Express Healthcare (Vol.11, No.8) August, 2017 by Indian Express

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CONTENTS MARKET Vol 11. No 8, August, 2017

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

HOSPITALPHARMACIES ABOOSTTO PROFITMARGINS

Editor Viveka Roychowdhury*

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

WORLD POPULATION DAY – DEVELOPING NATIONS, EMPOWERING PEOPLE

GST: A DOUBLE-EDGED SWORD

LIFE

Design National Design Editor Bivash Barua

Artists Vivek Chitrakar, Rakesh Sharma

HEALTH INSURANCE SECTOR: LESS PENETRATED BUT MORE OPPORTUNITIES

STRATEGY

Delhi Prathiba Raju

Graphics Designer Gauri Deorukhkar

BUREAUS Mumbai Usha Sharma, Raelene Kambli, Lakshmipriya Nair, Sanjiv Das, Mansha Gagneja Swati Rana

Senior Designer Rekha Bisht

CII (WR) TO ORGANISE HEALTHCARE CONCLAVE 2017

POLICY WATCH

Chief of Product Harit Mohanty

Asst. Art Director Pravin Temble

Hospital pharmacies are business critical to any hospital.Investing in its upliftment will ensure sustainable RoI | P-20

LEADERSHIP FOR NURSES IN INDIA: A FUTURISTIC PERSPECTIVE

BOOK REVIEW ; THE ACT THAT WASN'T

INTERVIEWS P10: RAVINDRA BURSE

P32: DR V MOHAN

Director, PS3 Engineering & Construction Services

Chairman, Dr Mohan’s Diabetes Specialities Centre

P12: MANASIJE MISHRA MD, Indian Health Organisation & Aetna India

P32: DR RM ANJANA MD, Dr Mohan’s Diabetes Specialities Centre

P33: RAJIV MATHUR P13: ZOYA BRAR MD and Founder, Core Diagnostics

Founder, Critical Care Unified

P31: DR UMESH KHOT VC, Dept. of Cardiovascular Medicine, COO, Section of Clinical Cardiology, Cleveland Clinic

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

Will increased scrutiny reform or reverse the healthcare sector?

foray into healthcare seems to be Kolkata-based ITC's latest bid to transform itself from a cigarettemaker into a diversified corporate across FMCG. ITC Chairman YC Deveshwar's announcement post the AGM that the company was looking to set up multi-speciality hospitals that will set “a new standard in healthcare by making patient care as the central focus, and not incentivise doctors to create revenue” was greeted with mixed responses. One major apprehension is given ITC's play in the premium hospitality segment , will an ITC hospital go the same way? The ITC Chairman sought to lay these fears to rest at a post-AGM press conference. He reiterated that a “different model” with patient wellbeing at the centre is being worked out for the hospital. While it is too early to predict how ITC's healthcare foray will pan out, one more player, and a big one at that, reconfirms that healthcare will continue to attract investment, inspite of the Government of India’s efforts to increase regulation. Even as the cover story of Express Healthcare talks about how hospitals could convert their on site pharmacies into a profitable revenue stream once they deploy more efficient systems and processes (See story: Hospital Pharmacies: A boost to profit margin), the price caps on medical devices and increasing span of medicines under price control have already eaten into their margins. The recent roll-out of GST too hasn't been kind to hospitals. Though healthcare has been exempted from GST, the input costs, in terms of several services in hospitals, has gone up to 12 per cent. Hospital infrastructure costs, like a comprehensive maintenance contract, has increased from eight per cent to 18 per cent. Estimates are that this increase could result in hospitals spending around four per cent more, a cost that most will pass on patients. (For detailed anaylsis, read: GST: A doubled-edged sword). There is one more regulation making its way through the regulatory channels: the proposed Uniform Code for Pharmaceutical Marketing Practices (UCPMP), which will increase scrutiny on pharma companies, forcing them to reform. As we saw with the price cap on stents and other medical devices, the UCPMP's goal is to break the alleged nexus between pharma companies and doctors as well as hospitals. According to industry sources, the UCPMP has been sent to the Law Ministry for a vetting,

