On December 19, 2016, the US FDA published a final rule to completely ban all powdered surgical and examination gloves. They judged that these products present an unreasonable and substantial risk to healthcare providers and patients. This rule is effective in the US as of January 18, 2017. Also hospitals in Europe and other regions are increasingly transitioning to powder-free gloves. An evolution that is set to accelerate on a global scale. So if you are still using powdered gloves: now is the time to change. As a world leader in providing superior health and safety protection solutions, we contiuously look to better protect patients and healthcare workers. That’s why we are initiating a new communication program to continue informing hospitals and healthcare workers on the benefits of powder-free surgical gloves. For both, there is significant clinical evidence that powder-free gloves offer numerous benefits: ! For patients, powder-free gloves can improve wound healing, prevent allergic reactions and decrease false test results. ! For healthcare workers, it can reduce allergic and other skin reactions and improve hygiene. If you share our concern for your own and the patient’s well-being and safety: consider the use of powder-free gloves, if it is not yet the case.
SCAN THIS QR CODE TO TRY FREE SAMPLES OF ANSELL’S POWDER FREE GLOVES
CHECK OUT THIS EYE OPENING VIDEO BY ANSELL
J. K. Ansell Private Limited Raymond Complex, Pokhran Road No.1, Jekegram, Thane (West) 400 606 II Tel: (022) 6152 7000 medical@jkansell.in l www.ansell.com
l
Fax: (022) 6152 7752
CONTENTS MARKET Vol 11. No 5,MAY, 2017
Chairman of the Board Viveck Goenka
FUTURE TRENDS IN RADIOLOGY
Sr Vice President-BPD Neil Viegas Editor Viveka Roychowdhury* Chief of Product Harit Mohanty
08
SECOND EDITION OF HEALTHCARE SENATE TO BE HELD IN HYDERABAD
09
17TH EDITION OF MEDICALL TO BE HELD IN CHENNAI
10
JP NADDA INAUGURATES INDUCTION TRAINING PROGRAMME FOR NEW RECRUITS OF CHS
10
HEALTH MINISTRY LAUNCHES ‘TEST AND TREAT POLICY FOR HIV’
BUREAUS Mumbai Usha Sharma, Raelene Kambli, Lakshmipriya Nair, Sanjiv Das, Mansha Gagneja Delhi Prathiba Raju Design National Design Editor Bivash Barua Asst. Art Director Pravin Temble Senior Designer Rekha Bisht
Radiology Special| P-29-39
Graphics Designer Gauri Deorukhkar Artists Vivek Chitrakar, Rakesh Sharma Photo Editor Sandeep Patil MARKETING Regional Heads Prabhas Jha - North Harit Mohanty - West Kailash Purohit – South Debnarayan Dutta - East Marketing Team Ajanta Sengupta, Ambuj Kumar, Douglas Menezes, E.Mujahid, Mathen Mathew, Nirav Mistry, Rajesh Bhatkal PRODUCTION General Manager BR Tipnis Manager Bhadresh Valia Scheduling & Coordination Ashish Anchan CIRCULATION Circulation Team Mohan Varadkar
INTERVIEWS
STRATEGY
P21: DR VIJAY SATBIR SINGH Additional Chief Secretary, Health, Govt of Maharashtra
P24: REKURAM VARADHARAJ Co-Founder and COO, healthi
P25: BIPLAB CHATTERJEE CEO, Bureau of Pharma PSUs of India
P27: SOUMYA KANTI PURKAYASTHA CEO, Berkeley HealthEDU
P40: DR SURESH REDDY VP, Association of American Physicians of Indian Origin
41
MEDTRONIC INDIA: FURTHER, BUT NOT TOGETHER?
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
Finding a middle path
T
he government’s commitment to rein in the cost of healthcare, has pitted various stakeholders of the sector against each other. For instance, soon after National Pharmaceutical Pricing Authority’s (NPPA) February 21 notification to fix ceiling prices on heart stents, medical device manufacturers/importers pointed out that procedure costs and specialist doctors' fees were at the discretion of hospitals. Similarly, when Prime Minister Modi announced that there would soon be a legislation to mandate that doctors prescribe generic medicines, associations representing doctors across India, while supporting the move, deflected the attention to the weak drug monitoring infrastructure as well as the poor quality record of pharmaceutical companies. While the government has succeeded in shaking up these traditional alliances, will we see a new normal? The NPPA seems in no mood to back down. In its latest memo dated April 28, it has threatened to prosecute medical device manufacturers/ importers under the relevant provisions of the Essential Commodities Act, if they do not submit weekly production and distribution schedules of heart stents. The memo points out that not a single company has complied with this part of its February 21 notification to date. This rap on the knuckles comes two days after it rejected the applications of two MNCs, Abbott and Medtronic India, who requested withdrawal of their high end stents from the India market, on the grounds that post the price caps, it was unviable to do so. A similar application of a third MNC, Boston Scientific, was still under review at the time of going to press. According to a Grant Thornton report, India is the fourth largest medical devices market in Asia, (trailing Japan, Chain and South Korea). Estimated at $4.2 billion in 2014, India's medical device is expected to grow at a CAGR of 16 per cent during 2014 – 2018, according to a FICCI-QuintilesIMS paper, Medical Technology Sector in India – Enabling Swastha Bharat. Thus it is no wonder that the industry is trying hard to change the pricing watch dog's stance. Having realised that the government cannot
6
EXPRESS HEALTHCARE
May 2017
The larger question is, what happens after the sixmonth validity of NPPA’s February21 order? Will there be an extension beyond August?
and will not back down completely on the price cap issue, the effort now seems to be to win the ideological battle and find niches where smaller victories can be won. For instance, an April 28 statement from Medical Technology Association of India (MTaI) makes the case for ''categorisation so that quality and innovation are rewarded to keep that segment attractive and viable.' Supporting this reasoning, AdvaMed, another device association, provides a classification system for DES, where a majority of stents are in Class 1 DES, Class 2 - DES for complex cases and Class 3 - Innovative DES. The larger question is, what happens after the six month validity of NPPA’s February 21 order? Will there be an extension beyond August? While May 1 is celebrated as Labour Day across the world, Maharashtra and Gujarat also mark their state formation on this day. But an analysis of Maharashtra's status on public health in the May issue of Express Healthcare raises some red flags. In a comparison of 21 states, Maharashtra state topped a health index brought out last October. The study by the Indian Institute of Management-Ahmedabad placed Maharashtra as the best performer, followed closely by Tamil Nadu and Kerala, in terms of performance-based output which took into account the inputs available or created. The study spanned over five years of data from 2008 till 2012. But is the success story in danger of unraveling? As the cover story analyses, Maharashtra’s public health spend has declined in the past three decades, from one per cent of GSDP in 1985-86 to just 0.49 per cent in 2017-18. If this is the case, then the state's vision of a disease-free, Arogya Maharashtra seems a tall task. (See story, 'Arogya Maharashtra' – Reality or mirage?, pages 12-16, May Express Healthcare). Of course, the next health index from IIM A might just have Maharashtra again topping or near the top of the health index, because it measures not just quantum of resources invested but efficiency of implementation. Watch out for analyses of more states in forthcoming issues and as always, do keep the feedback coming in. VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com
LETTERS QUOTE
APRIL 2017
Antimicrobial resistance is a serious threat to global public health that requires action across all government sectors and society and is driven by many interconnected factors. Single, isolated interventions have limited impact and coordinated action is required to minimise the emergence and spread of antimicrobial resistance
JP Nadda Check out the online version of our magazine at
www.expresshealthcare.in
HEAD OFFICE Express HealthcareÂŽ MUMBAI Douglas Menezes The Indian Express (P) Ltd. Business Publication Division 2nd Floor, Express Tower, Nariman Point Mumbai- 400 021 Board line: 022- 67440000 Ext. 502 Mobile: +91 9821580403 Email Id: douglas.menezes@expressindia.com Branch Offices NEW DELHI Gaurav Sobti The Indian Express (P) Ltd. Business Publication Division Express Building, B-1/B Sector 10 Noida 201 301 Dist.Gautam Budh nagar (U.P.) India. Board line: 0120-6651500.
Union Minister of Health and Family Welfare at Inter-Ministerial Consultation on AMR containment in New Delhi
Mobile: 91-9810843239 Fax: 0120-4367933 Email id: gaurav.sobti@expressindia.com CHENNAI Mathen Mathew The Indian Express (P) Ltd. Business Publication Division 8th Floor, East Wing, Sreyas Chamiers Towers New No 37/26 (Old No.23 & 24/26) Chamiers Road, Teynampet Chennai - 600 018 Mobile: +91 9840826366 Email id: mathen.mathew@expressindia.com BENGALURU Mathen Mathew The Indian Express (P) Ltd. Business Publication Division 502, 5th Floor, Devatha Plaza,
Residency road, Bangalore- 560025 Board line: 080- 49681100 Fax: 080- 22231925 Mobile: +91 9840826366 Email id: mathen.mathew@expressindia.com HYDERABAD E Mujahid The Indian Express (P) Ltd. Business Publication Division 6-3-885/7/B, Ground Floor, VV Mansion, Somaji Guda, Hyderabad – 500 082 Board line- 040- 66631457/ 23418673 Mobile: +91 9849039936 Fax: 040 23418675 Email Id: e.mujahid@expressindia.com
Under the pressures of demographic ageing, rapid urbanisation, and the globalized marketing of unhealthy products, chronic non-communicable diseases have overtaken infectious diseases as the leading killers worldwide. Increased political attention to combat heart attacks and stroke, cancer, diabetes, and chronic respiratory diseases is welcome as a powerful way to improve longevity and healthy life expectancy.
Dr Margaret Chan Director-General,WHO
The Indian Express (P) Ltd. Business Publication Division JL No. 29&30, NH-6,Mouza- Prasastha & Ankurhati,Vill & PO- Ankurhati, P.S.- Domjur (Nr. Ankurhati Check Bus Stop) Dist. Howrah- 711 409 Mobile: +91 9831182580 Email id: ajanta.sengupta@expressindia.com
AHMEDABAD Nirav Mistry The Indian Express (P) Ltd. 3rd Floor, Sambhav House, Near Judges Bunglows, Bodakdev, Ahmedabad - 380 015 Mobile: +91 9586424033 Email Id: nirav.mistry@expressindia.com
Important: Whilst care is taken prior to acceptance of advertising copy, it is not possible to verify its contents. The Indian Express (P) Ltd., cannot be held responsible for such contents, nor for any loss or damages incurred as a result of transactions with companies, associations or individuals advertising in its newspapers or publications. We therefore recommend that readers make necessary inquiries before sending any monies or entering into any agreements with advertisers or otherwise acting on an advertisement in any manner whatsoever.
KOLKATA Ajanta Sengupta
EXPRESS HEALTHCARE
7
May 2017
MARKET PRE EVENTS
Second edition of Healthcare Senate to be held in Hyderabad The event from September 7-9, 2017, will revolve around the theme ‘Building a Future Ready healthcare sector for India’
A
fter the successful event of Healthcare Senate in 2016, Express Healthcare is ready to launch the second edition of healthcare Senate with the theme, ‘Building a Future Ready healthcare sector for India.’. The summit will be held in Hyderabad from September 79, 2017. Thought leaders from the healthcare industry will congregate to share knowledge, innovative ideas and build healthy connections. The following topics will be covered at Healthcare Senate 2017. Topics to be covered in panel discussions: ◗ Overcoming obstacles in business expansion: This panel experts will discuss strategies, infrastructure required and resource development needed for expansion of businesses. ◗ Healthcare policies: Are they making or breaking the sector?: Association heads of AIMED, NATHEALTH, NABH, AHPI, NPPA and government officials will discuss the impact
of the pricing policies, quality codes etc., on the sector. The panel will further discuss if there is a need for an affordability act in India. ◗ Fighting the Antibiotic Apocalypse: Infection control experts, hospital administrators, pharma companies, NABH representatives will discuss ways to control the increasing burden of antibiotic resistance ◗ Ensuring cost efficiencies within capital intensive department: Radiology department heads of hospitals, imaging diagnostic promoters, Cath lab heads, OT heads and hospital CFOs will discuss how to reduce
operating costs of these capital intensive departments to make the business profitable. ◗ People first: Hospital CEOs, promoters, nursing heads, HR heads, management consultants will discuss on building talent and capabilities for the future. ◗ Revenue cycle transformation- a must for healthcare organisations: Hospital CA, financial experts, hospital CFOs, COO or CEO and PE investors will discuss on ways and means to increase their net revenue, accelerate cash flow, and reduce costs by addressing people, process, and technology components within their hospitals.
Single sessions: ◗ Building an effective supply chain inventory management system ◗ Developing a physician leadership programme within hospitals ◗ Effective brand building for business success ◗ Understanding medical laws: a must for healthcare providers ◗ Medical tourism: An ocean of opportunities for India ◗ Evolving role of hospital pharmacies in India To register: Contact: Vinita Hassija Mobile: 9820590053 Email: vinitahassija@gmail.com
71st annual conference of IRIA to be held in Mumbai THE BIANNUAL conference AOCR 2018, the 17th Asian Oceanian Congress of Radiology and the 71st Annual Conference of the Indian Radiology and Imaging Association (IRIA) will be held in Mumbai from January 25 to 28, 2018. The event will see four days of lectures spread across five halls, six halls for presentation of scientific papers, E posters on screens across the conference arena, more than 20,000 sq feet of space for scientific exhibits, Mumbai Chaat Street, three consecutive nights of top-notch social events. A strong participation from AOSR group of countries is expected for this event, with participation from international and national faculty. Notable faculties, who will participate in the event are, Richard Barr, Professor of Radiology, Moulay Meziane, Dr. Deepak Patkar, Director, Medical Services, Dr Bhavin Jankharia, Radiologist, Dr Sanjay Vaid, Consultant Radiologist, Dr Parvez Masood, Radiologist, Dr Nitin Chaubal, Dr A. Anbarasu, Dr Ashok Khurana, Shrinivas B Desai, Dr Chander Lulla and Dr Bijal Jhankaria.
Hospital Planning & Infrastructure to be held in Nagpur HPI will focus on opportunities in the Indian healthcare sector and bring together solution providers to discuss the challenges of building sustainable and profitable hospital infra HOSPITAL PLANNING & Infrastructure (HPI), India’s only international exhibition and summit focussed on the challenges of building sustainable and profitable hospital infrastructure across the region, will be held in Nagpur on June 16,
8
EXPRESS HEALTHCARE
May 2017
2017. HPI is a perfect platform for companies showcasing highend capital goods and trying to win tenders, drive sales and increase their market share in the healthcare build space. The event will be organised by the IDEX.
HPI in its third edition, is set to raise the benchmark for the hospital infrastructure industry with leading and relevant names at the show, because it's here where 'Decision Makers Get Together and Business Happens.'
HPI will focus on tremendous opportunities in the Indian healthcare sector and brings together solution providers to discuss the challenges of building sustainable and profitable hospital infrastructure across the region. It is organised with the
objective to contribute towards the healthcare sector by educating and spreading knowledge. Speakers featuring some of India's top leading professionals in the sector will discuss the importance of design and planning in healthcare facilities.
MARKET
17 edition of Medicall to be held in Chennai th
Medicall will serve as a platform to share expertise with the fellow medical fraternity
tants, promoted by Dr Manivannan, Joint Managing Director, Kauvery Hospital, a1000 bedded hospital in South India. This hospital was started 11 years back with 30
THE 17TH edition of Medicall will be held in Chennai from July 28, 29 and 30, 2017 and the 18th edition in Mumbai from October 6, 7 and 8, 2017. Express Healthcare is the media partner for the event. The exposition will be attended by doctors – physicians and surgeons. hospitals owners and decision makers, dealers distributors and manufacturers of medical equipment, owners of diagnostic and other healthcare centres, medical directors, academicians, biomedical engineers, key policy makers from the governmental sectors, purchase managers, healthcare professionals and paramedical staff and healthcare consultants. Exhibitors profile include building automation and facility management, consumables, electrical and lighting solutions, endoscopy equipment, healthcare consultants, healthcare IT solutions, hospital beds, furniture and floorings, housekeeping solutions, HVAC and Medical Gas, implants, laboratory equipment, laundry equipment, life support systems, mannequins and teaching equipment, medical disposables, OT & ICU equipment, patient monitoring systems, physiotherapy and orthopaedics, radiology equipment, recycling and hospital waste management, refurbished equipment, rehabilitation products, sterilisers, surgical instruments, telemedicine, wound care products. It will be organised by Medexpert Business Consul-
EXPRESS HEALTHCARE
9
May 2017
beds by young professionals with limited knowledge about hospital industry. Medicall was born with the idea to share their expertise with the fellow medical fraternity.
Sundararajan – Project Director is assisted by a dedicated team of professionals who have vast experience in the industry. Since MEDICALL is being organised by
people who have been in this field for many years, the content and the quality of the visitors are expected to be better than any other previously held event.
MARKET
JP Nadda inaugurates induction training programme for new recruits of CHS Urges them to imbibe new thoughts and experiences to enhance their skills THE UNION Minister for Health and Family Welfare, JP Nadda inaugurated the firstever induction training programme for the newly appointed General Duty Medical Officers (GDMOs) of the Central Health Service (CHS) Cadre at National Institute of Health and Family Welfare (NIHFW), at New Delhi. Faggan Singh Kulaste and Anupriya Patel, Ministers of State for Health and Family Welfare, also graced the occasion. In his address, Nadda congratulated NIHFW and the Ministry for designing this nine week training module for the new recruits. Nadda urged them to keep an open mind and imbibe new thoughts and experiences. “Please switch on your receptors for communication to take place. The more you learn, you will understand that you know so little,” Nadda said. “This is the first time such
a foundation training programme is being undertaken. This will also orient you to your roles and responsibilities about healthcare delivery systems in the country, legal ethical issues, and schemes programme of the Ministry, OPD, emergencies, pharmacies, administration AYUSH, Yoga, etc. You will learn new things,” Nadda mentioned. Nadda further stated that the course provides an opportunity to expand ones horizons, learn the philosophy and depth of life. “Trainings pro-
vide a platform to further know your strengths, weaknesses and be dedicated to your service,” Nadda added. Speaking at the function, Kulaste said that these trainings will provide an opportunity to enhance the existing potential and skills for being more effective medical officers. “The nine week course especially designed for the new recruits will enable the medical officers to broaden their knowledge base, confidence level and experience in public health facilities,” Kulaste said.
Patel stated that this course will contribute greatly to the public healthcare of the country. “With technical skills, soft skills are also important as doctors deal with lives and wellbeing of patients,” she said. Encouraging the participants, she stated that understanding administrative procedures, enhancing inter-personal behavioural skills and better knowledge of healthcare schemes/ programme will improve their capacity for higher efficiency. CHS Cadre is a cadre governed by the MoH&FW and its
doctors are working all over the country providing health care services to a large number of people. CHS has four sub-cadres, namely, GDMOs, teaching, non-teaching specialists and public health, with a sanctioned strength of more than 4000 of which the GDMOs constitute the largest chunk, more than 2000. On an average, every year around 400 to 600 doctors are recruited through UPSC. Incidentally, throughout the under-graduate and post-graduate education and thereafter, these doctors are not been trained in the areas of management, supervision, leadership, communication, conduction of office procedures, etc. The training module is designed to fill this gap so that they can look after the administration of the organization and implementation of various national health programmes for which they have very limited exposure.
