does not need any software or any power supply and fits into the R&Mfreenet platform range. R&MsafeLine can be installed in just a few simple steps. The transmission capacity goes up to 1000 BaseT Ethernet or 1000 Mbit/s. The dielectric strength is 4 KV AC. This means patients and medical technology have the best possible protection against currents and overvoltage. raelene.kambli@expressindia.com

TRADE & TRENDS

Dr Narendra Vaidya, Lokmanya Hospital, Pune, introduces X-press TKR technique to treat osteoarthritis The technique has yield rewarding results in the past few hundred surgeries TODAY, OSTEOARTHRITIS has witnessed a phenomenal rise, which is more common in elderly ladies, between the age group of 65 to 70 years. Sometimes, the younger generation suffers from rheumatoid arthritis, when Total Knee Replacement (TKR) is needed.

TKR has been a successful and rewarding procedure for years. There are inherent issues in classical TKR surgery.

The classical TKR surgery leads to extensive loss of soft tissues and bone fragments, losing of ligaments, inserting rods in the femur (thigh bone) all to maintain the angles of the skeletal structure of the limb.

TKR leads to prolonged rehab period and is one of the biggest obstacle at an old age,

patients tend to have other morbidities like DM, HTN, cardiac problems, renal issues etc.

To counter this, Dr Narendra Vaidya from Lokmanya Hospital, Pune, introduced X-press TKR technique, which benefits patients.

In X-press TKR technique, the posterior cruciate ligament along with the peripheral bone in the femur is not excised and various tissues and bone structures are preserved, resulting in faster mobilisation and less morbidity or disability of the limb. Secondly, ortho align instrument is used, which is a kind of navigation device and works on principles of accelerometer and gyroscope. It helps to guide in precision of defor-

mity/defects where rods are not inserted into the bones.

Thus TKR is not a replacement surgery but actually resurfacing procedure, where a cushion is inserted, which has a poly component inside and the patella is preserved. This technique has yield rewarding results in the past few hundred surgeries, which Dr Vaidya has performed, with excellent reduced rehab time.

In fact a patient can walk the same day and both the limbs can be operated on the same day. On second and third day, the patient can climb the stairs. This is because the ligaments and a lot of bone tissues can be preserved, thus leading to longitivity and lifetime of the implant.

BD launches BD Phoenix M50 System The new product delivers modularity, reliability, affordability and high-quality susceptibility results needed by clinical microbiology laboratories BECTON, DICKINSON and Company (BD), a leading global medical technology company, announced the launch of its next generation diagnostic instrument for the rapid identification of bacteria and detection of antimicrobial resistance (AMR).

The new BD Phoenix M50 ID/AST system helps deliver the same rapid, accurate and costeffective testing as the legacy BD Phoenix 100, within a smaller footprint. The system is highly reliable and requires no preventative maintenance, thanks to innovative materials and engineering techniques employed during

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its development.

“The healthcare community is facing unprecedented challenges with the spread of multi-

drug resistant organisms, and today’s clinical microbiology laboratories are under increasing pressure to provide fast and

accurate bacterial identification and antimicrobial susceptibility testing(ID/AST) results to influence clinical decision and outcomes. The BD Phoenix M50 system is an attractive solution for microbiology laboratories in India and intensifies our support to the fight against antimicrobial resistance,” said Noel Wentworth, Business Director of Diagnostics Systems for BD in Central and South Asia.

Neeraj Raghuvanshi, Business Director of Diagnostics Systems, BD in India added, “Over-the-counter access to an-

tibiotics is a problem. Improvements in clinical and laboratory practices, combined with effective deployment and use of medical technology, can help to ensure antimicrobials are utilised appropriately, reducing risk to patients and lowering costs associated with resistance. Antimicrobial resistance is a threat that can be solved with a collective effort and with the launch of our technology we want to play an active role in this public health challenge.”

Contact details: Visit bd.com/ds

TRADE & TRENDS

Lumens Medical: Life enhancing technology

LUMENS MEDICAL manufactures LED operation theatre surgical lights. Best quality LEDs are used by the company. Power drivers and power supply units are designed to give the best derived output of LUX from the LEDs. Cool lighting: Each satellite doom is provided with individual cooling fan system, to enhance the life of LED’s and reduce the overhead temperature on surgeons head to minimum and give cool light.