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As we sawwith the price cap on stents and other medical devices,the UCPMP's goal is to break the alleged nexus between pharma companies and doctors as well as hospitals

which is generally the process before it is notified. The DoP was reportedly unhappy that the pharma industry wasn't voluntarily following the Code. With Prime Minister Modi's push to cut prices of medicines and healthcare costs, the UCPMP might be notified and become mandatory, in spite of opposition from industry. The Alliance of Doctors for Ethical Healthcare (ADEH) Groups of doctors, has written to Minister of Chemicals and Fertilizers Anant Kumar, with copies to the PM and Minister of Health & Family Welfare, concerned that the June order of the DoP, meant to regulate the UCPMP, has many clauses which could be misused. The ADEH letter states that medical devices are not part of the order (Clause 1, Sub Clause 3), which means a large chunk of expensive items where the companies make huge profit have been exempted, leaving a big scope of corruption by the companies. Hence this must be included in the order. But this is refuted by the Medical Technology Association of India (MTaI) which denies that its member companies make huge profits on their medical devices. In fact, according to MTaI, the duly verified and audited margins made by each of their member companies are readily available with the Registrar of Companies. The ADEH letter also asks the DoP to omit Clause 3, Sub Clause g, (provided a pharma company may sponsor any seminar...) as it leaves scope for pharma companies to spend huge amounts in the name of holding CMEs. For the same reason, the letter from ADEH says that the clause on health awareness camps is liable to be misused and should be done away with. The letter also reasons that all drugs should be in the National List of Essential Medicines so that they are brought under the Drug Price Control Order as once any chemical is labelled as drug it automatically becomes essential as it does not remain for commercial consumption but for the use of healthcare on the advice of the doctor. One of the other points brought up in the ADEH letter is there is no mention of penalty to companies for manipulating drug prices, like hospital price and MRP. Thus the healthcare sector will have to navigate these challenges even as it seeks to capitalise on the opportunities. VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com

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LETTERS QUOTE

JULY 2017

Mission Parivar Vikas will focus on 146 high fertility districts in seven states with high TFR. Under this, specific targeted initiatives shall be taken for population stabilisation through better services delivery

We can share our experiences of hepatitis infection openly, challenging social taboos and can express solidarity with persons affected by hepatitis, creating a culture of empathy and care

JP Nadda Check out the online version of our magazine at

www.expresshealthcare.in

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Union Minister of Health and Family Welfare, at a function organised by Jansankhya Sthirita Kosh (JSK) to mark the World Population Day in New Delhi

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Dr Poonam Khetrapal Singh WHO Regional Director for South-East Asia, said on the occasion of World Hepatitis Day

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A good hospital design proves to be a great business venture Infrastructure planning is an important aspect for any hospital business to be sustainable. Ravindra Burse, Director, PS3 Engineering & Construction Services, talks about how infrastructure planning proves to be of business sense, in an interview with Raelene Kambli How do you see the hospital infrastructure space changing with time? Hospital infrastructure has gone through significant changes with time. The trend of hospitals taking design cues from luxurious facilities like five-star hotels etc., has now changed. The focus today is on sustainability, adaptability and flexibility. From public hospitals to expensive modern hospitals, need of cost-effective designs have become an utmost necessity to provide benefits of quality and cost together to the patients. Operational efficiency and energy efficiency are the key factors in new designs. With increased load, elimination of human error is one of the major challenges healthcare industry is facing. Automation and standardisation in design concept plays an important role to address this issue. The major investment in any hospital project is procurement of medical equipment and machines. Considering the specific requirement, location and prime need of the equipment, more precise analysis with the help of the consultant need to be carried out to provide a cost-effective solution. ‘Green Hospital’ concept, which gives sustainable designs specifically for hospitals, is the need of future engineering. Healthcare being the most rapidly increasing sector in India, investors are keen for the long-run operation of hospitals. Thus, the concept of hospitals nowadays has