Health Ministrylaunches ‘Test and Treat Policyfor HIV’ Nadda states that anybody who is tested and found positive will get ART irrespective of CD count or clinical stage “AS SOON as a person is tested and found to be positive, he will be provided with ART irrespective of his CD count or clinical stage.” This was stated by the Union Minister for Health & Family Welfare, JP Nadda at the launch of the ‘Test and Treat Policy for HIV’, at a recently held event in New Delhi. “This will be for all men, women, adolescents and children who have been diagnosed as a HIV + case. This will improve longevity, improve quality of life of those infected and will save them from many op-
10
EXPRESS HEALTHCARE
May 2017
portunistic infections, especially TB,” Nadda further added. The Health Minister also announced that India will soon develop a National Strategic Plan for HIV for next seven years and these seven years will be crucial for ending AIDS. JP Nadda also felicitated eight scientists and community workers for their exemplary work in the field of HIV/AIDS. Laying stress on addressing stigma and discrimination towards HIV, Nadda said that ending stigma is of paramount
importance to enable persons infected and affected with HIV access health services. “To facilitate reduction in stigma and discrimination, the long pending HIV/AIDS Act has been passed very recently, which is an historical step. Very few countries globally have such a law to protect rights of people infected with HIV,” Nadda elaborated. The Health Minister further informed that the key provisions of HIV/AIDS Bill are prohibition of discrimination, informed consent, non-disclosure of HIV status, anti-retro-
viral therapy and opportunistic infection management, protection of property of affected children, safe working environment and appointment of ombudsman in every state. Speaking on the occasion, Nadda said that the Health Ministry has intensified its efforts to find all those that are estimated to be infected with HIV. “Out of 21 lakh estimated with HIV, we know only 14 lakh. To detect remaining we have revised national HIV testing guidelines and are aiming to reach out to people in commu-
nity and test them where they are, of course with proper counselling and consent,” Nadda mentioned. “We have nearly 1600 ART and Link ART sites where treatment is provided across the country and recently we crossed the one million people on ART, second country in world to have such large numbers on free lifelong treatment. We have been able to avert 1.5 lakh deaths due to ART and we will be able to avert 4.5 lakh more deaths by expanding provision of ART,” Nadda informed.
MARKET
MoH&FW announces finalisation of national action plan to contain AMR Pledges to adopt a holistic and collaborative approach towards prevention and containment of antimicrobial resistance JP NADDA, Union Minister of Health and Family Welfare announced the finalisation of India’s comprehensive and multisectoral national action plan to contain antimicrobial resistance (AMR) at the recently held ‘Inter-Ministerial Consultation on AMR containment’ in New Delhi. Ram Vila Paswan, Minister of Consumer Affairs, Food & Public Distribution, Anil Madhav Dave, Minister of Environment, Forest & Climate Change, Anupriya Patel, MoS (Health & Family Welfare) were also present on the occasion. The Ministers signed a ‘Delhi Declaration’ for collectively strategising to contain AMR. It pledges to adopt a holistic and collaborative approach towards prevention and containment of antimicrobial resistance (AMR) in India. It calls on all stakeholders including UN, WHO, FAO and other UN agencies, civil society organisations etc., to support the development and implementation of the national and state action plans on AMR. Nadda highlighted, “Antimicrobial resistance is a serious threat to global public health that requires action across all government sectors and society and is driven by many interconnected factors.” CK Mishra, Secretary (MoH&FW), Dr Soumya Swaminathan, Secretary (DHR) and DG (ICMR), Dr (Prof) Jagdish Prasad, DGHS, Prof K Vijay Raghavan, Secretary (DBT) and Dr Henk Bekedam, WHO Representative to India and other senior officers of the Health Ministry were present along with representatives from Ministries of Agriculture, Pharmaceuticals, Information and Broadcasting, Chemicals and Fertilizers, Water and Sanitation, AYUSH, Food Processing Industries, ICMR, NCDC.
EXPRESS HEALTHCARE
11
May 2017
cover )
12
EXPRESS HEALTHCARE
May 2017
(
F O C U S : M A H A R A S H T R A P U B L I C H E A LT H
AROGYA D MAHARASHTRA AREALITYOR MIRAGE? With the state’s public health spend declining from one per cent of GSDP in 1985-86 to just 0.49 per cent in 2017-18, will Arogya Maharashtra become a reality? BY PRATHIBA RAJU
espite Maharashtra being one of the affluent states in the country with the highest Gross State Domestic Product (GSDP), contributing 14.42 per cent of India’s GDP and ranking highest in industrialisation, yearover-year the state’s expenditure on public health has dipped as a proportion of the GSDP, declining from one per cent in 1985-86 to a dismal 0.49 per cent for 2017-18. The low levels of public health spending reflect the shortfalls in the public health system, be it health facilities, shortages of specialists and deteriorating health infrastructure. The state’s annual budget allocated for 2017-18 was ` 8,195 crore in public health sector, which was 5.4 per cent less than what was spent by the state last fiscal year, raising eyebrows over the state government’s commitment towards Arogya Maharashtra.
Crippling health budget a pitfall? Stepping up investment in public healthcare is pivotal for sustainable economic growth. Though Maharashtra health indicators are better than the national average, they are certainly not equivalent to its economic development, according to experts. A study by New Delhi-based International Institute of Health Management Research (IIHMR) stated that the state needs to increase its health spending to over ` 7,400 crore by 2018. “Maharashtra health budget needs to be a little more ambitious to overcome the lack of public health and medical facilities and fill in skill gaps of
huge vacancies in rural hospitals, primary health centres (PHCs) and other centres as well. The annual budget allocated for the health sector has to be increased to address the rising cost of medical care, especially in view of the growing rate of urbanisation,” the study stated. According to World Health Organisation (WHO), every state government should spend five per cent of the GSDP on healthcare. Giving insights into why Maharashtra should improve its health budget, Dr DK Mangal, Dean Research, Indian Institute of Health Management Research (IIHMR) University, Jaipur, said, “With rising healthcare inflation, year-onyear the health budget should increase rather than decrease. Maharashtra’s health indicators may be better than the national average but they are certainly not commensurate to its economic development. If the state has to maintain its achievements in infant mortality rate (IMR), maternal mortality rate (MMR) and further reduce them and move towards the sustainable development goals (SDG), it needs to allocate more budget towards health in next five to ten years. I cannot find any justification for the reduction of the health budget. On the account of efficiency, leveraging other funds could be some justification, but I don’t think that will explain this reduction. The only justification by the state government could be that they would have some competitive priorities on which they wanted to allocate, and may be they would enhance the budget in subsequent years. Moreover, in view
EXPRESS HEALTHCARE
13
May 2017
cover ) In view of the new National Health Policy where it has been mentioned that the states have to increase allocation for the spending of health sector from the current level of 5.6 per cent to eight per cent, the state’s budget should have been enhanced, not reduced.
The budget allocation depends upon the total revenue and money available with the state government and at times there is a shortfall in the resources. That becomes the main reason for the state government not being able to provide sufficient funds
A share of state health spending in state’s aggregate expenditure indicates a sense of prioritisation that any states attaches to healthcare.That is why the new health policy has set an ambitious target of raising this share in each state to eight per cent by 2020
Dr DK Mangal
Dr Vijay Satbir Singh
Dean Research, Indian Institute of Health Management Research (IIHMR) University, Jaipur
Additional Chief Secretary, Health, Government of Maharashtra
Development Economist, formerly with the Bill & Melinda Gates Foundation and the World Bank
14
EXPRESS HEALTHCARE
May 2017
ambitious scheme is Mahatma Phule Jan Aarogya Yojna, cashless treatment for the poor, for which the budget allocated is ` 1,000 crore. These two schemes take away about ` 1300 crore of the total money available. Due to this, the other health schemes face fund crunch. These are the few teething problems, but we are making efforts to make sure that money is made available for every important health scheme,” Singh said. Singh also said that unlike other states, in Maharashtra you can find that health sector has several resources to fund its schemes. “Urban areas like Mumbai have Brihanmumbai Municipal Corporation (BMC). They provide funds for their jurisdiction. As far as the Mumbai city is concerned, most of the health schemes are looked after by BMC. Apart from it, we have King Edward Memorial (KEM) Hospital, LTMG Sion, BYL Nair and Cooper Hospital, which are entirely funded by BMC. So you should not look at the amount of money spent only by public health department. You should also take into consideration the money spent by BMC and other corporations in their jurisdiction in urban areas. We have medical
Source - National Health Profile, Ministry of Health & Family Welfare
of the new National Health Policy where it has been mentioned that the states have to increase allocation for the spending of health sector from the current level of 5.6 per cent to eight per cent, the state’s budget should have been enhanced, not reduced.” Explaining the state government stand point on the health budget provisions, Dr Vijay Satbir Singh, Additional Chief Secretary, Health, Government of Maharashtra, informed that the budget depends upon the total revenue and money available with the state government and at times there is a shortfall in the resources. That becomes the main reason for the state government not being able to provide sufficient funds. “Whenever we find that a particular sector needs more money, we ask for supplementary budget. In public health department, ` 126 crore is allotted for cancer hospital in Aurangabad and ` 1,549 crore for rural health services. Apart from these schemes, Maharashtra has two exclusive health schemes like emergency healthcare service, under which ambulance is operated 24X7. We have allotted ` 240 crore for a year. Another
Rajeev Ahuja
(
F O C U S : M A H A R A S H T R A P U B L I C H E A LT H
college department, which is spending money for hospitals, and looks after majorly tertiary healthcare. Food and Drugs Administration (FDA) is taking care of controlling the licensing of drugs, storage and manufacture with its own budget. Health budget cannot be measured only by what the state government allots to public health department.” Highlighting that states have the opportunity to prioritise health, Rajya Sabha Standing Committee in a report stated, “In order to improve the overall healthcare of the county, the most effective solution remains greater expenditure by states through their own budgetary provisions. As per the 14th Finance Commission devolution, states have the opportunity to prioritise health and implement programmes that are customised to their state-specific needs and thereby improve health outcomes. According to experts, the crippling public health budget will have aggressive impact on the quality of the service and access to the service and this gets reflected in the abysmal condition of the public health system with deteriorating infrastructure, shortfall of doctors and nurses. Due to these factors, the state sees a proliferation of the private medical sector.
Mission (NHM), Mangal said, “The state government should find out a permanent solution and make sure that the minimum number of specialists, doctor’s position defined in In-
The crippling public health budget will have aggressive impact on the quality of the service and access to the service
ECG MONITORS VENTILATORS DEFIBRILLATORS SPIROMETRY INFUSION PUMP
PORTABLE CT ROBOTIC NEURO SURGERY EQUIPMENT MOBILE/ FIXED CATHLAB TELEMEDICINE
Shortfall of services Despite Maharashtra having over 50 medical colleges, there is a huge gap in the doctor-patient ratio in government hospitals. The specialist doctors remain unavailable year after year. Large public hospitals, which deal with scores of patient a day don’t have patientfriendly guidance or grievance redress systems. Overworked doctors and impatient patients lead to tussles and doctors’ strike in the state. Informing that recruiting doctors on contract and giving incentives for performance are short-term solutions, which have been already tried by the state under National Health
EXPRESS HEALTHCARE
15
Protecting Life For or enquiries contact : sales@schillerindia.com
TToll-F oll-Free ree No No.. : 1800 2098998
Swiss H. Q.: Schiller AG,Altgasse 68, P. O. Box 1052, CH -6341 Baar, Switzerland, Indian Corporate Office: Schiller Healthcare India Pvt. Ltd., Advance House, Makwana Road, Marol Naka Metro Station, Andheri (East), Mumbai - 400 059. Tel. : + 91 - 22 - 61523333 / 29209141 Fax : + 91 - 22 - 2920 9142, mail: sales@schillerindia.com, support@schillerindia.com Factory: No. 17, Balaji Nagar, Puducherry - 605010
Regional/ Branch Offices: Mumbai: 022-61523333/ 09323799863 Email: sales.west@schillerindia.com New Delhi: 011-41062067/ 09312432205 Email: sales.north@schillerindia.com Bengaluru: 080-26564045 / 09379036923 Email: sales.south2@schillerindia.com Chennai: 044-28232648 / 09383620520 Email: sales.south1@schillerindia.com Puducherry: 09383620520 Email: sales.south1@schillerindia.com Bhopal: 0755-4274421/ 09329542691 Email: sales.central@schillerindia.com Kolkata: 033-23593102/ 09874766668 Email: sales.east@schillerindia.com Nepal: 00977-9852030389, Email: thakur@schillerindia.com Hyderabad: 09533552969 / 09379036923 CIN: U33110MH1997PTC111307
May 2017
W Website ebsite : www.schillerindia.com www.schillerindia.com
cover ) dian Public Health Standard should be filled in. If they have to be filled, the state should provide at least minimum facility in the district, CHC, PHC as many doctors and specialists are reluctant to work because of the conditions in these centres. For all these measures, again the state would have to optimise the health budget.” Highlighting the option the state government is offering, Satbir Singh states that the state governments are providing an option of tele-medicine and are appointing Bachelor of Ayurveda Medicine and Surgery (BAMS) doctors in rural and tribal areas to fill in the gap. Mangal chooses to disagree and informs, “Ayurveda doctors could work in PHC or in remote areas where they can undertake the roles which they are trained in, but they cannot replace MBBS doctors or specialists. The doctors via tele-medicine can give only second opinion.” According to Central Bureau for Health Intelligence (CBHI), Maharashtra has the worst doctor- patient ratio. The state needs 1,440 specialist doctors in rural hospitals across the state, but only 578 are available. The shortfall is a whopping 60 per cent. Out of the 360 rural hospitals in Maharashtra, only 127 meet Indian Public Health Standards. Throwing light on the implementation of digital technology, Rajeev Ahuja, Development Economist, formerly with Bill & Melinda Gates Foundation and the World Bank, said, “Digital technology is changing the way healthcare services are delivered the world over. It is challenging the older brick-and-mortar model of delivering care. Telemedicine, e-consultation, patient helpline, task shifting to lower cadre of health workers, shifting of care to primary level and so forth are fast becoming standard templates of delivering care. Use of technology has the potential to make healthcare accessible to patients in home setting and at a much
16
EXPRESS HEALTHCARE
May 2017
Source - National Health Profile, Ministry of Health & Family Welfare
lower costs. Any durable strategy to integrate the use of digital technology in delivering healthcare is a welcome move, provided these are properly piloted before scaling. Use of technology has the potential to alleviate constraints of health personnel to some extent but given the huge shortage of such personnel in India it will still mean continued emphasis on increasing their supply at
least for next few years.” Experts also cite conflicts and violence between doctors and patients, which indicates the failure of the overall health system. A substantial increase in health budget will help in providing better infrastructure and technology, which will lead to increase in healthcare staff, which would ensure essential services in public hospitals.
Boosting funds – Road ahead Maharashtra needs to revive its public health spending by increasing the health budget. As the new National Health Policy clearly states that health is a state subject and its regulation lies with states. The state has to spend significantly more on health, for its healthcare delivery to improve. According to Jan Swasthya
Abhiyan, a global network which brings together grass roots health activists, civil society organisations, Maharashtra was performing well in public health services until the mid1980s. However, given the subsequent crunch on financial resources, as well as declining political priority and the privatisation of healthcare, there were shortfalls in providing health services at various levels, forming the backdrop to rising public dissatisfaction. Reiterating that Maharashtra government needs to make the public health system work, for which there is a tremendous scope, Ahuja said,“Since two-thirds of total government health spending comes from the states, state governments spend too little on healthcare. In absolute terms, Maharashtra spends the second highest amount, after Uttar Pradesh. But this doesn’t mean much in per-capita terms as Maharashtra also has second highest population, after Uttar Pradesh. A share of state health spending in state’s aggregate expenditure indicates a sense of prioritisation that any state attaches to healthcare. That is why the new health policy has set an ambitious target of raising this share in each state to eight percent by 2020.” According to experts, the failing nature of better health outcome can easily be reversed with high level of public funds allocation in this sector. Specifically, Maharashtra, one of the wealthiest and most urbanised state, needs to increase its health spending from its existing level. “Maharashtra health systems will remain ailing and a large numbers of its citizens, who cannot afford expensive private healthcare, will remain diseased and undernourished. In order to enhance the delivery system highest, political commitment and strong leadership and vision is required. In the end, nevertheless health is a state-subject,” concludes Mangal. prathiba.raju@expressindia.com
(
F O C U S : M A H A R A S H T R A P U B L I C H E A LT H
Ensuring access to quality healthcare HLL Lifecare has joined hands with Government of Maharashtra to begin a movement to drive preventive healthcare within the state by providing free diagnostic services at state-run health facilities
D
iagnostics are an integral part of any healthcare system and provides information needed by service providers to make informed decisions about care provision related to prevention, detection, treatment and management. In India, out of pocket expenditures on diagnostic tests are high and rising, sometimes even more than the cost of medicines. The poor who access public healthcare facilities have limited access to diagnostic services. Government of Maharashtra, in a path breaking initiative to reduce out-of-pocket expense in healthcare, is in the process of establishing around 100 diagnostic labs in 33 districts of the state to provide free laboratory
tests to the public. The state government has partnered with HLL Lifecare Ltd (HLL), a Government of India (GoI) enterprise under the Union Ministry of Health and Family Welfare (MoH&FW) to implement this prestigious project.An agreement was recently signed between HLL and State Health Society, National Health Mission (NHM) and Director of Health Services (DHS), Mumbai, for providing laboratory services in the health facilities of the state. As per the agreement, free laboratory testing services will be provided to the public in nearly 2,300 government hospital centres under DHS, more particularly at the level of Pri-
A package of essential diagnostic tests made free of cost in public health facilities across the state will reduce the burden on the poor. It will substantially reduce the out-of-pocket expense in healthcare mary Healthcare Centre (PHC), child health centres, government hospitals, district hospitals and super speciality hospitals. A package of essential diagnostic tests made free of cost at public health facilities across the state will not only reduce the burden on the poor but will
also be accessible to all sections of the society. HINDLABS Diagnostic Centres have already been rolled in eight districts of Maharashtra — Pune, Thane, Parli, Jalna, Nandurbar, Mumbai, Aurangabad and Nagpur and the project is being swiftly under-
taken in all 33 districts simultaneously. It isexpected to cover the entire state by end of July 2017. The main feature of the project is monitoring mechanism on a real time basis by IT-enabled systems which track the details of patients’ samples collected from the collection centre to the lab for testing and reporting. The latest module of Laboratory Information System (LIS) software will be used for the project to create an online dashboard to view the current status of sample collection, testing and reporting from all government hospital centres in Maharashtra. The PHCs and rural hospitals have limited laboratory infrastructure for diagnostic tests. Once fully, operational, diagnostic tests will be made available to the public in the remotest villages of Maharashtra. The project is expected to bridge the availability gap by establishing laboratories near hospitals with all the divisions like haematology, pathology, biochemistry, immunoassay and microbiology. The state government is providing high quality products and services at free of cost to the people of Maharashtra from all strata of the society. It has earned huge reputation in the country for bringing down the costs in the highly fragmented diagnostic services. HLL has always been the torchbearer for implementation of most of the prestigious government healthcare projects.