Colour correction: For colour correction, the company uses a central yellow LED and remaining pure white LED’s.

Focus: The pre-focussed alignment makes the positioning of dooms easy, with optimal illumination.

Intensity adjustment: Three level intensity adjustment make it suitable for any OT. Laminar flow compatibility: The dooms are designed to allow clear passage to laminar air without any obstruction.

The company manufactures products on private labelling also on OEM basis.

The designs can be customised and LUX intensity for contract manufacturing.

Service: All the modules and

boards are aligned on the dooms for very simple replacement, on site, in case of any defects .Since the boards are manufactured by the company directly, replacement availability is consistent and easy.

Contact details Lumens Medical 2-24-113/3/B/NR, Laxhminarayana Nagar, Uppal, Hyderabad-500039 Telangana

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TRADE & TRENDS

Meditek Engineers: Reforming healthcare,inspiring life Meditek Engineers is an ISO 9001:2008 and ISO 13485 certified company and is engaged in the business of manufacturing and marketing full range of medical beds and furniture 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. We have an efficient infrastructure and highly trained and multi-skilled 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 1989.

Meditek Engineers is an ISO 9001:2008 and ISO 13485 certified company and is 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 provides solutions for every need of the hospital. Meditek Engineers is headquartered in Mumbai. The display showroom and manufacturing plant is based in Ambernath near Mumbai. With exceedingly superior hospital solutions, the company has marked its international footprints in African countries.

The management The managing body of Meditek Engineering is a team of experienced domain experts. The team’s proficiency encompasses all the factors, necessary for the governance of a successful hospital equipment manufacturing company.

A state-of-the-art

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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 has developed a setup that is absolutely wellequipped and state-of-the-art as per global standards.

The company offers turnkey medical device manufacturing services that spans the entire supply chain from component procurement to distribution, all within a quality-controlled environment. It starts with working with to generate, develop and refine product concept to ensure all 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 surprisingly 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 make patient's stay comfortable.

1101A - Five Function ICCU BED (Manual) With split type safety side rail (Set of 4), polymer moulded head and foot board. ◗ Easily removable polymer moulded head and foot end boards for easy access to the patients. ◗ Approx. 60mm x 30mm

1102A - Three Function ICU Bed (Fixed height)

CRCA rectangular tube frame ◗ Four section perforated CRCA sheet top ◗ Three separate screws for backrest, knee rest and trendelenburg and reverse trendelenburg position by individual SS folding handles ◗ Four 125mm-dia non rusting castor wheel two with brake ◗ SS telescopic IV rods ◗ Urine bag holder ◗ Pretreated and epoxy powder coated

Manual with new design SS Collapsible side rail, polymer moulded head and foot board. ◗ 60mm X 30mm Approx

Contact details Mob: 9820855328 sales@meditekengineers.com

CRCA rectangular tube frame ◗ Four section perforated CRCA sheet top ◗ Stainless steel telescopic IV rod ◗ Four non rusting 125 mm dia. polyurethane casters 2 with brakes and 2 without brakes ◗ Pre-treated and powder coated

TRADE & TRENDS

Hemant Surgicals Industries: On a growth path The products are widely used in hospitals and acknowledged for being reliable, trouble free performance, optimum in functionality, highly efficient and have longer working life INCORPORATED IN 1985 in Mumbai, Hemant Surgical Industries has gained recognition as the leading manufacturer, exporter and importer of JMS range of products. Under the guidance of Hanskumar Shah, MD, Hemant Surgical Industries, the company has been able to supply quality assured range of surgical disposable and renal care products since its inception.

The products have been designed and manufactured under the supervision of quality controllers using excellent quality components and cuttingedge technology in compliance with the international quality standards. The prodcuts offered are widely used in hospitals and acknowledged for reliable, trouble free performance, optimum functionality, high efficiency and longer working life.

Moreover, Hemant Surgical Industries' offer product range in various specifications at industry leading prices.

After having gathered an enriched experience and knowledge in the field of medical and surgical products and being amongst the pioneers in the aforementioned field, the company expanded its reach in the Indian market by diversifying into the pharmaceutical sector.