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changed to smart, future ready and sustainable with low operational cost. What are the new designs that hospitals these days are looking for? Many of the upcoming hospitals are planning to make their facility a good, positive and vibrant environment for the patients, staff and doctors. Good architecture or interior design is given maximum importance. Colourful rooms, attractive frame and wall work keeps the patient in a positive mood and relaxed for faster recovery. The hospitals have to radiate positive energy. Persistent sound and noise around the ward can disturb the patient and increase fatigue, hence maintaining a certain dB level is imperative. Also, the patient’s room should provide maximum visibility with large glass windows, transparent ceiling in open wards, monitoring with CCTV camera and surveillance. This will allow maximum visibility of the patient without disturbance. Nowadays, this design is achieved by using low noise, quiet equipment and quiet utilities with private rooms and insulated partitions. Large glass windows for natural light and view, a larger room can also include required space for family members, which will encourage family involvement and provide additional comfort to the patient. Due to modern trend of multispeciality hospitals, there is an increase in hospital borne diseases. Hence the design should consist of better

‘Green Hospital’concept, which gives sustainable designs specifically for hospitals, is the need of future engineering. Emphasis should be given on future ready designs to adopt changes due to technology development isolation atmosphere of the patient considering the containment aspect. Contagious or air borne diseases should be treated separately while doing the design. The concept of flexible

canopy for the isolation of patients is also an evolving trend. What are the elements of infrastructure planning that hospitals tend to ignore and how ignoring these

elements can add a lot of cost? At the initial stage of the hospital planning, it is important to involve project management consultant, architects, hospital consultants, doctors and investors so that everyone is on the same page. These practices are needed for better communication and also to avoid deviations or to have minimal deviations from concept modelling to actual execution and completion of the project in terms of cost, quality and timelines of the project. Involvement of the project management consultant right from the beginning gives advantage in maintaining the project timelines which is directly related to the cost of the project. The focus should be very clear from day one in terms of infrastructure planning, budget of the project, longterm operational cost and return on investment planning. The intention should be to reduce the operational cost by introducing latest costeffective designs and reliable hospital management systems which reduce a lot of overheads, in terms of operational cost. It also involves proper utilisation of human resources and optimisation of work, giving more importance to quality rather than quantity. To provide effective and good services to the patient, and develop trust is the only element wherein more revenue of the hospital can be generated. Training and development

MARKET of the staff need to be considered as an investment rather than expense, which most of the hospitals tends to ignore. On a long-term basis, these activities reduce the operating cost of the hospitals and improve quality standards. With technology playing a key role in healthcare delivery, hospitals these days are upgrading their infrastructure to suit this development. How should hospitals plan for this in advance? Technology in the healthcare sector is changing rapidly. It is essential that planning and designing of the hospital be done by keeping in mind the rapid change in technology. Emphasis should be given on future ready designs to adopt changes due to technology development. Effective use of IT models is vital in today’s scenario. Many modern equipment or machines require specific conditions for smooth operation. With compact machines and cloud-based systems in hospitals, the infrastructure with efficient work space area is being built. Utilisation of effective digital media for proper care of patient and to extend the care beyond hospital walls is crucial. It is also important to have a consultation and trust on reliable authorities and delegates to provide technology and procurement assessment and guidance for proper investment. Adopting new technologies that are man power saving and integrative across the hospital is required. Thus, with technology development it is also necessary for the infrastructure to be of utmost standards. What are the pre-requisites of infrastructure that hospital of the future need to have? In modern day, hospitals are considered to be an important part of the healthcare industry, pharmaceuticals and other associated fields. Making patient and employee-friendly hospital setups and environment is the

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biggest challenge in hospital design. The aspects of patientfriendly concept in hospital design is the need of the hour and are relevant within the context of sustainability in healthcare facilities. Hospital acquired infections is one of the major challenges nowadays. New designs should necessarily