EXPRESS HEALTHCARE
17
May 2017
cover ) Think beyond a strike Flaws in our medical system and uncertainty surrounding the security of medical professionals call for concrete measures to bring back trust among doctors and patients
DOCTORS' DEMAND WERE AS FOLLOWS: ◗ Increase jail term of attackers from existing three years to seven years, under Doctors Protection Act, 2010
BY RAELENE KAMBLI
◗ No bail for accused for at least three months ◗ Form a medical committee to decide how serious a violation is ◗ Enact a strict law to prevent trespassing in hospital ◗ Consider it violation of law if a patient is accompanied by more than two relatives ◗ Suspend security personnel if they fail to prevent an assault on doctors ◗ Release funds to implement the law and appoint a brand ambassador to spread awareness for the safety and security of doctors
R
ecently, Maharashtra witnessed one of the worst healthcare crisis when 60 per cent of resident doctors across the state went on a strike. The strike was led by Maharashtra Association of Resident Doctors (MARD) in order to raise their voices against the rising incidences of violence against doctors and medical establishment. The strike lasted for five days affecting around 40 hospitals in Mumbai alone, resulting in a serious resource crunch that caused severe disruption to healthcare services. The most affected units in the state were the emergency health services, surgeries, post-operative care departments, ICUs and OPD services. As per Brihanmumbai Municipal Corporation’s (BMC) report on March 24 , 2017, 135 patients died due to lack of availability of emergency services in three BMC hospitals in Mumbai. The worst hit were patients coming from the lower socioeconomic strata who lined up outside government hospitals across the state waiting to be treated. Owing to the crisis situation, the
18
EXPRESS HEALTHCARE
May 2017
60 per cent of resident doctors across Maharashtra went on a strike causing serious disruption to health services
Maharashtra government and the Bombay High Court had come down heavily on the doctors and had threatened them to be suspended or terminated from their services. In a press conference, Maharashtra CM, Devendra Fadnavis, gave a legisla-
tive warning to the doctors and asked them to resume work immediatel., He also said that he failed to understand the insensitive attitude of doctors of leaving patients to die. However, doctors were too perturbed to understand the damage that was caused due to the strike.
Legal threat escalated the issue giving it a pan-India colour. Doctors from around 40 government hospitals, including RML, Lady Hardinge Medical College, Safdarjung Hospital stayed away from work, while those at AIIMS continued with their protest against assaults on doctors by wearing helmets at work. Even the Indian Medical Association (IMA) extended its support to the strike. They claimed that attacks on doctors have often resulted in serious injuries, half of which go unreported. According to the IMA, last year alone there have been over 50 cases of attacks on doctors reported while the government did nothing to resolve this issue and provide security to doctors. In a survey, the IMA found that over 75 per cent of doctors faced mental or physical violence at least once. A number of private hospitals, including Sir Ganga Ram hospital also joined the strike in Delhi. Apart from the National Capital Region (NCR), junior doctors from the Guwahati Medical College Hospital, also extended support to their colleagues in Maharashtra by
(
F O C U S : M A H A R A S H T R A P U B L I C H E A LT H
wearing helmets in the hospital. Ironically, this issue divided industry opinion into two viewpoints- one in support of the strike and the others refuting the strike.
Some thoughts shared... Dr Prateek Rathi, Fellow Member Post Graduate Program In Public Policy Management IIM, Bangalore and Special officer, ESIC Maharashtra, opines, “Though the government acted swiftly and condemned the attacks on doctors as well as assured all possible measures to curb such incidents, the assurance could not satisfy the agitating doctors. There is a huge trust deficit. The argument made by the striking resident doctors was that they have received such assurance in the past from the government and there has been a High Court order to that effect but there has been no change in ground realities. On the contrary, such incidents of attacks on doctors, vandalism in hospitals, assault, verbal abuse etc., showed a substantial increase in recent months. The striking doctors were also of the view that the conviction rate of these assault cases is almost negligible and the law made in this regard is toothless”. Presenting a counter argument on the same, Dr Kunal Saha, President, People for Better Treatment (PBT), Consultant & Adjunct Professor, Columbus, Ohio, USA says, “We never condone physical attacks on doctors or hospital vandalism on any ground, even in the event of a genuine case of medical negligence. The medical community will have to try harder to realise why an otherwise peace-loving and law-abiding citizen suddenly lose control after seeing his loved one dying from real or perceived “medical negligence” and take law into his own hands. It is because ordinary people in India find no reasonable path to get justice against the powerful doctor/hospital. Doctor-only members in the medical council function primarily to shield their errant medical colleagues without caring for the pain and suffering of the ordinary patients. Finding medical justice in the court of law is also a seemingly impossible task for an ordinary man in India in the absence of any supporting opinions from another doctor. Until the medical fraternity can restore public trust on doctors and medical councils are transformed to provide equitable justice to the victims of genuine medical negligence, doctor bashing and hospital vandalism are not likely to end in India.” Dr Suleman Merchant, Dean, Lok-
manya Tilak Municipal Medical College and Hospital informed that the matter could have been handled in better way. He said, “Resident doctors are the backbone of public health delivery and their security is vital. However, disruption of healthcare services is an immoral act. The government needs to create a conducive learning environment for these doctors as they are the future of our healthcare sector. We talk about retaining talent in healthcare, how can we do so if our medical colleges do not have an encouraging learning environment?” he questioned. Further, he updated that the court has been observant of this issue and has recommended the government to set up a committee to inspect the security services at government hospitals across the state.
What happens after the strike? Nevertheless, the strike came to its end when the Bombay High Court took cognizance of this issue and directed the government as well as hospital administrations to provide at least 500 security guards in these state hospitals, including four hospitals in Mumbai, by April 5 and the remaining 600 by April 15. The court also mentioned that the court would be monitoring the physical security and other issues within these hospitals every 15 days. This is one part of this story. What happens after the strike is over? Dr Vijay Satbir Singh, Additional Chief Secretary, Health, Government of Maharashtra, informs, “The state government has taken the issue of attacks on doctors very seriously. Already, Chief Minister Devendra Fadnavis has made it clear that security for doctors would be beefed up. We are strengthening the security system in the government hospitals by recruiting more security officials. We are also planning to form a
team under IPS officer who can work over the security arrangements of the government hospitals and medical colleges. I don’t know how far it will be of help, but we are putting in our sincere efforts. Moreover, we are installing CCTV cameras, so that violence against doctors can be curbed.” Until April 15, 2017 the inspection had not began and only 330 security guards were deputed at these four hospitals, informed a trusted source from a government hospital in Mumbai who did not wish to be quoted. He also informed about a growing unionism among resident doctors, which has been supported by politicians in order to fulfil their political agendas. When Express Healthcare approached the Public Health Department and the Directorate of Medical Education and Research, we were confirmed that the inspection process has begun recently and has picked momentum. Dr Pravin Shingare, Director Medical Education and Research, Government of Maharashtra informed that until 26, April, 2017 around 16 hospital across Maharashtra were examined and the security strength was increased to about 1100 guards. “We have begun our inspection process and feedback on the same is that the security still needs to be heightened at government hospitals,” disclosed Dr Shingare. If we carefully analyse the vulnerability of this issue, it will be clear that the issue continues to remain unaddressed. Violence against doctors, nurses and medical establishments continue to exist and more so trust among patients and relatives for doctor continues to decline. Why are medical professionals being attacked so often? Why is doctor striking a frequent phenomenon these days? Why are private hospitals being lashed out for commercialisation of services? Why is the number of medical negli-
gence cases increasing in India? And most importantly, why are patients loosing trust in the most trusted profession called – medicine? Several questions still remain unanswered as the entire focus is shifted on taking sides. Whether the doctor fraternity is right to go on strikes in order to demand protection or whether the agitation from patients and relatives is justified? Also, has this entire issued been handled in the right manner? Both sides have their arguement and counter arguments to validate their point of view. What's more important is to understand the ways and means to build trust between the medical fraternity and patients.
Measures suggested Explains Dr Rathi, “There is a broad consensus that the cases of assault against doctors is on rise and has to be tackled with a firm hand. The question remains in regards to the instrumentality for such action. The issue could be handled by having some short-term solutions and a long term vision to improve the health system. Short-term solutions can be by having a more stringent law for such assaults, making in non-bailable, punishing the guilty by a fast track justice system, which acts as a deterrent for future such action and other measures like having adequate security measures; security guards, CCTV camera, entry of limited relatives with the patients and alarm system. But all of the above are short term and myopic measures. If we want to solve this problem, substantial and significant measures need to be taken on the policy front which will get to the root of the problem and minimise such attacks. The philosophy of the measures should be to fulfill the patient’s aspirations, his expectations, minimising his out of pocket expenditure and avoiding any delays in quality treatment.” He further lists down some of the measures to resolve this issue in the long run: ◗ Increasing the healthcare budgets ( Government spending on healthcare in India is hardly 1.2 per cent of GDP) ◗ Improving the healthcare infrastructure. ◗ Increasing the human resources in the health sector. ◗ Use of technology to improve satisfaction and convenience of patients and also bringing efficiency in the system. ◗ Involving patients in the decision making process through various platforms (As proposed in the National Health Pol-
EXPRESS HEALTHCARE
19
May 2017
cover ) icy 2017) , making the Health Systems patient centric, with the moto No decision about me without involving me. And how will these suggestions be helpful? Increased health spending will ensure better services if the money invested is utilised in strengthening public health, which means increased access to healthcare services, added infrastructure, additional manpower to serve patients, less waiting time for patients and better outcomes. However, these need to be monitored on a regular basis. But will this build trust among patients and the medical professionals? Can building a healthy communication line between doctors-patients-relatives be fruitful? In a recent survey conducted by IMA on patient satisfaction and their response, the organisation found that of the 1,246 patients they interviewed, 70.4 per cent of them expect their doctors to tell their patients about themselves, 90.1 per cent want doctors to listen to them in great detail during the first consultation, 80.4 per cent want the doctor to explain in detail about the drugs, investigations and the treatment, and 39.4 per cent expect the doctor to say ‘thank you’ to them. This indicates that communication between doctors-patients-relatives is key to effective healthcare delivery. Indeed, it is the most important element that has been ignored to a large extend. Dr Merchant also emphasises on the importance of building a healthy communication line. He informs that at Lokmanya Tilak Municipal Medical College and Hospital they have been constantly training junior doctors on effective doctor-patient communication. They also follow a strict rule that in an event of death of a pateint only senior doctors would break the news to the realatives. This is done with the understanding that senior doctors would be able to answer the questions raised by patient relatives in an appropriate manner. Morever, under the guidance of senior doctors, the resident doctors can also get trained in patient communication. He also speaks on the need to provide good hostel facilities, appropriate training centres and good working conditions for resident doctors. Additionally, he says that about the need to make the resident doctors work in shifts, this will give them enough time to rest as well as for training purpose.
Time to change Another aspect to solve this issue is pos-
20
EXPRESS HEALTHCARE
May 2017
BMC report on March 24 , 2017 mentions that 135 patients died due to lack of availability of emergency services in three BMC hospitals in Mumbai
(All pictures used are for representational purposes)
itive reinforcement of the good work done by medical professionals. Dr Aniruddha Malpani, an Angel Investor of Malpani Ventures and a Funder funding frugal innovation in India and strong advocate of information therapy has come with Good Doctors website. This is a website where patients can share stories of their positive interactions with doctors. Dr Malpani in his post writes that the idea behind developing this website is to inject positivity within the healthcare industry, especially the doctor fraternity. This exercise will hopefully inspire other doctors as well, who can emulate these best practices. Similarly, social media blogs such as Think Change India and Being Indian posts stories of extraordinary examples of selfless service by doctors working in rural India. One such example is the story of Dr Ravindra Kolhe and Dr Smita Kolhe. The couple has been working in a tribal village of Melghat district in Maharashtra for several years. They have improved health outcomes in the area and helped the villagers gain access to electricity, roads and primary health centres. What's more interesting of their journey is that they have transformed the Poorest Regions of Mahrashtra into a 'Farmer Suicide-Free Zone' which even the government with all its efforts could not subdue.
This unknown story was brought to light with the help of social media. Moreover, the good news is that now the government has taken special interest in the district and has committed to convert this region into a digitally connected village. Microsoft has partnered with the government to help achieve this dream. Initiative like these need to be taken up on a large scale to bring back the trust among patients. At the end, Dr Saha demands for a complete overhaul of the medical system in India. In his article in the British Journal he writes, “Unlike in the West, it is a common knowledge today that there are virtually no checks and balances for doctors in India. The Medical Council of India (MCI), highest medical regulatory authority in the country, has become a "den of corruption" as held by the Delhi High Court. The number of disciplinary action against doctors taken by the medical councils/boards for medical and/or ethical violation is virtually non-existent in India when compared to developed countries like
UK or USA. Unlike in the Western countries, doctors in India are always reluctant to testify against errant medical colleagues making cases involving medical negligence almost impossible to win in the court of law. A complete overhaul of the entire medical regulatory system is necessary to restore public trust on the medical system and bring an end to the unfortunate incidence of doctor bashing in India”. A complete overhaul at this point of time is certainly not possible in India, especially in times when the country is still struggling to provide equitable access to healthcare for all. However, a change is necessary. We still do not have concrete solutions on the government's front to resolve this issue. Nevertheless, every step taken in this direction will be fruitful if executed with the right intent. Moreover as per government sources, the issue will be further discussed in court and a concrete solution can be expected in the near future. raelene.kambli@expressindia.com (With inputs from Prathiba Raju)
(
F O C U S : M A H A R A S H T R A P U B L I C H E A LT H
I N T E R V I E W
‘Government of Maharashtra has always been encouraging the PPP model in healthcare’ In a wide-ranging interview, Dr Vijay Satbir Singh, Additional Chief Secretary, Health, Government of Maharashtra, talks about various health initiatives of the state like the upcoming new Vision 2030 document on health, a new nutrition policy and a partnership with the software giant Microsoft to boost IT in the state in an exclusive interaction with Prathiba Raju How do you plan to achieve the dream of having an Arogya Maharashtra? Our vision of Arogya Maharashtra is to provide affordable, accessible and quality healthcare to the people of the state, with a special focus on women and children, along
the expenditure of all health schemes? Besides, what are the reasons for the reduction in health budgets? Well, this is a problem most of the states are facing. The revenues allotted to the state governments keep on changing and there are many rea-
funds to various sectors like health and education. At times, the state also has some unexpected expenditures which has its impact on the money made available for each sector. For the 2017-18 financial year, the budget allocated for public health is Rs
Whenever an income of the state fluctuates, it leaves an impact on the allocation of funds to various sectors like health.At times, the state also has some unexpected expenditures which has its impact on the money made available for each sector with the people living in tribal areas. We are working to get the appropriate policies and suitable amendments in place. With rising cost of healthcare, do you think the amount allotted can cover
sons for it. For example, this year in Maharashtra, we had registered a shortfall in our revenue, particularly related to excise, property transactions were below the expectations. Whenever an income of the state fluctuates, it leaves an impact on the allocation of
8195. 18 crores, including an expenditure of Rs 4051.61 crores for the schemes and rest is the committed expenditure, which comprises expenses like salary and other commitments. What was the reason for the
EXPRESS HEALTHCARE
21
May 2017
cover ) nutrition schemes budget being lowered than what was allotted in the last budget? The Government of Maharashtra has always given top priority to issues and schemes related to nutrition, which is related to children and women. There are many schemes run by the government out of its own budget and the central government also contribute to some of these. Whenever there is dearth of funds for a particular scheme, we make it available by re-appropriation of funds or by getting money from the unspent fund from any other department. Apart from funds, we are coming out with Maharashtra Nutrition Policy, which is at its final stage of shaping up and it will be implemented by the end of June. The policy will have many unique features, which will be implemented for the first time in the state. For example, we will have a scheme where kitchen gardens will be implemented in educational institutions, anganwadis and primary schools. Besides, supplementation of food with micro nutrients will be taken forward in a major way across the state. However, one should know that when it comes to eradicating malnutrition, it is not just the public health department’s responsibility, but it needs more synergy of all the stakeholders like NGOs and the private sector. Even within the government, the other departments, be it water and sanitation, rural and urban development, should work in tandem. Nearly 40 per cent of posts for specialists such as paediatricians, gynaecologists, nutritionists, obstetricians and ophthalmologists are vacant in the state. What steps are being taken to fill the posts? The scarcity of doctor-patient ratio is not just in Maharashtra, but it is prevalent pan-India. There is a huge difference in the availability of doctors in
22
EXPRESS HEALTHCARE
May 2017
urban and rural areas. Many specialists also join private hospitals instead of government hospitals. Most of the doctors, nurses, paramedics prefer urban areas, particularly the specialists. We run several programmes to bridge this gap. We pay more incentives to the doctors who serve in rural and tribal areas, at least 15 per cent high entitlements. Apart from that, in postgraduate courses, we give reservation for the doctors who are in service. Many doctors who join the government service is because of the reservation they get. After completing PG courses, specialists do not want to serve rural areas. They are reluctant about the skills they acquire that are underutilised. Hence, we execute a bond with the students who study in the government-run medical colleges, so that either they have to complete conditions written in the bond or they have to pay money. Several measures are taken to tackle the mismatch of the doctorpatient ratio. The state government is also running tele-medicine consulting services for a year now in five district-level hospitals where government-run medical colleges and hospitals’ specialists are connected. We are also trying to connect the telemedicine centres with the nine central prisons in the state, so that the prisoners are not often taken out of the prison premises. How will the plan to digitally connect 29,000 gram panchayats be implemented? What are the steps taken to boost e-health in the state? The tribal Harisal village in remote Melghat district is being transformed into a digital village. People are given services of tele-consultation to connect with the doctors. We are also going to sign a Memorandum of Understanding (MoU) with Microsoft very soon as they will provide us
HLL will establish around 100 Hindlabs in the 33 districts, particularly at the level of the Primary Health Centres (PHC).They will implement the project within a period of 90 days and commence the lab services to the general public.The project will be monitored on a real-time basis by ITenabled systems which would track the details of patients’samples collected from the collection centre to the lab for testing and reporting with IT-enabled solutions and initiatives. Microsoft will also be helping us in a big way to connect with the service providers as well as to get feedback from the people about the quality of the services provided by the government. We are working on the MoU and the IT giant has also been given varied options where they can provide their expertise. The state has seen Infant Mortaity Rate (IMR) and Maternal Mortality Rate (MMR) falling to 25 from 36, and 87 from 130, respectively. What further steps are being taken to lower these rates further? Maharashtra ranks third in the country when it comes to the infant mortality rate (IMR). Our Maternal Mortality Ratio (MMR) level is better than almost all the other states, except Kerala. We are working on a vision document exclusively for the health department what we aim to achieve by 2020 and 2030. The idea of the vision document came from the adoption of Sustainable Development Goals (SDG) by the UN after the Millennium Development Goals (MDG). SDG has the largest number of indicators on health. We are working out a vision document similar to it and adding more guidelines which is relevant to Maharashtra’s health parameters.