With a goal to excel in its new pharma venture, it established state-of-the art facilities in its business of manufacturing small volume parenterals in vials and ampoules and external preparations. The facility layouts have been planned and developed in accordance with the current International WHO and GMP standards and it is spread across a plot area admeasuring 3100 sq.mts. The proposed facility is planned and developed as a ground plus one storey building. RCC is of 16,000 sq.ft.

The company has another facility situated at Atgaon which has a well-constructed infrastructural unit that is armed with innovative manufacturing technology and machinery. The unit facilitates skillful team members to manufacture a complete assortment in bulk at a very fast production rate. In addition to this, the company has segregated its infrastructure into many units such as procurement, designing, production, quality testing, research and development and warehousing and packaging. All these units are handled by an adept team of professionals, who holds rich industrial experience and knowledge. The company's professionals work in

With a goal to excel in its new pharma venture, the company has established state-of-the art facilities in its business of manufacturing small volume parenterals in vials and ampoules and external preparations

Product Range: Dialysis machines Refurb Fresenius 4008H Dialysis Machine Refurb Fresenius 4008S Dialysis Machine Nikkiso DBB-27 Dialysis Machine JMS SDS-50 Dialysis Machine

Dialysis equipment Dialysis RO Plant (100-1000 LPH) Dialysis Chair Bicarb Mixture Dialyzer Reprocessor Machine

Renal care consumables Dialyzer ( Size 1.4 to 1.6 ) Blood Line Tubing A.V.Fistula Heparin Sodium Injection Iron Sucrose (5 Ampule/Box) Concentrated Dialysis Fluid Citro - H Cold Sterilant Transducer Protector Dialysis Catheters

AERO Healthcare Devices Aero Pulse Oximeter Aero Oxygen Concentrator Aero Piston Compressor Nebulizer Aero Digital Thermometer Aero Anti Decubitus Mattress

JMS Surgical products JMS Meditape JMS Blood Transfusion Set JMS Scalp Vein Set (21G to 26G) JMS Infusion Set JMS Pediatric Infusion Set JMS Burette Set

Surgical products Skin Grafting Blade Skin Stapler 3 Way Stop Cock Disposable Scalp Vein IV CANNULA Silicone Foley Catheter (8F to 24F) Syringe (2ml to 20ml) Adult Diapers

close coordination in order to understand the specific requirements of clients. In the quality testing unit, each product ismeticulously inspected in compliance with a set international quality parameters in order to offer a perfect range at the clients' end. Crucial training sessions are also organised for team members in order to polish their skills and knowledge.

Highlights ◗ An exclusive importer of JMS Surgical Products (Japan) since 30 years ◗ Authorised importer for JMS Surgical products (Singapore) for their disposables pertaining to infusion and blood transfusion therapies ◗ Manufacturer of healthcare products under a brand name ‘AERO’ ◗ Specialised in carrying turnkey project for dialysis setup with regular supply of dialysis consumables which are manufactured by the company. ◗ The company has established a strong distribution network of more than 300 dealers. ◗ 24-hours technical assistance and excellent customer service. ◗ The company has successfully installed more than 900 dialysis machines Contact details Hemant Surgicals Industries Ecstasy Office No. 523, 6th Floor City of Joy Commercial JSD Road Mulund (West) Mumbai - 400080 Tel: 022 25912747 Mob: 9619484952 email: sales@hemant surgical.com

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TRADE & TRENDS

DiaSys Diagnostic Systems: Benchmarking quality Sachin Singh, Head : Strategic & Operational Marketing, DiaSys Diagnostic Systems, elaborates on changing Indian market dynamics, challenges the salient features they offer Indian market dynamics and challenges The diagnostic market has showcased several emerging trends over the past few years.

Some of most definitive trends have been advent of unique parameters in light of accuracy of test results compared to standard technologies. The clinical chemistry and immunodiagnostic market are undergoing significant transformation. They are meeting customer requirement of workflow solution and parameters available with unique features and with advances in diagnostic technologies by moving from immunology to chemistry platform using immunoturbidimetry principle which helps to provide the workflow solution.

This evolving market place creates existing opportunities of new instruments and reagent parameters.

Companies are launching different parameter of biochem-

istry reagents in closed systems which will create demand with expanding capabilities, thereby securing the future of next generation laboratory for unique test.