New hospital design should emphasise on standardisatio n, automation, scalability

take care of such issues. Another important factor in design to be considered is human errors, which need to be minimised. Apart from the quality of care, the new hospital design should emphasise on standardisation, automation, scalability and adoptability to develop smart and future

ready hospitals. The cost of construction of hospitals is increasing over the years. Patients are looking for the quality care with minimum cost. Considering the aspects of safety and environment, a good hospital design may prove to be a great business venture. raelene.kambli@expressindia.com

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â&#x20AC;&#x2DC;We aim to make quality primary healthcare accessible in India at an affordable priceâ&#x20AC;&#x2122; Manasije Mishra, MD, Indian Health Organisation & Aetna India, in an interaction with Prathiba Raju, elaborates on how vHealth, an integrated primary care ecosystem, can play a crucial role in improving healthcare delivery How did the concept of vHealth by Aetna evolve? Why did you chose to introduce it first in India and in which other countries it will be launched? Aetna has chosen India as the first market to launch vHealth by Aetna, a global digital primary care service. The concept of vHealth by Aetna evolved from the analysis of the healthcare systems across the globe. Very few emerging economies have a robust primary healthcare system. With vHealth, we aim to make quality primary healthcare accessible in India at an affordable price. Tele-consultation is a relatively new concept in India. While there are a few players who have entered this market space, there is a huge scope for vHealth to thrive. The pattern shows that Indian audience only leverages these services in case of emergencies which is inappropriate. After the successful launch in India, vHealth by Aetna will be introduced in other global markets like Singapore, the UK and the UAE. India will be the global centre of excellence for our subsequent launches in international markets. Can you throw more light on vHealth by Aetna model and how it works? vHealth is an integrated primary care ecosystem that provides unlimited tele-consultation for a family of four members and access to our discount medical partner network for a modest price of ` 2400 per year. With this membership, our members can consult vHealth doctors for any health concern in the family. The vHealth doctors

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will spend time to fully understand the patient's medical and social history and the presenting symptoms. In about 70 per cent of the cases they are able to make a firm diagnosis and prescribe medication. They also issue a detailed care plan. In case, further diagnostics or specialist consultations are required, our team can support the patient by making appointments for physical consultation with specialists, coordinate diagnostic services and medicine delivery at their doorstep, all this at up to 30 per cent discounted fee. Our vhealth team also follows up to ensure that the patient gets proper support throughout the journey of the disease. Our in-house doctors are well trained and certified for tele-consultation and follow robust evidence-based scientific clinical protocols and follow-up mechanisms to deliver quality care. By using vHealth as the first point of contact for any health concern/query, our members can potentially avoid over 50 per cent of physical consultations and get appropriate guidance and motivation to navigate through the complex healthcare system. The service is available through our toll-free number and video consultation through our mobile app, vHealth by Aetna. Do you think it is possible to have four million members by 2020, if yes how? Lack of access to a robust primary healthcare system, increasing out of pocket medical costs and poor doctor to patient ratio are some of the key challenges in the Indian health-

ation with our global partners, these products will focus on chronic disease management and preventive health.

Lack of access to a robust primary healthcare system, increasing out of pocket medical costs and poor doctor to patient ratio are some of the key challenges in the Indian healthcare sector care sector. As a result, the disease burden of the country is increasing. The challenge can be tackled better by bringing quality digital primary healthcare system within reach. India has 432 million mobile users with over 76 per cent of people using the mobile Internet. Availability of high-speed 3G and 4G connectivity are driving the usage of apps and videos. We are confident that we will be able to accelerate

growth and achieve the four million member target by 2020. As of now, our user base is nearly six lakh and we intend to add one million members by March 2018. Which customised technological and health management solutions are in the pipeline? Our product pipeline looks strong and we will launch two new products in 2017. In associ-