This will give a clear cut roadmap of what our government intends to achieve in the health sector viz to improve life expectancy, malnutrition, NCD, and TB control. Can you share the details on the diagnostic service which HLL would provide to Maharashtra Hospital? HLL Lifecare Ltd (HLL), a Mini Ratna PSU of the Union Ministry of Health and Family Welfare (MoH&FW), has signed an agreement with the Maharashtra government. HLL will establish around 100 Hindlabs in the 33 districts, particularly at the level of the Primary Health Centres (PHC). They will implement the project within a period of 90 days and commence the lab services to the general public. The project will be monitored on a real-time basis by IT-enabled systems which would track the details of patients’ samples collected from the collection centre to the lab for testing and reporting. Anybody who requires any diagnostic test can approach these centres and conduct their test for free, as the expense will be borne by the state government. If HLL is able to implement it properly, this initiative will be a huge success. Apart from it, we find the concept of Amrit outlets by HLL and Jan Aushadhi Kendras (JAK) by Bureau of Pharma PSUs of India (BPPI) highly beneficial as both these
outlets help the common man to substantially reduce the out-of-the-pocket expenditures by purchasing medicines. We have few JAK outlets in the state and we are also in the process of discussion to bring in more Amrit and JAK outlets across Maharashtra. At the same time, the government hospitals are also providing affordable medicines. How encouraging is Government of Maharashtra when it comes to PPP model in healthcare? The Government of Maharashtra has always been encouraging the PPP model in healthcare. We welcome any initiative which involves PPP model of finance in health services. We have Mahatma Jyotiba Phule Jeevandayeeni Yojana, which covers 1,100 ailments, hip and knee replacement, sickle cell and anaemia treatment. Benefits under this scheme has been increased from Rs 2 lakh and Rs 3 lakh in case of kidney transplantation. The state government invests Rs 1000 crore. We find it difficult to run these schemes at the same time we want to continue the scheme as it provides immense benefits to the public. If private players can help us to run the scheme, it will be a huge benefit for the common man. prathiba.raju@expressindia.com
(
F O C U S : M A H A R A S H T R A P U B L I C H E A LT H
Malnutrition free Maharashtra: An attainable goal Maharashtra, was ranked the state with the best infrastruc ture in 2016, in the ‘State of States Reports’ and . However, the state struggles to cope with high rates of child malnutrition. The situation aggravates during lean seasons by a sharp increase in child deaths, attributable to malnutrition. Many develop ment partners including Tata Trusts is collaborating to make the government’s vision of malnutrition-free Maharashtra a reality, writes Dr Rajan Sankar, Senior Adviser, Nutrition, Tata Trusts
T
he National Family Health Survey 4, (NFHS-4) shows that 34.4 per cent of children under the age of five are stunted, i.e. they are too short for their age. But acute malnutrition as evidenced by wasting (low weight for height) has increased from 16.5 per cent (NFHS 3) to 26.1 per cent (NFHS 4). Wasting, which represents recent failure to receive adequate nutrition and increased vulnerability to acute illnesses, is severe in the state. Anaemia levels remain high, with nearly 48 per cent of women in reproductive age and 54 per cent of children below five years suffering from anaemia. The survey also found that a fourth of women were chronically energy deficient, ie. having low Body Mass Index (BMI), an established risk for the mother as well as her offspring. In order to streamline efforts towards improved nutrition, health and well-being of the community, the state has been running numerous welfare programmes. Integrated Child Development Services (ICDS) is one of the critical programmes for improving maternal and child nutrition. The programme offers health, nutrition and hygiene education to mothers, non-formal pre-school education to children, supplementary feeding for children, pregnant and nursing mothers, growth monitoring and promotion, and links to primary healthcare services such as immunisation. These services are delivered in an integrated manner at the anganwadi centres and the number of anganwadi centres have increased in recent times. Over one lakh Anganwadi centres in Maharash-
tra cater to around 60 lakh children. Immunisation coverage can be used as a surrogate indicator of how well the anganwadi centres are functioning. It indicates how efficiently the services are delivered as well as the seeking behaviour of the population. Immunisation coverage in Maharashtra has remained unacceptably low at 56.3 per cent and it has been the same over the past decade. ICDS and National Health Mission (NHM) have unmatched reach and are intended to serve the most vulnerable populations. Together they are structured to deliver the essential nutrition and health inputs required to improve health and nutrition status of the population. However, they are not delivering. Some of the key problems identified are poor targeting and poor implementation. Lack of community ownership is another major gap. There is a need to focus on the consumers too. The creation of demand is necessary. If people do not want, do not demand them, then even limited supplies and services can prove superfluous.
Our programme, the ICDS in particular is ‘hardware’ oriented, concentrating on the supply factor – on the assumption that demand is automatically appeased by supply. Focus on mass mobilisation is to increase demand and community ownership of the ICDS. Science has now shown that this 'window of opportunity' has a major effect on the future of a child, his community. Maharashtra need to aggressively focus on this period where millions of children are facing the most critical development period of their lives. Nutritional status results from a complex interaction between food intake, access to safe water and sanitation, nutritional knowledge of caregivers and access to care and appropriate medical services. NFHS4 reveal that in Maharashtra only half of the infants are exclusively breastfed in the first six months of their lives, only 6.5 per cent of children aged six to 24 months receive an adequate diet. Children during this phase of development require continued breastfeeding and age appropriate complemen-
DR. RAJAN SANKAR, Senior Adviser, Nutrition, Tata Trusts
tary foods. Individual families and communities have to take the responsibility to adopt and practice appropriate infant feeding practices, hand washing and take responsibility to utilise services provided by ICDS and NHM. Community pressure is sure to improve the efficiency of delivery of services in these otherwise poorly functioning services. A multi-sectoral approach to nutrition is necessary to eliminate malnutrition. A number of interventions need to converge and should be targeted to the most vulnerable geographies and vulnerable people within it. Such convergence approach has become the central tenet of successful nutrition programmes. Maharashtra achieved rapid decline in stunting rates, nearly a 15 per cent decline in six years (2006-2012), by adopting a mission approach. The state has renewed its commitment to address malnutrition. Tata Trusts have adopted a multipronged approach to be able to address the issue of malnutrition and has effectively started to work in Palghar district that has one of the worst indicators. The plan is to demonstrate scalable model that works with and within the government and communities to increase coverage of both nutrition specific and nutrition sensitive interventions to the most vulnerable populations, with speed and with quality. The state has the necessary infrastructure, human capacity and financial resources needed to sustain this and scale it up across the state. It is time to act and rid Maharashtra from the scourge of malnutrition.
EXPRESS HEALTHCARE
23
May 2017
START-UP CORNER I N T E R V I E W
‘Our ambition is to reach up to 1.6 million people by 2018’ healthi, a fast growing digital preventive health startup has grown 9x in the first two years of its operations. Rekuram Varadharaj, Co-Founder and COO, healthi talks about the company’s vison, its business model, various initiatives, tie ups with Government of India and more, in an interaction with Prathiba Raju How did the concept of healthi evolve? I used to opt for preventive health checkups as a personal choice but I realised that the results were not that clear. Similarly, another person from Stanford (US), after his annual health checkup was unable to completely understand, how to correlate the test results with his health status. All these tests gave gave common solutions like diet and exercise but there was no complete, individual, analysis. We wanted to make a module to come out with easyto-understand reports, so that one can easily seek expert help and guidance from specialists after understanding their health status. Our main focus was to demystify health and make it simple. At the same time, we wanted to answer three simple questions – 'How healthy am 1?' 'What do I need to continue or change in order to stay or get healthy?' 'Who can help?'. So, this was the genesis of healthi which started its operations in May 2014. Before we started off, for almost a year we had to work on predictive analysis. Our team consists of data scientist, bio statistician and population health experts. They can understand health data and come up with scientifically valid models which can predict chronic disease. healthi offers a personalised health check package which is tailor-made for individuals based on their unique needs from millions of potential options. In partnership with
24
EXPRESS HEALTHCARE
May 2017
leading healthcare brands, we deliver these programmes across the country. Right now, we are present in 130 countries and 600-plus locations across the country. What efforts did you put in to promote disease prevention and wellness? Anywhere between 40 to 60 million Indians, mostly from the organised workforce, go through annual health checkups. 60 per cent of them are facilitated by companies and 40 per cent go on their own. Preventive healthcare sector is the fastest growing sector. Post health checkup, healthi’s comprehensive and simple reports enable users to understand their health status with ease. Our customer satisfaction scores are 94 per cent. Out of every 100 employees who participate via the corporate programme, nearly 50 people come back to us and do check-ups for their family members. We don’t just list out how their health is but also quantify the long term impact of those factors and make it clear to them that it couldn’t be ignored. Be it the habit of smoking, poor diet, less exercise or high stress, combined with an individual's genetic predisposition, they mean that he/she had a high risk of diabetes and heart disease. We create a plan and connect them with appropriate doctors and other specialists so that they get on the path towards better health. Our packages start from `300 and can go up to thousands as per
healthi’s comprehensive and simple reports enable users to understand their health status with ease an individual's needs. We are working with e-commerce, insurance, retail, financial services and IT/ITeS corporate sector to easily roll out their preventive health programmes as well. Can you elaborate more on the partnership with Government of India and others? We have a unique
research partnership with Government of India and are working on bringing efficacy in chronic disease prediction models. In three years of attending to users from the length and breath of the country, we are seeing certain trends and patterns in non communicable diseases (NCDs). For example, 80 per cent-plus women inform that health is a priority for them, however, a lot of them are anaemic, deficient in Vitamin D and Vitamin B12 and have high levels of TSH. Apart from it, cancer detection and prevention is another blind spot. The two most prevalent cancers are breast cancer and cervical cancer. Nearly one in every three Indians are detected with cervical cancer, globally. So, we have thousands of people calling us from across the country. Data is collected seamlessly as every user adds to the global archive of knowledge. At the moment, we have a large repository of longitudinal preventive healthcare data. We capture biometrics and lifestyle data to give them insights on their health. Without disclosing any personal data, healthi will come out with a study on the health landscape of India which will showcase how healthy we are as a country. The Ministry of Science and Biotechnology, Government of India, is interested in doing population-level health trends. We are bringing efficacy in chronic disease prediction in India. We have a primary
research agreement but are yet to finalise the model. In addition to this, we have partnered with Mayo Clinic as it helps us to deliver personalised, clinically validated and relevant preventive health content to users. Tell us more about the USP of healthi? We are a healthcare technology and analytic company and our whole idea of healthcare in the digital context needs to be smart and personalised. It should be one size fit one, and not one size fit all. We measure our people's aptitude towards health like how many of them are considering health as a priority and willing to change. healthi helps those who are willing to change to quickly access those changes. While for those who don't, we educate them. It itself showcases in the name healthi -- 'i' denotes intelligent and personalised. Health has a unique context, it was very important for us to have on board a team of advisers who are comfortable, both in healthcare and technology. What is your user base now and how much do you want to achieve by the next fiscal? We measure ourselves by the number of lives we touch. Last year, we had 150,000 plus users. Growing on an average of 9X, our ambition is to reach up to 1.6 million people by 2018. We are well set to touch the target. prathiba.raju@expressindia.com
POLICY WATCH I N T E R V I E W
‘Our intent is to provide quality medicines at an affordable price’ Biplab Chatterjee, CEO, Bureau of Pharma PSUs of India (BPPI), shares his plans in scaling up the Pradhan Mantri Bhartiya Jan Aushadhi Pariyojana (PMBJP) and promoting generic medicines across the country. In an interaction with Prathiba Raju, he touches upon important aspects such as procurement methods, their strategy for expansion and consumer awareness What is the intent of BPPI for Pradhan Mantri Bhartiya Jan Aushadhi Pariyojana (PMBJP)? Pradhan Mantri Bhartiya Jan Aushadhi Pariyojana (PMBJP) is a noble mission introduced by the government in 2008. However, the scheme was not very successful due to many reasons. The number of stores which were over 200 went down to 89. Since some of the products were not available at the stores, there was trouble in supply chain as well and the programme was about to be closed. The government saw the intrinsic strength and modified the scheme, and now they are very keen for the scheme to succeed. The Bureau of Pharma PSUs of India (BPPI) under the Department of Pharmaceuticals (DoP), Government of India, was made the implementing agency of PMBJP and the retail stores under the scheme was named Pradhan Mantri Bhartiya Jan Aushadhi Kendra (PMJAK) instead of Jan Aushadhi Stores. Our intent is to provide quality medicines at an affordable price for the citizens of the country. As of now, BPPI has opened 1014 stores and soon we would be touching 3000 stores. How do you go about procuring generic drugs for the stores? We procure products from three sources: the World Health Organisation’s (WHO)
Our intent is to open up at least one JAK in each and every district pan-India.We procure products from three sources: one is the WHO GMP certified generic drug plants, Schedule M, GMP accredited organisations and from the Central PSUs
GMP-certified generic drug plants, Schedule M GMP-accredited organisations and the Central PSUs. Firstly, we look at the different data available in the market, then the formulations which are selling high, and next we examine on thousands of prescription data that is available and finally pick up our products. Once the product is sorted, we decide to procure and float tenders. In tenders, we have technical and financial bid. In technical bid, there are stringent considerations that the suppliers who participate in the bid need to possess. There are also pre-tendering processes through which we identify them, then the tender is floated and we pick the products procured through the lowest bidder. After the product and the manufacturer are identified, we place order and the products come to central warehouse in Gurgaon. Each batch of drug supplied to PMBJP Kendras are tested initially in the plant and random samples are taken from where they reach the central warehouse. Thereafter, they are sent to National Accreditation Board for Testing and Calibration Laboratories (NABL), accredited laboratories empanelled by BPPI, for testing. Only after the clearance of NABL comes, they are sent to JAKs. Health experts inform that over-dependence on
Central PSUs have led to delay in supply of generic drugs and there are not enough stocks available in certain JAKs. How are you addressing this gap? BPPI is an organisation created by Central Public Sector Undertaking (CPSUs). We do consider them at the same time and don't give them huge amount preference. Moreover, we go by L1 format (the lowest bidders); many a times, the pricing they offer does not fit in with the rates that are given to L1. A majority of our supplies come from WHO GMP, Schedule M and the private manufacturers. The percentage of procurement from CPSUs is very less. Hence, there is no delay in supply of the generic medicines. How many JAKs are currently working across India and how many will open by the end of the year? Is there any set target? Our intent is to open up at least one JAK in each and every district pan-India. Kerala is one of the states where people understand and are familiar with the generic medicines. They have 177 kendras opened and most of them are private. Chhattisgarh is the second state which has 145 kendras out of which 136 kendras are opened by government and nine by private organisations. Uttar Pradesh has 141 kendras and ranks third, Gujarat falls in fourth place followed by
EXPRESS HEALTHCARE
25
May 2017
POLICY WATCH
Maharashtra. Considering the geographical challenges, our presence is fairly well in the North Eastern states. We have 14 kendras in Arunachal Pradesh, eight in Tripura and three in Mizoram. We want to establish these kendras across the length and breadth of the country. All this while, we were concentrating on signing MoUs with state governments but we found that these are not resulting in opening of JAKs. Thus, after our internal analysis, we knew that a majority of the kendras are private. So, we approached the people directly and advertised in dailies across regional languages with an application form. We got 27,000 applications out of which we have given inprinciple approval for 21,000. Thereafter, we are also organising camps in each state to make few selected people understand on how to open a store, and on various other processes, including how to get a license. Before June, we expect to open 3000 kendras. On an average, how much does a person benefit by buying in JAKs. Can you share the price difference of the drugs sold in JAKs and the market? The mandate from the government is that whether it is from the National List of Essential Medicines (NLEM) or non-NLEM, the price should not cross 50 per cent of the prices of the branded products. We identify the top three branded products and take their MRPs; for example, amoxicillin pill is priced at Rs 25 and the other products in the market cost Rs 22 and Rs 21. We take an average of these three and our procurement process is L1. In many instances, our product can be sold at 15 to 10 per cent of the average brand prices but we have to give margins to retailers (20 per cent) and distributors (10 per cent). Besides, the franchise agency gets six per cent and
26
EXPRESS HEALTHCARE
May 2017
drugs such as Amlodipine (5 mg) and Atenolol (50 mg), film coated tablets-- Ramipril (5 mg), Losartan (50 mg) and Hydroclorothiaze (12.5 mg) are eight to 10 times costlier than the generic medicines in JAKs. If a person is spending Rs 1000 for medicines bought from a branded shop, he can avail the same medicine for Rs 250 to 300. JAKs can be a boon for people who are aged 56 to 60 as they could get quality medicines at an affordable price.
four per cent for promotional activity and then we have the channel and administrative cost as well. If a patient of diabetes has to take Metformin
Hydrochloride (500 mg), the price of branded products is Rs13.90, while in JAKs, it is sold for Rs 5.15. Likewise, average price of leading brands of cardiac treatment
Prime Minister Narendra Modi has indicated that his government may bring in a legal framework under which doctors will have to prescribe generic medicines, which are cheaper than equivalent branded drugs to patients. How will this help JAKs? The move will promote the JAKs immensely. In any JAK, a pharmacist may not be able to identify the generic medicine without a prescription. So, prescription is a must. With the doctors prescribing generic medicines, people can go to the nearest JAK and show the prescription with generic medicines and get medicines. The conver-
sion of branded prescribed medicines to generic medicines is not needed. The legal framework will also instil a culture among the doctors, who have been habitual of prescribing only branded drugs. This will lead to a positive disruption of the existing pattern. What are your plans for consumer awareness on generics? In order to spread awareness about the use and affordable availability of generic drugs in the country, we have initiated publicity campaigns around JAKs through hoardings, bulk SMSes, mobile exhibitions, distribution of pamphlets, etc. Also, a 15-day radio/FM campaign was also launched in various states of the country. Apart from it, we will be soon coming out with a toll-free helpline number through which patients can ask their queries. Also, a mobile application will be launched in which they can log in with their pin codes to get details about the nearest store and the products available. The scheme provides over 600 medicines and 154 surgicals and consumables. prathiba.raju@expressindia.com
KNOWLEDGE I N T E R V I E W
‘Our vision is to touch and impact 20 million lives by 2020’ Designed to give doctors, nurses, paramedics, and other healthcare professionals hands-on experience and simulation-based training, Berkeley HealthEdu, the learning solutions provider for the healthcare sector is trying to create a new definition for healthcare, informs Soumya Kanti Purkayastha, CEO, Berkeley HealthEDU in an interaction with Prathiba Raju How is Berkeley HealthEdu different from traditional theory-based model of learning? The Indian education system provides very good academic knowledge but a lot of handson training and practical skill development in health education are missed. Berkeley HealthEDU bridges this wide gap by offering courses for doctors, medical students, nurses and allied healthcare professionals which are scenario based and combine global best practices with actual clinical application, backed by research and evidence-based data. We give simulationbased training to the medical professionals. For example, we enable them to manage unexpected response of patients to anaesthesia in near real-life scenario and apply complex problemsolving skills, decisionmaking skills and teamwork behaviours. Health education needs practical knowledge and evidence-based practice, as it upgrades the skills of healthcare professionals. For instance, in our country, nurses learn a lot after joining their job. But our custombased courses with high fidelity simulation labs, where we create OT emergencies like golden-hour approach of an accident victim, equips them to learn about real-life patient scenarios and improve critical thinking and medical decision making in
complex situations. All the content developed is contextualised and customised according to the Indian hospital environment. What is your role in healthcare at home space? Homecare employees are categorised in three groups doctors, nurses and General Duty Assistants (GDA). GDAs usually get the certified course from the National Skill Development Corporation (NSDC) and Berkeley is also a partner of health sector council of NSDC. Berkeley HealthEDU has customised two weeks’ courses for GDAs and nurses as these add value to their basic skills and take them to the next level of specialised skills making them ready for the industry. There is immense talent in the home care market and it is developing rapidly. The talent pool needs to be adequately skilled in order to be gainfully employed and we are adding value to the workforce by upgrading their skills. The healthcare sector is expected to drive the economic growth as well as play a significant role in generating employment and Berkeley HealthEDU is contributing significantly in the healthcare at home space.