DiaSys Diagnostic Systems- Choosing quality DiaSys Diagnostic Systems is a specialist in the development and manufacturing of innovative diagnostic system solutions of highest quality, trusted by customers in more than 100 countries for over 25 years. The product portfolio comprises more than 90 plus clinical chemistry and immunoturbidimetric reagents for routine and special diagnostics including suitable calibrators and controls. The DiaSys instrumentation product range covers automated clinical chemistry analysers, semi-automated analysers and POC instruments for patient-near test-

Sachin Singh

ing. DiaSys India provides complete haematology solutions instruments, immunological reagents of advanced technology reagents along with controls and calibrators. Ecoline which is manufactured by the manufacturing unit of DiaSys Diagnostics India.

Technology Update-Next Gold Standard in HbA1c measurement: HbA1c FS

Diabetes constitutes a major health problem, since incidences are increasing rapidly worldwide and particularly in India.

To initiate intervention strategies and to overcome late diabetic complications, early diagnosis of diabetes is crucial. In the past glycated haemoglobin A1 (HbA1c) was used for monitoring diabetes only, but since 2011 HbA1c is also recommended by international organisations such as WHO and ADA as a suitable marker for the diagnosis of diabetes. DiaSys’ new enzymatic HbA1c assay - HbA1cNETFS – reveals outstanding specificity and precision. Moreover, this test correlates to HPLC but also to IFCC reference material and is unaffected by interferences from Hb variants. By application of HbA1cNETFS to the fully automated DiaSys system response910, workflow is optimized, due to the implemented on-board haemolysis, thus elimi-

nating error-prone and timeconsuming manual preparation.

Salient features ◗ Liquid-stable, ready to use 2component reagent ◗ 1-level calibrator (auto-dilution); 2-level control ◗ Wide measuring range: 20-150 mmol/mol IFCC (4-16 per cent DCCT/NGSP) within a haemoglobin concentration from 6 to 30 g/dLFS ◗ High calibration and on-board stability of up to 6 weeks ◗ Excellent precision ◗ Standardised against IFCC reference method, traceable according to DCCT/NGSP network

Contact details DiaSys Diagnostic Systems Alte Strasse 965558 Holzheim, Germany Phone: +49 (0) 6432 - 9146-0 Fax:+49 (0) 6432 - 9146-32 Email: info@diasys.de

India supports FDAban on dangerous powdered medical gloves The ruling marks only the second time in history that the FDA has banned a medical device THE MUCH awaited ban on dangerous powdered medical gloves will come into effect on January 19, 2017. The agency first proposed the ban back in March 2016 and issued a final ruling December 16, 2016.

This ban can be termed as one of the best New Year resolution taken by worlds largest

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US-based regulator. The ruling marks only the second time in history that the FDA has banned a medical device. The only other time the agency has banned a medical device was in 1983, when it banned prosthetic hair fibers.

The FDA determined that simply adding a warning label

to powdered gloves was not enough to address the risk, the agency said. "While medical gloves play a significant role in protecting patients, health care providers and other individuals in close proximity, powdered gloves are dangerous for a variety of reasons," the FDA said in a statement.

Ansell, a global leader in hand barrier protection segments, spearheads India and sub continent region with extensive powder free gloves portfolio. With an eye on futuristic clinical needs, the organisation also provides even safer solutions in the form of non latex powder free surgical and

examination gloves.

Hundreds of surgeons in India also participated in signature campaign in support of US FDA ban on powdered medical gloves. This campaign was organised at annual conference of surgeon and orthopedics in India which was collectively attended by almost 8000 delegates.

Ansell has taken an initiative to start making healthcare powder free in India, Pakistan, Sri Lanka, Bangladesh and Maldives. The region has started adapted powder free practice but marginally. Alke US, we also expect regulators out here to ban such clinically hazardous powdered medical gloves.

BUSINESS AVENUES

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BARIATRICS At Ease!

ISO 9001:2008 Certified Company

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Blood Bank Equipments

Blood / IV Fluid Warmer

Plasmatherm Blood Donor Chair

Blood Collection Monitor

Blood Bank Centrifuge

Biological Refrigerator

Platelet Incubator with Agitator

Benchtop Sealer

Centrifuge Bucket Equalizer

Blood Bank Refrigerator

Biological Deep Freezer

REMI SALES & ENGINEERING LTD.