Tell us more about your partnership with What is so unique about Swiss telemedicine standards? While digital primary care is still evolving in India, we see this at an advanced level in Europe. Medgate in Switzerland with its experience of over 15 years in telemedicine and two million consults have developed a detailed clinical protocol, patient management system, a training programme with detailed assessment and certification to deliver quality clinical outcomes. Training and certification are critical components to deliver quality as per Swiss standards. The doctors undergo certification every year. Our Swiss medical protocols are helping doctors to make a good diagnosis. In over 70 per cent of the cases, our doctors have been able to provide diagnosis and treatment remotely. In other cases, we have arranged further investigations and referrals to specialists. Several patients have commented that we have to identify the root cause of their long-standing medical problems. We have a clinical partnership with Medgate, a Swiss market leader in telemedicine and has over 15 years of experience. We also use their clinical and training protocols. Countries like Australia, Abu Dhabi, Philippines have successfully used this proprietary information for successful implementation of tele-consultation services. prathiba.raju@expressindia.com

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Indian diagnostic industry takes about a decade to fully implement global trends Shedding light on the current trends in the diagnostic industry, Zoya Brar, MD and Founder, Core Diagnostics, ellucidates about the measures to be taken to catch up with the global scenario, in a chat with Mansha Gagneja Could you brief us about the trends in the diagnostic industry, both in India and globally? There are four dominant trends in the diagnostics industry: ◗ Making the tests more specific and reliable ◗ Making the tests more actionable ◗ Making the tests more efficient and convenient ◗ Making the tests more affordable The diagnostic industry is achieving these goals by increasingly turning towards processes and technology that improve accuracy of disease detection, make tests more convenient, and deliver results in real time. Examples of these developments include a focus on liquid biopsies that use blood or patient’s saliva to detect presence of cancer,

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MARKET faster pathogen detecting cultures for tuberculosis, tests that determine drug resistance in microbes, etc. There is an increased attention towards decentralising diagnostics in a manner that puts the patient at the centre of the process. This is illustrated through the many technologies that are focussed on healthcare at home and point of care testing. Digital devices to test sugar, blood pressure and use of IT to deliver the reports directly to doctors are examples that are improving patient convenience. Other significant trends are the move towards preventive diagnostics and use of genetic and genome testing. Finally, the future of diagnostics also includes population trends monitoring that will allow government and healthcare bodies to plan for the future and also control the disease before it spreads. What measures have been taken nationwide towards keeping pace with these global trends? Typically, the Indian diagnostic industry takes about a decade to fully implement trends that are global reality. However, in the recent years, a number of startups including CORE Diagnostics are trying to quickly bridge the gap and accelerate the adoption of the best available technologies from across the world. As an example, at CORE, we focus on partnering with organisations globally that have innovative tests and technologies to enable the availability of their products to patients in India. For several tests, we have reduced the lag-time from to just a few months after launch in the US or Europe. Elaborate on the growth potential of this industry and the major growth segments. How is CORE Diagnostics poised to leverage it? As accessibility of healthcare increases, there is immense growth potential for the diagnostic industry. Major growth

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segments include cardiovascular disease, oncology - as the incidence of cancers is on a rise, reproductive diseases, neurological diseases, as well as infectious diseases. CORE Diagnostics has established itself as a leader in oncology diagnosis and our services include some of the most advanced genetic tests that predict the risk of cancers in individuals. Such tests are recommended for high-risk individuals who have a family history of certain type of cancers, and allow them to be better prepared. An important aspect of genetic testing is genetic counselling. The last thing you want is a family understanding their genetic risks, and then worrying perpetually. Unless families are patiently and continuously guided through the follow up steps, it is almost a disservice to conduct genetic testing. CORE has established itself as the thought leader and the market leader in this area. What are the challenges faced by the industry? The most important challenge is the lack of skills and technical expertise in our industry. Whilst there is enough capital to be had for the right idea, the lack of people that can implement is often the largest constraint. We have taken it upon ourselves to fix this challenge – by recruiting people with empathy and passion, and teaching them the skills. This contributes not only to the diagnostic industry, but to the overall goal of skilling India, even if at a smaller scale. The long-term goal that Modi government has set can only be achieved by grassroots efforts. We are committed to that. Of course, it carries the risk that we skill the people and others hire them away from us. In most cases, however, people come back to us. Suggest the measures needed from the government to mitigate these challenges?