Health education needs practical knowledge and evidence-based practice, as it upgrades the skills of healthcare professionals
Do Berkeley HealthEDU provide training to frontline workers like ASHA and ANMs? The frontline workers like ASHA and ANMs is another
important segment which we would like to focus upon. For this, we have been talking to various state governments. As of now, under the National Health Mission (NHM), most of the state governments are into building the hospital infrastructure. I hope that once these are in place, Berkeley HealthEDU has a great opportunity and it could add great value to the ASHAs and ANMs who are the most important segment in the healthcare chain. Right now, the Kerala government has invited us to put up a skill centre in Kochi which will be a PPP model, where they will give us the infrastructure and we will provide high-end skill training. But in general, my vision for the state governments is to set up four or five skill labs in the different regions of the state, make it a five-year PPP model on a continuous basis and train batches of doctors, nurses, paramedics. We have already discussed this with various state governments and many of them have shown interest. Every state has its unique requirement but large-scale programme is a must for the North East as quality nurses and GDAs pass out from these areas. Give us the details of the courses and workshops you conduct in a year? We have a list of 40 to 50 multiple courses and the top
EXPRESS HEALTHCARE
27
May 2017
KNOWLEDGE
10 courses are very popular with which we train about 1,500 doctors or nurses per year. Altogether, we have trained about 5,000 healthcare professionals in the last three years. The trained professionals have impacted at least four to five million lives. Our vision is to touch and impact 20 million lives by 2020. Currently, our focus is more on short-term courses which is long as six months. Our training sessions and workshops are held onsite at client locations or offsite at our highly advanced facilities in Delhi and Mumbai. One of our popular programme is a 12-day infection control programme in hospitals for nurses. Each of these hospitals have two nurses to control infections. After the course, they go and practice and in three months they update on the activity and a plan for the next three months. After they complete
28
EXPRESS HEALTHCARE
May 2017
six months, we review their performance and give them the certificate. All our programmes have a review. Our cost varies between Rs1,000 to Rs 40,000 and it completely depends on the programme a person chooses. Do you think the Virtual Reality (VR) lab would be an apt fit for a country like India, which has low doctor to patient ratio? How can these labs help? As of now, India is lagging behind in the usage of training facility in healthcare space. Even senior doctors who are trained in simulation, are finding it difficult to convince their hospital chains or others that it is the apt way of practical training. Moreover, a lot is spend towards infrastructure and equipment. So, many hospital chains are not keen in investing in the manpower skill development. The other main cause is
Berkeley EDU gets 25 per cent of its business from such greenfield projects yearly.We are also trying to explore on providing trained manpower to the hospital who are industry ready, instead of hospitals recruiting and sending us for training attrition. After they train the healthcare staffs, about 60 per cent tend to leave the job, but they don't think about the remaining 40 per cent people who continue the service. As for VR labs, we are in touch with various solution providers in the US. Perhaps, in the next three to five years, we will be coming up with some VR lab facility in India. There is not enough knowledge about how such
healthcare training programme would help you to enhance level of skills and competencies required for professionals to work in this sector which would build goodwill of the hospital or the hospital chain. Each state or city is working in silos but we need to create a national healthcare training platform where all the companies come together and educate the
healthcare industry that such practical training and upgrading skills would be the next level of growth. Are there any plans for partnership with the corporate sector? We regularly have batches of doctors, junior doctors, nurses coming from big hospitals for training. A lot of our work is with greenfield hospitals, as they need more skilling assistance. In Rohtak, a US doctor couple wanted to set up a multi-speciality hospital and they approached us and we worked right from the recruitment to the training of hospital workers. So, Berkeley EDU gets 25 per cent of its business from such greenfield projects yearly. We are also trying to explore on providing trained manpower to the hospital who are industry ready, instead of hospitals recruiting and sending us for training. prathiba.raju@expressindia.com
RADIOLOGY SPECIAL
FUTURETRENDS IN RADIOLOGY DAWN OF AN AI ERA? | PG 30
DIAGNOSING LIVER DISEASES WITH ELASTOGRAPHY | PG 32
TRENDS IN RADIATION ONCOLOGY | PG 34
EVOLVING ROLE OF A RADIOLOGIST | PG 35
RISE OF ADVANCED IMAGING TECHNOLOGY | PG37 EXPRESS HEALTHCARE
29
May 2017
RADIOLOGY SPECIAL
Dawn of an AI era? Healthcare sector is welcoming machine learning as it ushers accuracy and better predictive decisions. Mansha Gagneja catches up with Dr Vidur Mahajan, Associate Director, Mahajan Imaging to learn about AI’s impact on the radiology sector and understand its adoption at his centre
I
n the world of scientific revolution, simulation of human intellegence processes which includes learning, reasoning and self correction by machines took flight. Artificial intelligence(AI) was soon spreading its wings across healthcare spectrum. Bringing machine learning to healthcare proved to be beneficial for identifying critical medical conditions, which would potentially allow for earlier intervention and better outcomes. The biggest benefits of AI encompasses improving patient care while reducing costs. The radiology sector fails to remain untouched by the AI wave and is betting on new technology to boost the sector. To understand the application of AI in Indian radiology, we took insights from Dr Vidur Mahajan, Associate Director, Mahajan Imaging, who follows his passion of improving access and affordability of highend medical services with the help of AI. He gives an elaborate view on why AI is the next big thing that will revolutionise the industry. Having education and experience in both the clinical practice and business management he explains how healthcare providers want to provide faster, cheaper and more effective care to their patients and build a sustainable business.
Genesis Advent of AI was inevitable, but it came in much later, even though most of the mathematical models that are used by AI scientists today were developed during the 1950s-1970s. Earlier, computer systems were not dynamic, which in turn staggered the development of such technologies.
30
EXPRESS HEALTHCARE
May 2017
Radiologists have started using advanced post-processing tools and acquisition consoles ever since the development of CT, MRI and nuclear medicine techniques. The accuracy and efficiency of these post-processing tools has been improving drastically over the last few years for example, post-processing a coronary CT angiogram (a CT scan of the heart to see its blood vessels) used to take in excess of an hour till a decade ago – today it can be done in less than 5-10 minutes with the right tools. Dr Mahajan highlights that many of us use some form of Artificial Specific Intelligence (ASI) every day without even realising it. For instance, when we ask Google Maps to show us the way from one place to another, there is an AI system that does millions of computations to provide the shortest and quickest path. The next frontier is the development of Artificial General Intelligence (AGI) which will be designed to act more like a human and will be able to accomplish many tasks which were earlier only our forte. Analysing Indian demographics, we can draw conclu-
sions that physician to population ratio is quite inadequate. This issue may not be resolved by merely allotting more medical seats. Telemedicine service providers, along with the government, are taking great strides in improving the penetration of healthcare in India. However, it is imperative to incorporate some kind of AI system to streamline the process. Dr Mahajan comments, “While a lot of venture capital funding has gone into radiology, true integration of AI seems to be at least a few years away from truly transforming the industry, given the complexity of the human body, huge data requirements, ethical considerations, and legal connotations.”
Synthesis AI in Indian radiology is yet to pick up pace and to facilitate this, Mahajan Imaging is already experimenting with the new technology. He acknowledges,“This revolution is fundamentally transforming Mahajan Imaging’s long-term strategy causing a shift in our mindset of being a typical healthcare provider, to more of a technology company and have started using Mammog-
raphy-Computer Assisted Diagnostics(CAD) around four years ago”. He highlights that the doctors work on advanced radiology workstations – GE Healthcare’s Advantage Windows and Philips’ Intellispace Portal workstations. To aid the transformation of radiology, they have collaborated with multiple AI companies. These companies range from startups like Predible Health, Bangalore; Labsadvisor, Delhi; Semantic MD, US, to GE Healthcare. He adds, “One of our prized partnerships is with the Department of Brain and Cognitive Sciences at MIT, where we are helping develop computational models for human vision which we have been doing for eight years now.” Giving the companies access to their data and providing a platform to test their innovations in the real world may drive growth. And if this partnership turns out to be fruitful, chances are that Mahajan Imaging will attain customised products backed by latest machine learning. Dr Mahajan believes that AI will definitely transform radiology one day and they want to drive that transformation, versus just being an observer.
Metamorphosis Mahajan Imaging Centre acquired CAD system along with Fujifilm’s full field digital mammography system and it has enabled them to pick up lesions that might have otherwise been missed. The available applications improve efficiency which speeds up the process of post-processing of images, most commonly CT Angiograms, Liver Segmentation, Tumour Segmentation etc. In regards to accuracy, Mammography CAD has been
VIDHUR MAHAJAN Associate Director, Mahajan Imaging
around for a long time and is assisting radiologists read digital mammography scans more thoroughly. He identifies,“Our 'ah-ha!' moment came when we were able to pick up a lesion that one of the world’s leading hospitals in the US missed, on the same images, simply because we were able to use CAD.” Another emerging field is Radiomics, where quantitative analysis of images is performed to reveal deeper insights, is another aspect that will redefine the field of radiology as humans can only see a limited approach of the data acquired by imaging machines. These are only the tip of an iceberg. Most of the applications, that will eventually have a widespread impact are currently either under development, or under validation. The challenge that AI companies face today is the issue of accountability. Although AI systems would be suggesting diagnoses and assisting radiologists through analysing reports, soon AI systems would constitute a major role in diagnosis and prescription. Dr Mahajan expresses his concern as who would be held responsible for errors made? Would it be the software developer, the company that procured the software or the doctor who is signing off? This is the same issue that self-driving cars are facing today –who is to be blamed for an accident –the software, the manufacturer or the passenger? Indeed, if we are devising these innovations, the burden of identifying and rectifying loopholes rest with all stakeholders. How will the radiology sector take up these innovations and use it to thrive will unfold only with time. mansha.gagneja@expressindia.com
LOOKING FOR SPEED, PRECISION AND COMFORT? Head for the top of the line: the DR 600 high performance digital X-ray room. With high productivity, innovative features and ZeroForce Technology, the fully automated DR 600 streamlines workflow, increases throughput and enhances the experience of patients and operators alike, even in busy imaging environments. At its heart lies the ‘gold standard’ MUSICA image processing software, offering consistently reliable, high-quality image visualization. The bottom line is, the DR 600 takes Agfa HealthCare’s latest technologies and puts them to use to help you provide top-of-the-line imaging and delivery of patient care! Find out more, visit agfahealthcare.com
RADIOLOGY SPECIAL
Diagnosing liver diseases with elastography
DR MANOJ SHARMA Senior Consultant Radiologist, VPS Rockland Hospitals
With India witnessing 10 lakh new patients being diagnosed in a year with liver ailments, there is an urgent need to detect and prevent liver diseases. Dr Manoj Sharma, Senior Consultant Radiologist, VPS Rockland Hospitals, talks about real-time elastography to prevent the disease EVERY ONE IN five Indians is estimated to be suffering from a liver ailment. The dynamics of liver diseases in the country has seen a paradigm shift with about 10 lakh new patients being diagnosed in a year. Earlier caused by hepatitis B and C, the most common causes now are alcohol and other obesity-related disorders. Globally, hepatocellular carcinoma (HCC) – or a cancer in liver – is the second most common cause of death due to malignancy. Early detection and prevention are the solutions. A healthy liver should be soft and elastic. A stiff liver means more scarring (fibrosis). The advanced stage of fibrosis is cirrhosis. Early detection of liver stiffness helps in better treatment planning and halting the disease process in beginning. Common liver disorders include viral hepatitis, alcoholic and non-alcoholic fatty liver disease, drug-induced liver disease, primary biliary cirrhosis and immune hepatitis. Chronic liver disease causes increasing deposition of fibrous tissue within the liver, leading to development of cirrhosis with consequences like portal hypertension, hepatic insufficiency and hepatocellular carcinoma (HCC). The process of liver fibrosis is dynamic. Studies show that regression is possible with treatment of the underlying condition. The stage of liver fibrosis is important to determine prognosis and surveillance, and to prioritise for treatment and explore potential for reversibility. For a clinician, the most important question is whether or not the patient has cirrhosis. The diagnosis of decompensated cirrhosis (defined by presence of clinical complications
32
EXPRESS HEALTHCARE
May 2017
SWE image in a 50 yrs man. Note the white box that is the ROI where the measurement is obtained. Image demonstrates one of the 10 measurements. The median stiffness measure is 19.71, kPa, consistent with chronic liver disease
like ascites, variceal haemorrhage, jaundice, and/or encephalopathy) can be assigned clinically on the basis of patient history, physical examination and laboratory tests. However, the diagnosis of compensated cirrhosis is more challenging. Although some findings like low platelet count and a nodular liver surface on images can indicate the presence of cirrhosis, these findings are often absent in a patient with compensated cirrhosis. Thus, a non-invasive study to confirm or exclude the presence of cirrhosis is needed.
Wave frequencies Different histologic stages of progressive liver fibrosis range from no fibrosis (METAVIR stage F0) to cirrhosis stage (METAVIR stage F4). Using a combination of different blood markers and assessment of tissue elasticity based on transient elastography has shown promising results in determining the exact degree of liver fibrosis. Transient elastography (Fi-
broScan) is performed with an ultrasound transducer probe mounted on the axis of a vibrator. A vibration transmitted from the vibrator toward the tissue induces an elastic shear wave that propagates through the tissue. These propagations are followed by pulse-echo sonographic acquisitions and their velocity, which is directly related to tissue stiffness, is measured. The harder the tissue, the faster the shear wave propagates. Shear-wave elastography and acoustic radiation force impulse (ARFI) imaging allow for quantification of tissue stiffness, enabling more precise tissue characterisation. The shear waves created by the machine measure elasticity of liver in kilopascals (kPa). The higher the number, more advanced is the liver fibrosis. The mean, maximum, minimum and standard deviation of a shear wave speed (in metres per second) or the young modulus (in kilopascals) within the region of interest are displayed.
A strength of this technique is that it is performed with realtime imaging. So masses and large vessels can be avoided and areas with artifacts can be identified. It can also be used to assess multiple regions of liver. The larger area of measurement allows for a larger region of interest for the averaging of measurements. Further, realtime two-dimensional shear wave elastography allows an operator to see generation of elastographic measures in a colour display as they are accumulated. Real-time elastography is thus a new method to measure tissue elasticity integrated in a sonography machine and is technically different from transient elastography. With conventional ultrasound probes, echo signals before and under slight compression are compared and analysed. As tissue elasticity cannot be measured directly from reflected ultrasound echoes, methods analysing the displacement of phases (for example cross-correlation method) can be investigated. However, these measurements are associated with strong aliasing. To overcome these restrictions, real-time elastography based on the combined auto-correlation method and 3D tissue model can be deployed to determine phase displacement in real time without aliasing.
Promising results In elastic or soft tissue, the amount of displacement is high because soft tissue can be compressed more than hard tissue. In addition, with the combined auto-correlation method, echo-
frequency patterns of parallel ultrasound echoes are compared to detect possible lateral evasion of hardened tissue areas. In a second step, a strain field is reconstructed from the measured displacements (strain image). Conclusions concerning the elasticity of the underlying tissue can be drawn from these reconstructions abutted to a spring model. Areas of high elasticity (that is soft tissue) appear as places of high strain, areas with low elasticity (that is hard tissue) appear as places of low strain. By using the 3D tissue model (finite-element method), the examined tissue is divided in up to 30,000 finite elements of equal stiffness before compression. During compression, the displacement of each element is measured. The finite-element method can then determine the tissue elasticity from the calculation of each element. The calculation of tissue elasticity distribution is performed in real time, and the examination results are represented as colour-coded images with the conventional B-mode image in the background. It is likely that diagnostic accuracy of real-time elastography can be improved by further optimisation of images using different ultrasound probes, refined selection of liver tissue’s analysed area and more refined statistical assessment of elasticity images for a larger data set or a larger number of images for each patient. Especially, the diagnosis of cirrhosis seems to be improvable if more reliable assessments of variability between single images are available. Results of further studies are needed before real-time elastography can be introduced
RADIOLOGY SPECIAL widely in clinical practice. In addition, the combination of realtime elastography with other blood tests such as FibroTest may further improve specificity and sensitivity for the non-invasive estimation of liver fibrosis.
Reducing biopsies
◗ Various elastography techniques have advantages and limitations. No single technique currently can be recommended as optimal for all indications and circumstances. Depending on the indication, different modalities may be preferred. Ultrasound elastography techniques
are relatively inexpensive, portable, increasingly available, and generally provide good diagnostic accuracy for advanced fibrosis. Nevertheless, they sample relatively small portions of the liver and they may be unreliable in obese patients and those with narrow intercostal spaces.
niques integrated to clinical ultrasound and MRI systems can assess mechanical properties in vivo. Radiologists should be familiar with these exciting new technical capabilities to examine by imaging what once could be examined only by direct palpation.
•
•
•
For OsiriX
Call 8007 36 00 33 8007 36 00 99
MEDICAL 3D PRINTING & PATIENT SPECIFIC IMPLANT DIVISION
Patient Specific Implants
Dental & Surgical Drill Guide Templates
Minimal access surgery planning
Patient Specific Prosthesis/ Orthosis
RADIOLOGISTS: READY TO ADD NEW MODALITY?
HOW IT HELPS?
REDUCE INTRA SURGERY TIME REDUCE INTRA SURGERY BLOOD LOSS EXECUTE YOUR SURGERY PLAN EXACTLY SAVES MORE THAN IT COST!
WHY RADIOLOGIST? CALL 8308 533 533
May 2017
Minimal access surgery plan
33
Dental Drill Guide Templates
EXPRESS HEALTHCARE
Patient Specific Implants
◗ Research is needed to better understand the performance of elastography for monitoring longitudinal changes in fibrosis. Emerging indications of elastography include detection of hepatic inflammation, assessment of portal hypertension, characterisation of focal liver lesions, and evaluation of other abdominal organs. ◗ Potential confounders when using stiffness for assessment of liver fibrosis include technical and instrument-related factors and biologic and patient-related factors. The former include location and depth of measurements, wave frequencies, and device dependencies. The latter include concomitant hepatic steatosis, inflammation, and cholestasis; breathing; right heart failure and hepatic venous congestion; and fasting versus post-prandial state. ◗ Measured stiffness is frequency dependent. In general, measured stiffness increases as the frequency of the shear waves increases. Different techniques use different frequencies. Hence, observed stiffness values are technique dependent.
Patient Specific Prosthesis
Key learnings
•
A head-to-head comparison of transient elastography (FibroScan) and real-time elastography will be of future interest as well. This is state-of the-art technology for diagnosis of liver disease and provides immediate, non-invasive and painless measurement of liver health. It is useful in patients with fatty liver in order to identify those with fibrosis who have progressive disease. The technique has the potential to decrease the number of liver biopsies and offer safe, more repeatable tests to follow patients with liver diseases. The biopsy complications are high including pain and bleeding, often requiring hospitalisation. A liver biopsy samples only a very small piece of the liver which can lead to incorrect staging.
Magnetic resonance elastography samples larger portions of the liver and offers excellent diagnostic accuracy that probably slightly exceeds that of ultrasound-based techniques, but quality may be degraded in patients with marked iron deposition. Finally elastography tech-
RADIOLOGY SPECIAL
Trends in radiation oncology Dr J Mathangi,Consultant,Radiation Oncology,BGS Gleneagles Global Hospitals,Bengaluru,highlights benefits of technology-driven radiation oncology to annihilate a tumour while preserving the integrity of adjacent healthy tissue RADIOTHERAPY’S CONTRIBUTION to fight cancer is significant. The impact of radiotherapy in cancer survival has been estimated at 40 per cent, compared to 49 per cent of patients being cured by surgery and 11 per cent of patients for systemic treatments. It can be used to treat almost all cancers, anywhere in the body. It can be used alone or alongwith other treatments like surgery or chemotherapy. Radiation therapy allows organ conservation, may be a curativeoption for patients with inoperable disease, and may allow a curative approach for patients who have significant co-morbidity that precludes surgery. Radiotherapy has a major positive impact on local cancer control and is a highly effective in palliation of symptoms like pain, bleeding.
the intensity of the radiation can be changed to spare more adjoining normal tissue. Because of this an increased dose of radiation can be delivered to the tumour in spite of a dose limiting sensitive adjacent critical structure. This helps in improving the loco regional tumour control and indirectly improving the survival.