Remi House, 3rd Floor, 11, Cama Industrial Estate, Walbhat Road, Goregaon (East), Mumbai-400 063. India Tel: +91 22 4058 9888 / 2685 1998 Fax: +91 22 4058 9890 E-mail: sales@remilabworld.com l Website: www.remilabworld.com

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Business Avenues Please Contact: ■ Mumbai: Douglas Menezes 91-9821580403 ■ Ahmedabad: Nirav Mistry 91-9586424033 ■ Delhi: Ambuj Kumar / Gaurav Sobti 91-9999070900 / 91-9810843239 ■ Chennai/Bangalore: Mathen Mathew / Amit Tiwari 91-9840826366 / 91-8095502597 ■ Hyderabad: E.Mujahid 91-9849039936 ■ Kolkata: Ajanta 91-9831182580

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LIFE PEOPLE

Neeraj Lal joins Rainbow Hospitals Lal takes over as Vice President and Cluster Head, Bengaluru

E

nding a 12 year stint in Gujarat, Neeraj Lal, currently COO, Sunshine Global Hospitals, Vadodara will move to the Garden City as Vice President and Cluster Head of Rainbow Hospitals Bengaluru by January.

Rainbow Hospitals is a chain of paediatric hospitals, head-quartered in Hyderabad.

Lal was attracted to the opportunity to work with a group focused on paediatric and maternal care, as this segment is receiving considerable attention from investors as well as the government. The hospital

was one of the early healthcare players to raise PE funding, when it bagged `100 crore ($17.5 million) from the UK-based development financial institution CDC Group Plc and Dubai-based private equity investor Abraaj Group in 2013.

The Group currently has six centres in home city Hyderabad including one in Vijaywada, three in Bengaluru and plans to expand to New Delhi, its first in the North market by February 2017. Lal indicated that Mumbai and Chennai are next on the anvil.

Speaking to Express Healthcare, Lal says that his family will continue to be based in Ahmedabad. He jokes that wife, Neha, Senior GM, Operations & HR, GCS Medical College, Hospital & Research Centre, Ahmedabad already complains about him being a weekend dad to their eight-year-old son Rudra. He believes that this is the age a son needs his mother more than a dad and has promised her that he’ll take over as the ‘stern’ dad in a few years time!

EH News Bureau

OBIT: DR RAKESH SINHA

Never sayAdieu

D

r Rakesh Sinha’s successful journey as a doctor par excellence, a teacher, mentor, an entrepreneur, a fitness enthusiast and a writer has demonstrated that people can take on different roles in life and

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achieve greatness in each of these spheres, without being distracted. He was indeed a multifaceted personality, a vivacious individual and an exceptional human being.

Dr Sinha's clinical expertise noteworthy. He holds two

Guinness World Records for laparoscopic gynaecological surgeries. He was the former president of the Indian Association of Gynaecological Endoscopist. Also, Dr Sinha was an internationally-certified motivational speaker and a licentiate practitioner for Neuro Linguistic Programming (NLP). He has been featured on Jack Canfield’s Success Profiles. Additionally, Dr Sinha was the Founder and MD, Women’s Hospital, a specialised hospital for minimal access surgeries, and has also done a Post Doctorate Clinical Fellowship in Endoscopy at the Royal Free Hospital in London.

Each time, I have met him in the last five years, I have known him to be an extremely positive person, with a tremendous willpower to chase his dreams. The most

striking quality was his character of integrity. He would never say no to work, nor would he ever let down a patient. He loved his job and believed in sharing his knowledge and expertise with fellow workers as well as his students.

He once said to me, “I have achieved success in clinical practice and I am happy about it, but this drives me to pass on this knowledge to my students and colleagues so that more people can benefit and more importantly, this expertise of treating people should not fade out when I wont be around”.

Dr Sinha was very inspiring while teaching management lessons. When I met after the launch of his first book Anatomy of Success, he gave a different perspective on achieving success in life. His

words still linger in my mind, “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.”

Apart from this, Dr Sinha believed in maintaining a balance in life. For him, living a happy, healthy and spiritual life was imperative.

His sudden death has therefore shocked us. A man who never slowed down has suddenly left us. But his work and words are here to stay.

With a contrite heart, I share a few words of wisdom that he left me with, “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.”

(Compiled by Raelene Kambli)

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