The government can assist by partnering with the diagnostic industry and help to subsidise diagnostic tests or in other cases infuse funds towards research and development of new costeffective tests The government can assist by partnering with the diagnostic industry and help to subsidise diagnostic tests or in other cases infuse funds towards research and development of new cost effective tests. Also, the government could help create a regulatory environment that ensures that organisations get incentivised to focus on providing the right quality. What are the various initiatives started to bring in the next generation

diagnostic techniques? We work on two parallel dimensions in order to bring the next generation diagnosis technology to India. Firstly, we invest in indigenous R&D to develop and validate the tests locally. Secondly, we partner with global companies to introduce the most advanced diagnostic technologies and services in India. Any expansion plans in the offing? If yes, how much do you plan to invest and how are you planning to raise

the funds? A startup must always expand. While we have scaled up (by more than doubling, even tripling each year in the past five years), we continue to behave like a startup. We will grow along three axes over the near and midterm future. ◗ First is geographic expansion We are currently present in more than 100 cities across India and are adding new cities each month. Apart from expanding our presence in India, we have also established ourselves in Nepal, Sri Lanka, Bangladesh, Dubai, Myanmar, Oman, and Kenya. Many other countries are in talks with us, encouraging us to expand in their markets. ◗ Second is technological We have recently added a number of exciting technologies including liquid biopsies and a series of additional tests on the next generation sequencing platform. We are in the process of adding a few other technologies. Our investors – Artiman and Fidelity – have a very extensive portfolio in the diagnostics industry. That gives us an extensive pipeline of tests that can be launched in India. ◗ Third is clinical specialty We have recently added infectious diseases, reproductive disorders, rare disorders and neurology to our test range. We are focussed on expanding both our oncology test menu as well as the newer disease areas. We recently raised our series B of funding to support our expansion plans in each of these three areas. Other industry players have chosen the IPO route. do you intend to do the same? Please elaborate? Good companies are never sold. They are bought. The buyer can be the general public - in an IPO, or a strategic player who wants to expand its reach or scope. We are in no rush for either. mansha.gagneja@expressindia.com

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CII (WR) to organise Healthcare Conclave 2017 The event to be held on August 23 in Mumbai will look at the outcomes and impacts of the National Health Policy CONFEDERATION OF Indian Industry (WR) will organise the premier edition of Healthcare Conclave 2017 to divulge into the changing ideas and schemes of the healthcare industry. The conclave will be held in Mumbai on August 23, 2017. The conclave is also being supported by The Ministry of Medical Education and The Ministry of Public Health and Family Welfare, Government of Maharashtra. The Healthcare Conclave will be looking at the outcomes and Impacts of the National Health Policy and look at various aspects of it and hence the theme ‘National Health Policy – A New Era in Healthcare.’ Healthcare Conclave 2017 is expected to attract over 250 top healthcare professionals consisting of key officials from nodal government agencies and head, CEOs, MDs, Deans, strategy heads, healthcare stakeholders and other senior managers from the Indian healthcare, IT industry and who will present their perspectives on the future of the industry. During the course of the day, the conclave will deliberate on topics like ‘Public Private Partnership’; ‘Insurance – Last Mile’; ‘Digital Healthcare’ and ‘Primary Healthcare’. EH News Bureau

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August 2017

MARKET I N T E R V I E W

A young entrepreneur, redefining healthcare space Dr Ankit Gupta, MD, Park Group of Hospitals, elucidates on how Park Group of Hospitals has been able to provide affordable care to patients and also talks about it upcoming hospitals Operational since 1982 in Delhi, what was your USP to become one of the trusted brands in the healthcare space in northern India? How different is your super speciality hospital facility from others? Park Group of Hospitals has always been one of the most affordable hospitals in DelhiNCR. The group always aimed to provide finest and expert healthcare services with advanced and updated technology. The philanthropist approach of the management has helped gain the edge over others. The group has been operational since 35 years and has grown into a group of eight hospitals in Delhi-NCR. With facilities like 24X7 emergency, blood bank, pharmacy and ambulance, group’s hospitals have been serving the society with complete dedication. The group has a cancer hospital to its accolade along with other super specialities like oncology, neuro sciences, urology, cardiology, nephrology and gastroenterology. We screen people for dreaded diseases in military and para-military forces. We also conduct special medical screening for Delhi and Haryana Police. Delhi is saturated with corporate hospitals. You have eight hospitals in Delhi and NCR. How do you see this mushrooming trend of super speciality hospitals? The major reason behind mushrooming of super-speciality hospitals especially in Delhi is because this is a fast growing metro city. Secondly, such hospitals are helpful and would be really beneficial for the society as they prove to be