Volumetric modulated Arc therapy (VMAT/RapidArc) This is an improvisation of IMRT by optimising the whole tumour as a single volume and the treatment delivered in an arc fashion. This allows 360o freedom of placing the beams to improve shaping and better sparing. Also it helps in faster treatment delivery resulting in lesser time for tumour movement during treatment and a greater patient comfort.
Recent developments Continuing improvements in techniques and technologies are increasing the precision and accuracy of radiotherapy, allowing treatments that minimise the impact on healthy tissue and reduce treatment related morbidity. Notable developments to date are in the areas of intensity modulated radiotherapy (IMRT), Image guided radiotherapy (IGRT), stereotactic body radiation therapy (SBRT), 4D imaging, Gating and Tracking techniques for tumours moving with respiration, adaptive radiotherapy and particle therapy.
Intensity modulated radiotherapy (IMRT) Historically, the maximum radiation dose that could be given to a tumour site has been restricted by the tolerance and sensitivity of the surrounding nearby healthy tissues. The 3D conformal radiotherapy shapes radiation beams to closely approximate the shape of the tumour whereas in IMRT,
34
EXPRESS HEALTHCARE
May 2017
Stereotactic radiotherapy (SRS/FSRT/SBRT) A stereotactic radiation treatment uses a specially designed coordinate-system for the exact localisation of the tumours in the body in order to treat it with very high doses of radiation, using several beams of various intensities aimed at different angles to precisely target the tumour. This can be used in the brain (stereotactic radiosurgery-SRS) and rest of the body (stereotactic body ablative radiotherapy- SBRT) for small well defined inoperable tumours 4D imaging, gating and tracking techniques: The tumour movement with respiration can be imaged and taken into account for radiotherapy treatment planning with the help of 4D – CT, MRI and even PET scans. This along with the use of Gating (treating only in a given phase) or tracking (tracking the tumour in all phases of respiration) techniques helps us to reduce the amount of normal tissues with the treatment fields.
Integration of imaging in radiotherapy and adaptive treatments: The improvements in imaging features with high-quality images, 4D scans identifying tumour motion, PET/CT scans to show the different tumour biology and the real extent of tumour, integration of CT/MRI/PET CT/ DSA images all in a single platform ultimately allows clinicians to have accurate patient contouring, treatment planning and treatment deliveries. The integration of imaging devices with treatment machines allows the clinician to do imaging tests with good image quality on the treatment couch to check the position of the patient and the tumour before and during the treatment course. The important advantage is the adaptive treatments that can be adjusted as tumour and patient characteristics change throughout the course of radiotherapy like weight loss or the tumour size reduction in head and neck cancers and bladder cancers. Adaptive treatments improve patient outcomes and reduced longterm side effects
Radiotherapy and tumour biology Radiotherapy is by its nature a personalised treatment. Every patient’s plan is unique and tailored to their particular clinical circumstances and anatomy. It can be conceptualised as a biological intervention with profound effects at the cellular and molecular level, modulated through cellular signalling pathways and the immunological axis. With the evolution and better understanding of individual tumour biology, radiotherapy treatments and doses can be tailored to the specific tumour characteristics, with molecular and biological imaging enabling the already personalised therapy to be even more targeted.
Patient awareness and involvement in cancer care Patient awareness about new radiotherapy techniques and technologies will continue to increase in the coming years due to increasing availability of information via the Internet and increased awareness through multidisciplinary care teams. The role of the healthcare provider will increasingly be of a partner, who explains and demystifies the vast quantities of information, making them understand the best technique that suits the patient and his tumour making it advantageously personalised.
Communication and information sharing Clinicians must communicate with one another and coordinate and share the experiences and results that enhance better healthcare. With a mobile patient population, increasing numbers will present following initial treatment to a different radiotherapy centre and require re-treatment with radiotherapy or develop a second malignancy (requiring treatment with radiotherapy). Technological solutions to expedite the transfer the relevant imaging and previous radiotherapy treatment details to the treating radiotherapy centre will be important.
Future developments Imaging with CT for radiation therapy can be performed for simulation, daily set-up, adaptive planning, retreatments, therapy follow-up and monitoring – all of which can contribute to a patient’s cumulative lifetime dose for radiation exposure. To meet the imaging demands and addressing cumulative radiation doses, new solutions such as standalone MRI simulators that can produce images suitable for treatment planning, treatment delivery units that use MRI for
DR J MATHANGI Consultant, Radiation Oncology, BGS Gleneagles Global Hospitals, Bengaluru
on-board patient imaging, more biological imaging techniques etc. may take hold in future.
Challenges in India State-of-the-art technology is available within the private sector and a few hospitals in the public sector, but 75 per cent of patients in the public sector in India do not have access to timely radiotherapy. This inequity in access to radiotherapy in the public sector is amplified in rural areas. where majority of Indians live.
Opportunities in India A number of innovative initiatives to improve cancer treatment and access have emerged that could support such an investment. These include local production of equipment, twinning programmes between institutions in high and low-income countries to exchange knowledge and expertise, and non-governmental and statesponsored schemes to sponsor and support patients in their cancer journey.
Medical tourism Outstanding healthcare facilities and affordable costs of treatment has made India one of the most popular choices for medical tourism in the area of cancer care. This opportunity needs to be capitalised upon by streamlining the process and creating more facilities to choose from.
Epilogue The challenges in cancer care delivery can be overcome by making radiation oncology technology widely available. The offshoot of this endeavour would be associated increase in medical tourism in the field of cancer care. The end result would be a combination of exemplary service to humanity and sizeable economic development.
RADIOLOGY SPECIAL
Evolving role of a radiologist in healthcare
DR MEINAL CHAUDHRY Head of Department, Radiology, Aakash Healthcare
Dr Meinal Chaudhry, Head of Department, Radiology, Aakash Healthcare, elaborates how radiologists are now venturing into the realm of being the primary treating physician by the use of various interventional techniques RADIOLOGY AS a speciality is comprehensive, encompassing a range of imaging technologies and imagingguided treatments including X-ray, computed tomography (CT), ultrasound, mammography and magnetic resonance imaging (MRI). Continuing technological innovation in radiology is leading to more sophisticated techniques that results in prompt and specific diagnosis, but the demands of healthcare as a vertical are soaring. For instance, in contemporary times, doctors are treating diseases which are more complex and were unheard of in the past. To achieve this, all elements of healthcare delivery including physical examination, diagnosis and treatment of the person should be efficient involving stringent quality control measures. Hence, the role of integrated healthcare delivery becomes very important involving the role of a radiologist. Radiologists are medical practitioners who have comprehensive specialist training in performing and interpreting diagnostic imaging tests and imaging-guided procedures or treatments that involvesmultiple imaging modalities. However, present day radiologists add value beyond just image interpretation. Working alongside healthcare practitioners, radiologists are integral to the care of patients by guiding the Physician choose the right modality for diagnosis, making accurate diagnoses, prognosticating the outcomes, monitoring response to treatment and performing imag-
ing-guided treatments. Minimally invasive surgeries are the trend of the times where the surgeries are performed using small key hole incisions. These surgeries rely a great deal on the ability of a radiologist to identify and localise precisely the diseased area thus making him a partner in the treatment of the patient. Other less invasive techniques like laser, radiation therapy, high frequency ultrasound treatments etc., rely greatly on the information which the radiologist passes on to the treating physician or surgeon enabling the surgeon to perform these techniques with ease. Besides these roles, radiologists are now venturing into the realm of being the primary treating physician by the use of various interventional techniques.Such techniques at times prove to be a life saver for the patient, for instance - timely thrombolysis in a clotted artery by an interventional radiologist can lead to salvaging the extremity of the patient, stopping the blood supply to cancer cells so as to shrink the tumour vol-
ume. And all this is done with a very small incision on the skin surface. That’s the magic of an interventional radiologist. With the technological advances in healthcare, telecommunications and IT are assuming a pivotal role; the radiologists now are providing their expertise on a global level via teleradiology. Experts from various fields of radiology can provide their second opinion to the physicians, remotely placed, leading to accurate and rapid care whenever needed, without borders. In fact with the amalgamation of teleradiology, telemedicine and robotic surgeries have led to procedures, which happen at a location close to patients without the hassle of travelling. These technologies have added a great deal to the patient experience in the healthcare. Going further ahead with digitisation, Multimedia Enhanced Reporting in Radiology (MERR) now radiologist link the virtual images within the report where the treating physician can just click on that link to see insides the
body of the patient and correlate it with findings in the report. (So, all the broth is cooked, treating physician has just to dig the spoon right in and eat it.) However, technology has its own advantages and disadvantages. So, quality check of the teleradiology reports and its continuous improvement is also a responsibility of radiologist community and they are scoring wonderfully well on that front. Another important role of a radiologist in patient safety is ‘limiting’ excessive radiation to the patients. In the modern times when the population is becoming more and more aware of radiation and the risks associated with it. Radiologists perform a crucial role in personalising the radiation dose required by the patient for achieving certain diagnosis depending on the amount of information required from the study, enough to address the clinical need of the patient while keeping excessive radiation dose in check. Smart equipment which has automated dose regulations are available and technological strategies are certainly an important part of improving radiation safety, but in day to day practice, the role of the radiologist is to utilise clinical strategies to reduce patient dose to levels as low as reasonably achievable (the ALARA principle) while maintaining diagnostic quality images. This is also achieved by education the doctors and patients (self referral) to skip the tests that aren't necessary.
While radiation safety and contrast administration werethe two areas of patient safety in which radiologist had a role traditionally. Another issue which has gathered attention in recent times is the prevention of medical errors. Medical errors happen because of multiple small failures in the chain of events and we as humans are ‘fallible’. Current focus has shifted from finding a fault in a person (person approach) to making the system robust (systems approach) to decrease the probability of errors. For example, a poorly serviced equipment in radiology department will lead to missed diagnosis and further can affect patient safety. To identify the scope of improvements in the systems and processes happening in department of radiology (which is one of the busiest department in the hospital) is also a radiologist's job. So, a radiologist’s role in patient safety cannot be understated. Hence, the traditional perception of the radiologist in a dark room in front of a view box just for interpreting images is rapidly becoming obsolete. From just a helping hand or behind the scene medical practitioner, we are now joining the patient care team in the fore front by adding a lot of value in patient health outcomes. Being a part of least acknowledged but most important teams of healthcare, this evolution in role is only making us smile. On a lighter note, I'd like to say, ‘More power to radiolo-
EXPRESS HEALTHCARE
35
May 2017
RADIOLOGY SPECIAL
Innovations that make clear difference in radiology The fully automated DR 600 streamlines workflow, increases throughput and enhances the experience of patients and operators IN THE future of healthcare, which innovations will make the difference? Clearly, those that focus on answering real needs, like the DR 600 X-ray room, which finds new ways to simplify complex imaging problems. A complete and integrated solution, it provides high-quality images while maximising productivity, versatility and ease of use. And that makes it the right choice for hospitals and radiology departments seeking a solution to accompany them into their digital radiography future.
ZeroForce, maximum impact With ZeroForce Technology, all movements of the tube head, wall stand and table, in all different directions, are quick and easy, and require almost zero effort. Accurate auto-positioning is achieved by simply pressing a thumbnail on the workstation touchscreen. The risk of error is reduced, the patient process is quicker, staff comfort is increased and the imaging workflow is faster and smoother. Fiona Rooke, Diagnostic Services Manager, Yeovil District Hospital, UK said, “You can move the tube head actually with one finger. It is quite remarkable how easy it is to manoeuvre!... The patient is usually in and out in 15 minutes – about half of the time it took before.”
(GOS) technology1, plus leading-edge automatic exposure control for high-speed accuracy and collimators with dose area product meter, the DR 600 optimises and automatically reports doses.
MUSICA 3: Taking the best and making it better The powerful MUSICA image clarity provides additional dose reduction capability. Fully automatic and very easy to use, the gold-standard MUSICA image processing software gives maximum information from images, independent of whether the patient is thick or thin, or of the exam type. As a result, minimal reor post-processing is required. The first time is the right time, with MUSICA. Rooke said, “MUSICA is a key decision maker for us: it’s one of the reasons we stick with Agfa HealthCare, because the image quality is second to none.”
With fully motorised vertical and horizontal tracking, as well as angular tracking for dedicated exams the innovative EasyStitch technology supports simpler, more precise Full Leg/Full Spine (FLFS) imaging. Based on fully automated single focus technology, it minimizes distortions for high-precision FLFS imaging.
Ease of use
Everywhere, controlling and reducing patient radiation exposure during imaging is a priority. Offering a choice of fixed, tethered and wireless detectors with Cesium Iodide (CsI) or Gadolinium Oxy-Sulphide
The DR 600 is proof that 'topof-the-line' doesn’t have to mean 'complicated and hard to use.' The height-adjustable table and floating tabletop offer very easy positioning for a wide range of patients and types of
EXPRESS HEALTHCARE
May 2017
DR 600 high-throughput digital X-ray room at a glance:
EasyStitch Full Leg/Full Spine
Dose matters
36
protocol codes directly into exam tree settings. These additional workflow improvements help accelerate your return on investment.
studies, and you can choose the next exam on the acquisition workstation. Imaging is faster and more comfortable, with a smoother patient flow.
Precision and cost-effectiveness A complete range of high-quality detectors comes in all sizes – 10 x 12”, 14 x 17” and 17 x 17” – capturing every detail. These detectors can be shared across
our entire DR portfolio, to maximise both quality and cost-effectiveness.
Streamlined integration Solid integration with the hospital information system (HIS), radiology information systems (RIS) and picture archiving and communication systems (PACS) enables advantages such as configuring the system to translate RIS
◗ ZeroForce Technology, offering smooth operation with almost zero effort ◗ Angular tracking for dedicated exams ◗ Height-adjustable table and floating table-top ◗ Automated tilted wallstand bucky ◗ Superior user-friendly tube head display with image preview ◗ New dose sensing technology with dose measurement accurate to the millisecond ◗ Excellent image quality: next-generation MUSICA enables even better viewing of difficult areas ◗ Significant potential for dose reduction1, with the Cesium Iodide detector
RADIOLOGY SPECIAL
Rise and impact of advanced imaging technology
DR RAJEEV BOUDHANKAR CEO, Bhatia Hospital
Dr Rajeev Boudhankar, CEO, Bhatia Hospital, highlights the tremendous impact of medical imaging in improving health outcomes and elaborates on various techniques which have ushered new efficacy and efficiency in healthcare delivery MEDICAL TECHNOLOGY is undoubtedly indispensable to the health and improved quality of life of people. It has revolutionised healthcare over almost the past three decades, allowing doctors to find disease earlier and improve patient outcomes. In a utopian world, it would have been possible to diagnose, treat and cure patients without causing any harmful side effects. Since this is not possible, the efficacy of medical imaging cannot be overstated considering it has enabled doctors to see inside a patient without having to cut them open. It has ensured the early detection and treatment for cases such as lung, breast cancers etc. The chances of medico–legal issues too have been reduced due to delayed or incorrect diagnosis. There is some downside to the rise of imaging technology too. In the present era, the deterioration of skills in physical examination has become much more evident. Poor clinical skills in new doctors or even senior doctors losing their touch with clinical skills, has made meticulous examination extinct. Conventional ultrasound imaging relies on good contact between the transducer and the skin, using acoustic coupling gel. Without this, the ultrasound beam encounters a large acoustic impedance mismatch between the transducer and the air in front of it, which prevents beam transmission. This limits the use of ultrasound in some clinical scenarios, including imaging of open wounds and during surgery,
where sterile conditions are required. Now, researchers in Japan have demonstrated non-contact ultra sound imaging, where the transducer is separated from the skin by air. “The project is in its infancy, but the results to date have been very encouraging,” claims Gregory Clement, physicist and lead author of the study conducted at the University of Electro-Communications in Tokyo.
The non-contact technique exploits the greater focussing potential of ultrasound in air, in which focal diameters onequarter of that possible in tissue can be achieved. A high beam intensity in air compensates for the low transmission of the beam across the air–skin boundary. The group’s approach uses a bowl-shaped transducer to focus an ultrasound beam onto a 5 mm spot at the skin surface. The spot generates a point source of ul-
trasound that, when scanned over the surface of an object, can be used to perform diffraction tomography. “The method treats the skin surface as a ‘virtual’ transducer, allowing for a large effective number of sources and receivers, thus opening the potential for large regions to be imaged,” claims Clement. “Current medical probes can’t conform to the body, thereby limiting where they can be placed.” The team simulated and constructed a
40 kHz transducer prototype, comprising 400 elements arranged in a hemispherical array. Using a low, suboptimal frequency for imaging, elements capable of emitting 40 kHz that are commercially available at low cost the researchers’ have provided proof of-principle. After beam characterisation and transmission measurements, they acquired images using the transducer and a broadband microphone receiver. In vivo non-contact imaging of a hand was demonstrated with a conventional Cmode approach, which produces images for a fixed depth below the skin. The low-res scan showed varying contrast between the anatomy containing mainly bone and that containing only soft tissue. Clement says that the group will continue the development and clinical testing of the non-contact imaging technique over the next few years. Ongoing work in the lab includes optimising the receiver to increase technique sensitivity and investigating faster acquisition techniques to reduce scan times. The ability to visualise processes that take place in the brain during the development and progression of Alzheimer’s disease also provides a powerful aid for diagnosing the condition, monitoring treatments and testing preventive and therapeutic agents. With this aim, a research team at the National Institute of Radiological Sciences in Japan has developed a new type of imaging agent that enables visualisa-
EXPRESS HEALTHCARE
37
May 2017
RADIOLOGY SPECIAL tion of 'tau-protein' aggregates in the brains of living patients. In patients with Alzheimer’s disease, tau proteins aggregate together and become tangled, while fragments of another protein, amyloid beta, accumulate into plaques. Tau tangles are not only an important marker of neurodegeneration in Alzheimer’s disease, but also a hallmark of other neurodegenerative disorders that do not involve amyloid-beta plaques. And while imaging technologies have been developed to observe the spread of amyloid-beta plaques in patients’ brains, tau tangles have previously not been easily monitored in living patients. The researchers have now developed fluorescent compounds called PBBs that bind to tau inclusions and can be visualised using positron emission tomography (PET) and optical imaging. They showed that the PBBs could detect tau lesions in a mouse and a living patient. In the clinical PET study, PBB revealed a strong signal in the hippocampus of a patient with Alzheimer’s disease, in contrast to PET images recorded using a betaplaque tracer. “PET images of tau accumulation are highly complementary to images of senile amyloid-beta plaques,” claims the Institute. This is of critical significance because tau lesions are known to be more intimately associated with neuronal loss than senile plaques. There are other some latest cutting-edge imaging techniques that may become popular in the near future. Pocketsized hand-held ultrasound devices are predicted to replace the 200-year-old stethoscopes in near future. They can diagnose heart, lung and other problems more accurately than traditional stethoscopes. Similarly, Hyperspectral imaging may provide a non-invasive diagnostic method that allows determination of pathological tissue with high reliability. There are chances that this would also lessen doctor’s liability and reduce indemnity insurance premiums. This technology is in use in the defence
38
EXPRESS HEALTHCARE
May 2017
sector and is now finding applications in the healthcare imaging Industry. A modality called Electromagnetic Acoustic Imaging developed by the University of Oxford has been making use of electro – magnetic and acoustic waves for diagnosis. It helps to identify various types of solid cancers in the early stages of development. Another technology that goes by the name Wafer Scale Mega Microchip developed by the University of Lincoln is also used to enhance medical imaging techniques. The University says that images that are produced by the chip will enable doctors to detect accurately the effects of radiation on cancerous tumours, thus helping early detection. Besides, there are two other universities — the University of California, Berkeley and the Universidad Autonoma de Madrid of Spain who have claimed to have together made the use of 3D Meta material to augment ultrasound images by a factor of 50X. In case this technology is successful commercially, it would help current ultrasound investigations to capture high-resolution images for medical imaging in both diagnosis and interventional procedures. Another claim is by the University of Medicine, Berlin and Max-Delbruck Center for Molecular Medicine, Berlin who say they have produced a technology for capturing images of the beating heart in its MRI systems. They claim the magnetic field of resolution would be 150,000 times the earth’s magnetic field. It would thus aid in clearly demarcating between blood and heart muscle, enabling early diagnosis of cardiac malfunction. Scientists at Japan’s Railway Technical Research Institute, Tokyo, too have managed to develop a palm-size superconducting magnetic system. This would make current MRI System into mobile imaging applications. Iron oxide nano crystal technology is being considered for use in medical imaging. Super paramagnetic iron oxide
With so many advances in technology, healthcare facilities have definitely become more cutting-edge and have led to a better patient experience.The need of the hour is to balance the two factors of affordability and advanced technology particles have a variety of applications in molecular and cellular imaging. Evaluation of some of the recent research has concerned cellular imaging with imaging of in vivo macrophage activity. As per the iron oxide nano particle composition and size which influence their bio – distribution, several clinical applications are possible. The use can be checked for detection of liver metastases in cancers, metastatic lymph nodes, inflammatory and degenerative diseases. Research is also on in the field of stem cell migration and immune cell trafficking, as well as in the areas of targeted iron oxide nano particles for molecular imaging studies. Another study that is under focus is that on the ultra small super paramagnetic iron oxide particles that are being researched as blood pooling agents for angiography, tumour permeability and tumour blood volume or steady-state cerebral blood volume and blood vessel size index measurements.