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one–stop solution for all healthcare services and requirements of patients. They have the ability to treat and cure a patient who needs multiple treatments as in case of accidents, injuries or some critical diseases. Furthermore, super speciality hospitals also focus on the advanced and updated technology to be used for the treatment of patients, as the same helps them deliver the best.

GDP. Do you think it is achievable? What steps should be taken to achieve it? We as a country are far behind from the developed countries in terms of spending on healthcare and it is high time for us to increase our spending on healthcare to provide best of healthcare services at affordable price to the masses. It cannot be done overnight and we appreciate the seriousness of the government to achieve its target to increase its spending on healthcare from 1.16 per cent to 2.50 per cent of the GDP by 2025. It is very much achievable but requires aggressive execution plan, monitoring along with participation from the private sector.

As a private player in India’s healthcare industry, what are the challenges? The biggest challenge is the competition with regards to private as well as government hospitals. There is a perception that a private hospital is costly and is usually not affordable while government hospitals are affordable but the treatment offered is not satisfactory and up to the mark. Park Group of Hospitals fills up the gap of being affordable and yet offers best treatment with advanced technologies. Share few details on how you are trying to scale up Park Group of Hospitals. Are there any expansion plans ahead? Yes, we do have expansion plans in our mind. We have four upcoming hospitals i.e. Dwarka Expressway (Gurgaon), Shalimar Bagh (Delhi), Panchkula (Haryana) and Bhiwadi (Rajasthan). How challenging is it for private sector players to operate in the country’s healthcare space? As a private player, how do you balance the needs of the patients and commercial

interests of the organisation? It is not challenging as a private hospital to operate in the country. However, a private hospital has to consider certain domains while in operations. We have affordable rates compared to other private hospitals, as well as major government panels such as CGHS, ECHS, ESI, etc. We offer our patients technicallyadvanced treatment taking care of complete satisfaction of the patients. As a private

hospital, we organise CSR activities like free health checkups, health camps, along with other promotions and offers. Public health spending is 1.16 per cent of the GDP while the World Health Organisation (WHO) recommends spending five per cent of GDP. National Health Policy 2017 talks about increasing the spending to 2.5 per cent by 2025 but we haven't met the 2010 target of two per cent of

What sort of capex is Park Group of Hospitals planning for three years and how will it be funded? Currently, we have a total bed capacity of 1,500 across eight hospitals and the target is to increase this from 1,500 to 3,500 beds in the next three years. We hope the four hospitals in Delhi-NCR and Bhiwadi (Rajasthan), will add 1,000 beds by end of the next financial year 2018-19. Our proposed expansion requires a total investment of `400 crores in the next three years, which will be funded through combination of equity, debt and internal accruals. We are in discussions with few international investors for private equity infusion in the Group besides having huge leverage in the balance sheet to raise further debt from banks. prathiba.raju@expressindia.com