3D bio-printing has undergone seminal advancements in the recent times. 3D bioprinting is the process of creating cell patterns in a confined space using 3D printing technologies, where cell function and viability are preserved within the printed construct. This technique allows high precision fabrication of biological structures encapsulating cells and bioactive molecules, with applications in areas such as tissue engineering, drug development and bio-sensing. Recent advances have enabled 3D printing of biocompatible materials, cells and supporting components into complex 3D functional living tissues. 3D bioprinting is being applied to regenerative medicine to address the need for tissues and organs suitable for transplantation. Compared with non-biological printing, 3D bioprinting involves additional complexities, such as the choice of materials, cell types, growth and differentiation factors, and technical challenges related to the sensitivities of living cells and the construction of tissues. 3D bioprinting has already been used for the generation and transplantation of several tissues, including multilayered skin, bone, vascular grafts, tracheal splints, heart tissue and cartilaginous structures. Other applications include developing highthroughput 3D-bioprinted tissue models for research, drug discovery and toxicology. Researchers at Siemens Corporate Technology have developed a learning-based software that can identify and section out any organ in any digital medical image, irrespective of occlusions, angle of view, imaging modality, or pathology. The company says that this method can be used to synthesise a virtual high dose CT image from a low dose CT image, enabling reduction of the radiation dose to which the patient is exposed. Siemens has reportedly applied for a patent. The John Hopkins University has developed a procedure for precise characterisation of tumour burden and response to therapy from PET Scans.
Although this method is awaiting patent approval, it is known to provide reliable and reproducible PET tumour boundary definition and metabolic tumour volumetric quantification over a wide range of tumour sizes and shapes and for various levels of PET radiotracers uptake. This method will help clinicians in diagnosis, staging and planning of radiotherapy and surgery as well as determining treatment response. It can also help in cancer therapy research. At the Ohio State University, researchers have studied a new method for performing CT-based elastography. This method estimates local displacement of tissue in response to a mechanical stimulus from high-resolution images. It can also be applied to hard structures in the body like bone, teeth and cartilage as well as soft tissues. It can also be used to scan patients with pacemakers or metal implants that cannot undergo MR scans. A new technique has been developed by researchers at Philips that determines blood flow velocity. Philips has applied or a patent for it. The method uses ultrasound pulse at one location and the pulse is detected at a second location by an ultrasound receiver. The calculation is then done for flow velocity of blood in a blood vessel between the first and second locations. Barbados-based Synaptive Medical Company has developed a new technique for correcting warping in MR images caused by non-linearities in gradient field profiles. The patent for this new technique is pending. Meanwhile, with so many advances in technology, healthcare facilities have definitely become more cutting-edge and have led to a better patient experience. Nonetheless, the fact remains that though technology is aiding doctors to give better and quicker healthcare, it has escalated the cost of healthcare making it dearer for the commoners. The need of the hour is to balance the two factors of affordability and advanced technology.
RADIOLOGY SPECIAL
Carestream to sell dental digital biz to Clayton, Dubilier & Rice and Hillhouse/CareCapital Dental X-ray film and anesthetics are not included in the agreement and will remain with Carestream CARESTREAM, WORKING with its parent company, Onex Corporation, has entered into an agreement to sell its dental digital business to funds managed by Clayton, Dubilier & Rice (CD&R), a leading global private investment firm, and CareCapital Advisors (CareCapital), a specialist investment platform focussed on dental and consumer health in Asia and part of Hillhouse Capital Management (Hillhouse). The new independent company will be named Carestream Dental. Carestream’s dental digital business, which provides imaging systems and practice management software for general and specialist dental practices globally, has earned leading positions in attractive, highgrowth, oral healthcare markets and is well positioned for continued growth and success. CD&R and CareCapital intend to partner with the Carestream Dental team to build on the company’s leading positions and accelerate growth. Dental X-ray film and anesthetics are not included in the
agreement and will remain with Carestream. Lisa Ashby, President, Carestream Dental, will become CEO of the new independent company upon the closing of the transaction. “This is a landmark moment for Carestream Dental that positions the company for exciting future growth,” said Ashby, “With the strong support of our new partners, we look forward to becoming even more effective in serving the dynamic needs of the global oral healthcare industry with innovative products, high quality services and an unwavering commitment to excellence in all that we do.” “Our investment in Carestream Dental lines up well with CD&R’s strengths executing complex corporate carveouts where there is meaningful transformation and growth potential,” said CD&R Partner Derek Strum. “We are excited to invest behind a strong employee base and leading global brand in a consistently growing market with technology penetration
Carestream’s dental digital business, which provides imaging systems and practice management software for general and specialist dental practices globally, has earned leading positions in attractive, highgrowth, oral healthcare markets and is well positioned for continued growth and success tailwinds, and to partner with Hillhouse/CareCapital, who owns several dental platforms in China that will help Carestream Dental further capitalise on substantial emerging market growth opportunities.” Carestream is committed to work with CD&R and Hillhouse/CareCapital to ensure a smooth transition for its dental digital employees and customers. Carestream will focus on the continued success and competitiveness of its remain-
ing business, which include: medical imaging equipment, healthcare IT solutions, medical and dental film, non-destructive testing film and imaging equipment, and precision films and contract coating services. These businesses have earned attractive market positions and generate strong earnings and cash flow, and will benefit from recent investments in innovative technologies and growth initiatives. “Through their passion, in-
novation and customer focus, our dental digital employees have built market-leading positions. I’m excited that Lisa and her team will have the opportunity to build an independent leading global oral healthcare company,” said Kevin Hobert, CEO, Carestream. “With innovative new offerings in every segment of our remaining businesses, we look forward to focusing our resources and attention on our significant growth opportunities.” Subject to regulatory and other approvals, it is anticipated that the sale will close in the third quarter. With respect to France, where the opinion of the works council is mandatory for a project of this kind, Carestream will not undertake a legal obligation to sell the business until the relevant works councils’ consultation has been completed. Additional terms of the transaction were not disclosed. Jeffries Group served as exclusive financial advisor to Carestream. Contact details www.carestream.com.
EXPRESS HEALTHCARE
39
May 2017
LIFE I N T E R V I E W
‘Indian doctors (in the US) still face a glass ceiling in academic promotions, institutional hierarchies’ Dr Suresh Reddy, Vice President, Association of American Physicians of Indian Origin (AAPI), explains to Viveka Roychowdhury how his mission is to bring distinctive contributions from India to American medicine while championing the challenges faced by the Indian-origin medical fraternity in the US As the newly elected VP of the Association of American Physicians of Indian Origin (AAPI) who will be President in 20192020, how do you plan to take forward the mission and vision of AAPI? My mission and vision coincides with that of AAPI’s, which includes promoting professional solidarity in the pursuit of excellence in patient care, teaching and research. To bring to the American medicine the distinctive contributions from India, and advance the American creed of one nation under God, indivisible with liberty and justice for all. AAPI is a forum to facilitate and enable Indian American physicians to excel in patient care, teaching and research and to pursue their aspirations in professional and community affairs. What are the main challenges facing the medical fraternity today across the world? The main challenges faced are loss of clinical decision making that drives high standard of medical care. Interference by bureaucracy, control by hospitals and insurance companies have reached intolerable levels, and the lack of tort reform prevents any control of the runaway medical costs, making healthcare unaffordable.
40
EXPRESS HEALTHCARE
May 2017
What are the challenges faced by Indian medical graduates, doctors, researchers in the US during their practice and research? How is AAPI trying to resolve them? Indian doctors still face a glass ceiling in academic promotions and in institutional hierarchies. Although this seems to be easing, we will stay vigilant for our AAPI members. How do you feel about the fact that while every sixth patient in America is seen by an Indian doctor, India is facing an acute shortage of both doctors and other paramedical staff? I am very excited about the growing clout of Indian physicians in the US. A lot of them hold critical positions and have been instrumental in preserving the top class health care that we have in the US. Every sixth patient in America is seen by an Indian doctor, which is a matter of great pride. There are significant number of Telugu doctors practising in the US and their role is laudable. According to last count about 10,000 Telugu doctors live in the US. The recent statistics reveal that there are approximately 9.4 lakh qualified medical practitioners in India in 2014, which amounts to approximately six qualified medical physicians per one lakh popu-
lation in India. I am very saddened by it.
We organise global health summits every year in major cities of India to foster exchange of research and education.We also played a major role in enacting legislation to prevent smoking in public places
AAPI, through the AAPI Foundation in India, has been working with India's healthcare policy makers at the Centre and state level, as well as associations like the Medical Council of India, to address some of these issues, especially connected to the revamp of medical education in India. What has been the impact of these efforts so far? We, from AAPI, are running several free clinics all over India through our charitable foundation wing. We also organise global health summits every year in major cities of India to foster exchange of research and education. We have seen significant improvement in developing healthcare consciousness in India. Examples include awareness and educating the first responders in case of acute trauma, especially related to neuro trauma. We also played a major role in enacting legislation to prevent smoking in public places. Dr Prathap Reddy, founder of the Apollo Group of Hospitals, Dr Naresh Trehan, CEO, Medanta Medicity are two examples of return migrants who have contributed to putting India on the global healthcare map. Are you aware of other such examples who could
serve as inspirational role models for AAPI members? While Dr Prathap Reddy and Dr Naresh Trehan, have done in a big way, there are numerous other physicians who serve India, full time or part time, and give back to their country in whatever capacity they can. Are there avenues whereby Indian-origin doctors the US could give back to their motherland, even as US citizens, by coming back for short sabbaticals to practice here and share their skills, etc.? Is AAPI involved in such activities? Indian physicians, especially in their late 60s and early 70s, who are already highly accomplished career wise and financially, have intense desire to give the rest of their life back serving India. This is a great sign for healthcare in India. This group of semi-retiring physicians that wants to serve in India is increasing multifold by the year. What role is AAPI playing in the J-1 visa waiver policy? AAPI has been working intensely through our legislative committee wing to educate the senators and congressmen about the importance of a permanent J1 waiver visa and help to serve the physician requirements in underserved areas of the US. viveka.r@expressindia
STRATEGY
Medtronic India: Further, but not together? From designing the world's first wearable battery powered pacemaker in 1958, to the world's smallest pill sized pacemaker, Medtronic's credo has been "Further, together." But against the backdrop of the government's firm stand to make healthcare more affordable, what will be Medtronic India's strategy to remain commercially viable as well as provide patients access to the latest generation medical devices? By Viveka Roychowdhury
F
rom co-founder Earl Bakken's Minnesota garage in 1949, to 89 manufacturing facilities across the world, Medtronic today positions itself as the world's largest stand alone medical technology company. FY2016 total revenues touched $28.8 billion, with the lion's share (61 per cent) coming from the Americas, followed by Europe, Middle East and Africa (23 per cent), followed by Asia Pacific (11 per cent) and 5 per cent from Greater China. In terms of revenue mix across the company’s four business divisions, in FY2016 the cardiac and vascular group led with 35 per cent ($10.2 billion), followed by the minimally invasive therapies (formerly Covidien) at 34 per cent ($9.6 billion), restorative therapies (25 per cent, $7.2 billion) and diabetes (six per cent, $1.8 billion).
Setting the pace The Medtronic Medallion has three short directives inscribed on it: Alleviating pain, Restoring health, Extending life. The evolution of pacemakers is a good example of the transformation of medical devices, driven by patient need and made possible by continuous R&D. Medtronic co-founder Bakken is credited with the design of the world's first "wearable" battery powered pacemaker way back in 1958. Six decades later, Medtronic makes the Micra Transcatheter Pacing System, implanted directly in the right ventricle chamber of the heart. In terms of grammage, the pacemaker has shrunk from a 283 gm, external and wearable
Medtronic Singapore facility
device, the size of a notebook to today's 2 gm Transcatheter. Touted as the world's smallest pill sized pacemaker, the world's first leadless pacemaker was approved by the US FDA in April last year. According to reports, the miniaturised device topped US News & World Report's list of 2016's Biggest Achievements in Medicine. Clearly, R&D has been the cornerstone of such product evolution. (See visual: The evolution of pacemakers: From 1958 to today). Micra seems to have done well in clinical trials. In November 2015, preliminary re-
sults from the Medtronic Micra TPS Global Clinical Trial, published in the New England Journal of Medicine, showed the Micra TPS was successfully implanted in 99.2 percent of patients and that the system met its safety and effectiveness endpoints with wide margins. This was followed up with more data in August 2016, when new long-term data presented in a late-breaking clinical trial at the European Society of Cardiology Congress continued to reinforce these results, demonstrating consistent and sustained outcomes from early performance
EXPRESS HEALTHCARE
41
May 2017
STRATEGY
through 12-month follow-up. The Medtronic Singapore Operations (MSO) facility, a crucial part of the company’s cardiac and vascular group, the largest business group in terms of revenues, is reportedly Asia's first pacemaker manufacturing plant, operational from 2011. It is also the only plant in the world able to make pacemakers, leads and diagnostics, which require advanced production skill sets. According to MSO's Salvador Aloma, CRHF senior manufacturing director, 600,000 units of the Reveal LINQ ICM will be made in FY2017 at MSO. The company has invested over $56 million in the MSO, which supplies to the Asia Pacific, Greater China, Europe, Middle east, Africa and Canada markets. If R&D is the cornerstone, then a culture promoting quality has to be part of a company's DNA. Medtronic has a unique initiative to link the work quality of employees to patient at the end of the production line. Archives show that the founder made it a point to meet patients who used Medtronic products while other patients were invited to tour the production facilities where their pacemakers were made. The company now has made this part of the Quality Day programme, where a member of the production staff meets a patient using a device made by him /her. "This meeting ensures employees have a real connection with the patient," explains Darshan Shah, Quality Systems Director, at MSO. The "Quality begins with me" initiative started in 2016, with the realisation that assembly line jobs get monotonous and employees sometimes could lose sight of the bigger picture. Such interactions with patients ensure that all employees remember their role and responsibility to the patient. The initiative increases patient engagement too, with each patient leaving with a plaque and a duplicate of the device that this implanted in their bodies.
Medtronic in India Country wise revenues are not
42
EXPRESS HEALTHCARE
May 2017
THE EVOLUTION OF PACEMAKERS: FROM 1958 TO TODAY
WEARABLE EXTERNAL PACEMAKER
1958
IMPLANTABLE PACEMAKER
1960
RATE RESPONSIVE PACEMAKER
1986
MRI CONDITIONAL PACEMAKER
TRANSCATHETER PACEMAKER
2011
TODAY
QUICK FACTS: THE HEALTHY HEART FOR ALL INITIATIVE
FY2016 REVENUES ACROSS BUSINESS GROUPS
The Healthy Heart for All (HHFA) initiative was launched in Durgapur, Bengal in September 2010. Under this scheme, the company, through a third party financier, helps qualified families and needy patients implant heart devices such as stents, pacemakers, ICDs and CRT-P, heart valves, and aortic grafts by partnering with hospitals. According to the company, these patients pay as low as 15 per cent of the cost upfront and the rest through equated monthly installments over a period of time. Over 700 loans have been disbursed through the HHFA initiative as of March 2017.
35 PER CENT, $10.2 BILLION
◗ Launched in Durgapur in September 2010 ◗ Currently present in over 30 cities in partnership with over 120 hospitals ◗ Over 1450 camps conducted ◗ Over 175,000 patients screened ◗ Over 91,000 patients counseled ◗ Over 15,200 patients adopted therapy ◗ 1600 physicians trained Over 700 loans disbursed through third party (as of March 2017)
available but going by Medtronic's FY2016 figures, Asia Pacific region's 11 per cent slice of the global revenues pie, it is evident that there is a huge growth potential. India's medical devices segment, estimated at $ 4.2 billion in 2014, is expected to grow at a CAGR of 16 per cent during 2014 – 2018, according to a FICCI-QuintilesIMS paper, Medical Technology Sector in India – Enabling Swastha Bharat. Medtronic, like its peers in the med devices sector, are crafting new strategies to increase their visibility in these markets as well as cope with evolving regulations like India's recently released Medical Devices Rules 2017. Also worrying such manufacturers is the government's determined efforts to cap the
prices of life saving technologies like heart stents. Two months after the National Pharmaceutical Pricing Authority (NPPA) capped heart stent prices, Medtronic India asked permission to withdraw its Resolute Onyx stent from the India market on the grounds of “commercial unviability post fixation of ceiling price.” Abbott and Boston Scientific sent similar requests to the NPPA. On April 26, the NPPA rejected Medtronic India’s application for the withdrawal of Resolute Onyx on the basis of incomplete paperwork. The Medtronic India management intends to resubmit the application, and will continue to supply this stent until it is resubmitted and approved. The company's statement reiter-
Cardiac and vascular:
Minimally invasive therapies:
34 PER CENT, $9.6 BILLION Restorative therapies:
25 PER CENT, $7.2 BILLION Diabetes:
6 PER CENT, $1.8 BILLION ated that, ''All decisions to withdraw or introduce products to the market are made only after taking into consideration all guidelines and norms set by the government and applicable legal and regulatory requirements. Medtronic remains fully committed to work with the Government helping patients and their physicians in India gain access to innovative and high quality cardiovascular therapies.'' Given these realities, what kind of a future does Medtronic India see for itself? Price restrictions will obviously impact revenues, which in turn will influence further
investments from the parent company into the India operations. The company is no stranger to India, having set up base here in 1979. With an employee head count of over 1100, the company has a sizable footprint, with more than a dozen offices, R&D centres in Bengaluru and Hyderabad as well as an IT solutions centre in Bengaluru. Medtronic is conscious that price often over shadows value and the company has taken efforts to ease the price burden of its products through many programmes like the Healthy Heart for All initiative, through which patients are provided financing options. This is in addition to global initiatives through the Medtronic Foundation and philanthropic efforts like HealthRise, HeartRescue, RHD Action, etc. (See BOX: Quick facts: The Healthy Heart for All initiative)
Future options The NPPA's April 26 revert also points out that Medtronic had not complied with other requirements of its February order, namely to submit weekly reports of heart stents manufactured and distributed, along with the weekly production plan. The regulator is doing its best to ensure there is no shortage of heart stents but companies will obviously be wary of disclosing sales and production schedules. The government's order in February invoked Section 3 of the Drug Price Control Order (DPCO), 2013 which requires companies to continue to supply stents for six months after the order. Thus it is quite likely that Medtronic will re-apply for withdrawal two weeks before the expiry of Para 3 requirements, i.e. in August. Or will it heed the NPPA's suggestion and explore options of price revision provided under certain clauses of DPCO, 2013 before exercising an exit route? The coming months should see some answers on this front. (The author visited Medtronic's Singapore Operations on the invitation of the company) viveka.r@expressindia.com
TRADE AND TRENDS
JKAnsell’s mission with Operation Smile Improves the health and lives of children born with cleft through the highest standards of safe, surgical care SINCE 1982, Operation Smile has provided hundreds of thousands of free surgeries for children and young adults in developing countries who are born with cleft lip, cleft palate and other facial deformities. They have improved the health and lives of children born with cleft through the highest standards of safe, surgical care. These standards align with JK Ansell’s mission of providing innovative solutions for safety, wellbeing, and peace of mind, no matter who or where you are. JK Ansell’s partnership with Operation Smile and generous donations of Microtouch, Gammex, and MediGrip medical gloves as well as Sandel sterile marking pens, allow them to continue their global mission. But donations are not where the journey ends for Ansell. The medical GBU team has often gone beyond the donation to the heart of the cause – bringing smiles to the faces of underprivileged children. In January 2017, they did just that. Operation Smile needed assistance getting product into India so we gladly secured their needs for medical gloves. Moreover, two of their very own medical colleagues had the amazing opportunity to volunteer at Operation Smile’s global mission in West Bengal. Anna Lobanova, Director – EMEA/APAC Emerging Markets, and Rajat Khosla, Marketing Manager – Indian Sub-Continent, recall their experience. Adults may still express their pain but imagine a child with cleft palate who can’t
speak, rather doesn’t know how to speak. Try feeling the pain of a child who watches normal children enjoy delicious delicacies but he can’t even gulp properly. This is the reality of a child born with a cleft palate. To prepare for this mission, it took team Operation Smile India over six months to pre-screen a pool of nearly 400 people living with cleft through multiple camps in the region. They personally visited every one of these potential candidates for surgery to perform an evaluation. One can only imagine the phenomenal network they have built in order to reach every last patient/par-
ent in the mission area. It seems like one can name any big or a small institution and Operation Smile has them in their network. Let it be a police station or an Asha worker, they’re all supportive of this noble cause. After screening all candidates, almost one third of these patients were approved and then brought to West Bengal for the week-long mission where their cleft palate and lip surgeries were performed at absolutely no cost to the family. Operation Smile’s humanitarian model also scopes in logistics, food and shelter for the parents and their families who accompany the patient. The medical
and non-medical volunteers rope in from across the globe to contribute towards every single smile. During the mission, Operation Smile ensures to keep everyone smiling with little touches such as fun operating room theatre names. But this gentle, caring approach is also supported strongly with the best standards of care. This includes the safest or infection control practices, and best-in-class supplies. Their missions are so well-organised and respected that Operation Smile attracts some of the world’s best surgeons and nurses in the field to voluntarily operate on these young angels. One of the trained
professional, Dr Gaurav Deshpande from a Centre of Excellence based at MGM Hospital, Navi Mumbai, can correct a complex cleft palate in as few as 45 minutes. While the mission may be over in West Bengal, the work and the impact is just beginning. All the patients are continuously supported with post-operative counseling and check-ups scheduled regularly. Lives of 179 children were changed, 179 families have a fresh start, and more than 50 volunteers from India and abroad have the absolute pleasure to have participated. One smile at a time, the products are helping to change lives.
EXPRESS HEALTHCARE
43
May 2017
TRADE AND 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
44
EXPRESS HEALTHCARE
May 2017
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
TRADE AND TRENDS
SS Digitech Impex:Catering to business partners with easiest, fastest and most reliable way Partners with PROTEC for their analog products like automatic film processors SS DIGITECH Impex was incorporated with the aim to focus on medical imaging and printing industry. The journey started with appointment as national distributors for the 'HITI' range of Thermal Dye Sublimation Printers from Taiwan. The company's vision was to cater to its business partners with the easiest, fastest and most reliable way by bringing in the latest printing technology and solution in the medical imaging field. With promoters having over 20 years of experience in the radiology and imaging industry, the company also tied up with Villa Sistemi Medicali, Italy for their dental range of X-ray sys-
tems. Villa, Italy is one of the leading dental equipment manufacturing company in the world having a huge installed base of Orthopantomogram (OPG) & Lat CEPH( Lateral Cephalometric) machines in India since 1995. Villa product range includes intra oral sensors, intra oral X-ray system, analog and digital OPG & 3D/CBCT. The company has also partnered with PROTEC for their analog products like automatic film processors. Range includes table top models Optimax 2010 and Ecomax for small diagnostic centre to high-end model Compact 2 for big hospitals and government institutions. The
HITESH MEHTA Technical Manager — Sales & Service, SS Digitech Impex
company also represents them for their digital X-ray systems. After successfully implementing automatic film processors in India, we also introduced Pro-
tec’s NDT (Non-Destructive Testing) processors which caters mainly to industries like oil refineries, power plants, , railways, defence, metallurgy industries, etc. The introduction of OKI, Japan DICOM EMBEDDED plain paper Printers was the need of the hour, not only to complement the vision, but to introduce a revolutionary product in the radiology imaging field that could give environment-friendly printing solutions at fraction of cost as compared to the high-cost digital film media. SS Digitech Impex is a professionally-managed organisa-
tion, specialised in distribution and after sales services. To achieve stated goals, the company has incorporated marketing and service networks through channel partners and also at its own offices. With head office in Mumbai and branches in New Delhi, Kolkata, Chennai, Bengaluru, Patna and Ahmedabad, its reach is well coordinated nationwide. As part of its commitment to achieve 100 per cent customer satisfaction, it has created best-in-class service and support division, with dedicated and qualified technical team, who will help in promptly resolving any issues that may arise.
OKI:The first in digital printer technology OKI IS the first in digital printer technology, combining the cost effectiveness and high quality output of LED printer with DICOM software. This could largely benefit the hospitals and diagnostic centres to cut cost of using expensive polyester media (digital speciality films) and print patient referral on plain paper media thereby saving huge amounts of money. It is an inexpensive way to print very high quality glossy prints that physicians can use for treatment planning and consultation with colleagues and patients, especially when diagnosis is done on soft copy using high-end diagnostic monitors. DICOM (Digital Imaging & Communications in Medicine) is the primary international standard for handling, storing, printing and transmission of medical images and related information. OKI DICOM printer solution allows users to print medical images such as X-ray, MRI, CT
OKI largely benefits hospitals and diagnostic centres and cut cost of using expensive polyester media scan, ultrasound and nuclear medicine on inexpensive media and in colour, for purposes such as medical discussions and patient records. Normally, DICOM medical images printer prints on speciality film whereas in OKI printer, the same images can be printed on plain paper in either grey scale images or color images. OKI Printer receives DICOM images directly from modality and allows to print without the use of any conversion software or external print servers, thereby ensuring loss-
less/no resolution loss of image quality. One can further fine tune the print quality with easily accessible set defaults and adjust image quality output settings such as brightness, gray scale, and contrast for each modality. OKI printer is compatible with modalities using DICOM 3.0 standard, it fits effortlessly into existing work flows. Moreover, it does not require any special training as it gives almost near film quality output. From start to finish, working with film is expensive and labour inten-
sive. Replace film with paper and images can be shared with minimal expense, eliminate the need and cost for special processing, handling and storage, and reduce labour costs associated with tracking, filing and transporting film. Compliance and other environmental costs associated with using chemicalbased film can be saved, as well as minimise the impact on the environment. In fact, because the special printing, handling, storage, transportation, and other infrastructure needed for
film can be eliminated, it actually simplify the work process and that of referring physicians. In India referring physicians want physical images in their hand in order to fully explain them to patients. They do not have to deal with DVD, search database or have their internet bandwidth choked by huge image files. For which they require high quality images which they can review and share easily. This is where OKI DICOM embedded paper printer is an effective solution.
EXPRESS HEALTHCARE
45
May 2017
TRADE AND TRENDS
Medikabazaar receives ‘Healthcare IT Company of the Year’award The event was organised by Medgate Today MEDIKABAZAAR RECENTLY received ‘Healthcare IT Company of the Year’ at the 7th MT India Healthcare Awards 2017, which was organised by Medgate Today. The event was attended by many healthcare professionals across India. The award ceremony was held in the presence of Minister of State for Health, Faggan Singh Kulaste, who was the chief guest. The Guest of Honour was Dr Jagdish Prasad, DGHS. Medikabazaar is a tech-enabled pioneering concept aimed to address the large segment of medical procurement and supplies. It empowers medical institution to deal with complex problem of procurement and regular purchases including
supply chain and logistics. The event was participated by doctors, hospitals, hospital infrastructure and design, green hospital, diagnostics centres, lab, physiotherapists, young entrepreneurs, healthcare NGOs, healthcare IT, healthcare architects, healthcare consultant, pharma companies, and many more. “Medikabazaar is poised to become the largest online aggregator of medical supplies in India. This award is an important recognition for all our efforts. We are earnestly grateful for the recognition we have received. I particularly dedicate this award for those who have been part of this journey in any way since we started this venture, specially all our customers, sellers, vendors, employees and associates,” said Vivek Tiwari, Founder and CEO, Medikabazaar.
Vivek Tiwari, Founder and CEO, Medikabazaar receiving the award from Faggan Singh Kulaste, Minister of State for Health
Evolution of haematology market Harshad Bhanushali, Product Manager- Instruments, DiaSys Diagnostic India, elaborates on the factors, which is stimulating the growth of haematology market in India INDIA ACCOUNTS for one per cent of the Global IVD share and is expected to double its share to two per cent with expected CAGR of 15-18 per cent by 2020. The Indian IVD market can be classified into multiple segments. Biochemistry, immunoassay and haematology segments dominate the IVD market with 65-70 per cent share. 60 per cent of medical diagnostic equipment are imported and distributed within the country through regional distributors and their network of sub distributors. Reagents account for 60-65 per cent of value share as equipment are generally placed on rentals or seeded at customer place. haematology is the third
46
EXPRESS HEALTHCARE
May 2017
largest segment in the Indian IVD market with 18-20 per cent Indian market share and a value of approx ` 800-900 crores. Out of this, 63 per cent is on account of reagents and the balance 37 per cent is on account of instruments. Technological developments, integration of basic flow-cytometry techniques and developments in the high sensitivity point-of-care (POC) haematology testing are some of the key factors that are fuelling the growth of the haematology market. Factors such as developing healthcare infrastructure, large patient population, increasing investment toward the development of haematology products,
HARSHAD BHANUSHALI, Product Manager- Instruments, DiaSys Diagnostic India
growing focus of both international and domestic players and increase in incidence of diseases such as dengue, swine flu, malaria and chikungunya are stimulating the growth of haematology market in India. However, slow adoption of the advanced haematology instruments, high cost, safety and quality of analysers and reagents are some of the key factors hampering the growth of this market. Potential customers for haematology are pathology laboratories, commercial organisations, private and government hospitals, research institutes and CRO’s where increasing instances of reagent rental partnership among haematology in-
struments and consumables is a popular trend. DiaSys India is exclusively involved in branding, promotion, sales and service of the flagship three part cell counter known as Swelab Alfa. This is a state-ofthe-art instrument and also one of the fastest three part differential cell counters in Indian haematology market at present. Swelab alfa is available in three models namely: ◗ Swelab Alfa Basic ◗ Swelab Alfa MCI (patented micro-capillary mode) ◗ Swelab Alfa Auto sampler (Autoloader module for hands free operation) Contact details www.diasys.in
BUSINESS AVENUES
EXPRESS HEALTHCARE
Trusted solutions in STERILIZATION Where error is not an option
Pharmalab Sterilizers are designed to sterilize all range of hospital requirement such as surgical instruments, utensils, gown, wrapped/unwrapped goods and other healthcare instruments and supplies. Its compact design enables installation in smallest of CSSD. • Fully automatic with PLC controlled and touch screen HMI. • Enhanced controlling features to ensure the correct sterilization based on f0 value. Process optimization such as Dimpled jacket for better heat transfer in sterilizer, Non condensable gas remove, one touch operation and many more. • Equipped with all necessary safety measures in both the sterilizer and the boiler such as door interlocks, sensors, safety valves, Low water level indication and many more. Motorized and pneumatically operated Horizontal and Vertical doors. • Designed with high grade steel SS316L chamber, Jacket, Piping, Steam generator and contact parts. • Ergonomic design to make the operation effortless. • Prompt service through our large service base comprising of well trained service engineers.
Steam Sterilizer
Pharmalab sterilizers are compliant with all necessary regulatory bodies like 93/42/EEC and its revised version, EN ISO 14971, EN ISO 17665-1, IEC EN 61010-1, IEC, EN 60601-1- 6, EN 61326-1, H TM 2010 and ASME. Offers wide range of sizes starting from 182 Ltrs to 1296 Ltrs.
Pharmalab India Private Ltd.
Registered Office: Kasturi, 3rd, floor, Sanghavi Estate, Govandi Station Rd, Govandi (E), Mumbai 400 088, INDIA. • E-mail: pharmalab@pharmalab.com • Website: www.pharmalab.com • CIN No. U29297MH2006PTC163141.
EXPRESS HEALTHCARE
May 2017
47
BUSINESS AVENUES
48
May 2017
EXPRESS HEALTHCARE
EXPRESS HEALTHCARE
BUSINESS AVENUES
EXPRESS HEALTHCARE
Swelab alfa Like no Other...
Basic
MCI
Autosampler
Features
Bene ts
Maintenance Free Stainless Steel Rotary valve No start up & shut down
Accurate sampling resulting in high precision and reproducibility Patented principle. Less reagent consumption. No wastage of reagents. Constant cost per test. Does not uctuate with workload No cleaner reagent required. Cost e ective. High durability and shelf life
Working on two reagent system Patented Bipolar Silicone Valves
Direct Micro Capillary 20 ul blood
Finger prick/ heel puncture required
No preparation required
Fully automatic
THE FASTEST cell counter in the world
DiaSys Diagnostics India Pvt. Ltd. Unit No. 3B/33 & 34, 3rd Floor, Phoenix Paragon Plaza, LBS Marg, Kurla West, Mumbai - 400 070. INDIA Toll free No. : 1800-200-1120 | Direct Enquiry : +91 22 3371 4344 | Email Us at : info@diasys.in | www.diasys.in
EXPRESS HEALTHCARE
May 2017
49
BUSINESS AVENUES
50
May 2017
EXPRESS HEALTHCARE
EXPRESS HEALTHCARE
BUSINESS AVENUES
EXPRESS HEALTHCARE
BARIATRICS At Ease!
ISO 9001:2008 Certified Company
EXPRESS HEALTHCARE
May 2017
51
BUSINESS AVENUES
52
May 2017
EXPRESS HEALTHCARE
EXPRESS HEALTHCARE
BUSINESS AVENUES
EXPRESS HEALTHCARE
OXYGEN CONCENTRATOR OXYGEN THERAPY ..... REVITALIZE YOUR HEALTH
Oxygen retards the aging of human cells CO2 O2
Oxygen helps relieve headaches
Oxygen alleviates tiredness
Made in Germany
Oxygen boosts the immune system
Oxygen supports breathing in asthma and allergies
Oxygen helps in cases of depression
Oxygen improves physical performance by up to 25%
Benefits of O2
FEATURES: • • • • • • • • • • • •
Generate High Purity of O2 5 Lit/min. Whisper silent (35dB (A)) Simple operation Microprocessor-controlled Easily accessible filter and fuses USB – interface Modern design, easy to carry New, innovative measuring sensor Integrated flow adjustment Maintenance Free Long Life Prompt after sales service Economical Price
Available on RENTAL BASIS and OUTRIGHT BASIS
Hemant Surgical Industries Ltd. +91 - 96194 84952 +91 - 96194 84153
EXPRESS HEALTHCARE
Follow us on...
f in May 2017
53
BUSINESS AVENUES
54
May 2017
EXPRESS HEALTHCARE
EXPRESS HEALTHCARE
BUSINESS AVENUES
EXPRESS HEALTHCARE
AIR MATRESS
ANTI-DECUBITUS MATTRESS
• Bubble mattress • 2 to 1 alternating therapy • Adjustable hangers for most bed types • Durable medical grade PVC • Extension flags for stabilization • High quality pump • Weight indicator pressure adjustment setting • 6 minutes cycling time • Near silent low noise • For prevention and treatment of patients at low risk of pressure ulcers
Medical grade PVC
2 to 1 alternating therapy
Ext
for stabilization
Easy to use adjustment
SKIN STAPLER
Benefits:
• The characteristics of the stapler's handle design for good texture and is suitable for various surgeon's hand. • Angled head provides clear view to ensure precise staple placement and the staple could enter the tissue easily. • The elaborate design of the staple release mechanism actuate the stapler with easy for using. • Easy to use, reduce learning curve. • Two model skin stapler, three staple sizes (wide, regular and high) and nine staple counts in stapler are true of all surgical field. SPECIFICATIONS : 7 mm 35 W
4 mm
Fine 316L Stainless Steel
Suggest Applications: Operation Room Outpatient Surgery
Labor & Delivery
Emergency Dept.
Clinics and Physician's Office
Hemant Surgical Industries Ltd. +91 - 96194 84952 +91 - 96194 84153
EXPRESS HEALTHCARE
Follow us on...
f in May 2017
55
BUSINESS AVENUES
56
May 2017
EXPRESS HEALTHCARE
EXPRESS HEALTHCARE
BUSINESS AVENUES
EXPRESS HEALTHCARE
EXPRESS HEALTHCARE
May 2017
57
BUSINESS AVENUES
EXPRESS HEALTHCARE Advertise in
Business Avenues Blood Bank Equipments
Please Contact: ■ Mumbai: Douglas Menezes Blood / IV Fluid Warmer
91-9821580403 ■ Ahmedabad: Nirav Mistry
Plasmatherm Blood Donor Chair
91-9586424033 ■ Delhi: Ambuj Kumar / Gaurav Sobti 91-9999070900 / 91-9810843239 Blood Collection Monitor
Blood Bank Centrifuge
Biological Refrigerator
■ Chennai/Bangalore: Mathen Mathew / Amit Tiwari
Platelet Incubator with Agitator
91-9840826366 / 91-8095502597 ■ Hyderabad: E.Mujahid Benchtop Sealer
Centrifuge Bucket Equalizer
REMI SALES & ENGINEERING LTD.
Blood Bank Refrigerator
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
58
May 2017
91-9849039936 Biological Deep Freezer
■ Kolkata: Ajanta 91-9831182580
EXPRESS HEALTHCARE
BUSINESS AVENUES
EXPRESS HEALTHCARE
EXPRESS HEALTHCARE
May 2017
59
BUSINESS AVENUES
60
May 2017
EXPRESS HEALTHCARE
EXPRESS HEALTHCARE
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