MARKET INSIGHT

Health insurance sector: Less penetrated but more opportunities

MAYANK BATHWAL, CEO — Aditya Birla Health Insurance Co

Mayank Bathwal, CEO - Aditya Birla Health Insurance Co, elaborates on the importance of health insurance for Indian population and its future growth prospects HEALTHCARE ISSUES have remained a challenge in India for a very long time. A significant part of the population is ageing and the funds available for healthcare are lower than what is required. According to the Economic Survey 2015-16, the expenditure by the central and state governments on health as a percentage of GDP was 1.3 per cent. The World Health Statistics also suggest that India’s per capita government expenditure on health in 2012 was $60, while the US spent $4,153. While India has made significant gains in terms of health indicators - demographic, infrastructural and epidemiological, it continues to struggle with newer challenges. The country is now in the midst of a dual disease burden of communicable and non-communicable diseases. This is coupled with spiralling health costs, high financial burden on the poor and erosion in their incomes. The changing lifestyle patterns have made the Indian diaspora more vulnerable to diseases and the cost of medical expenditure is on a rise due to the growth of the private sector in the healthcare segment, lack of healthcare infrastructure available in the public sector and the government’s inability to provide benefits to a large number of people. All of this has led to higher out-of-pocket health care expenses in the country. A large number of Indians still pay their medical bills by either borrowing money or by selling assets. There is very low penetration of the health insurances with only 27 per cent of the total population of India being covered under the vari-

ous health insurance schemes. With the majority covered under either government or employer programmes and voluntary, private health insurance has around three per cent penetration of the country’s population. Clearly, there is an urgent need to pay attention on increasing the penetration of health insurance policies in the country. The health insurance sector in India is unable to keep up with the growth in GDP, which is one of the main causes behind its decline. However, there are multiple factors that have led to the low penetration of health insurance policies in the nation. Low awareness: Lack of awareness is one of the key reasons behind the country being highly un-insured or under-insured. Even today, most of the people are unaware of health insurance products and their benefits. Some people understand the significance of these products but take very little attempts to buy them. One might be covered by their corporates but with the rising inflation this cover isn’t sufficient and there is a need to have adequate health insurance coverage. The insurance companies need to widen their reach for increasing awareness. Inadequate coverage: Presently most Indian insurers are reluctant to cover people with chronic conditions because of the risks associated with them. Even if they are covered it is only for hospitalisation with a substantial waiting period and sub-limits. Since a big part of the medical expenditure goes uncovered, people end up paying out-of-

pocket which isn’t an ideal situation for them. Perception of affordability: The rising cost of medical expenses has also led to the problem of affordability of the insurance policies for the common man, especially in the tier II/III cities. Maximum health insurance companies falter when they try selling insurances mainly as a tax saving instrument instead of risk covering instrument. This has also led to the formation of misconceptions in the people’s perception about insurance products.

Potential for growth in this sector There is immense potential for growth as the Indian market is highly under penetrated and is vastly underexposed to benefits of health insurance. Last decade and a half has seen very rapid expansion of health insurance coverage in India. There are increasing attempts to create insurance awareness, and inflationary healthcare costs due to technological advancement in medical science is also contributing potential for growth. In 2003-04, the total premium for health insurance in India was `1370 core. which has risen in FY 2017 to `30,000 crore. This is a CAGR of nearly 30 per cent, making health insurance the fastest growing segment in the Indian insurance sector. Currently, the focus of health insurance is limited largely to covering hospitalisation expenses. So a large part of customer segment like the very young and healthy, don’t feel the need for health insurance as they don’t consider hospitalisation a serious

probability. In recent times, the health insurance industry has evolved and there are insurers who in addition to the no claim bonus incentivise their customers for staying active and fit. There are cash equivalent rewards which can be used for health related expenses like buying medicines and pay for diagnostic tests, day care treatment, out-patient expenses (OPD), alternative treatments (which are traditionally excluded) or most importantly can use it towards the payment of future premium. Besides changing lifestyles that cause conditions like diabetes and hypertension, high level of pollution across Indian cities is acting as a catalyst for diseases such as cardiovascular disease etc. According to the reports published by National Health Profile - Central Bureau of Health Intelligence and International Diabetes Federation, India is now both the cardiovascular disease and the diabetes capital of the world and the third most obese country behind the US and China. Earlier, Indian insurers were reluctant to cover people with chronic diseases; even if they are cover it was only for hospitalisation with a substantial waiting period and sub-limits. However, insurers have now introduced specialised treatment and management programmes for people with chronic conditions that is in addition to a comprehensive hospitalisation policy, which offers day one cover for diabetes, hypertension, hyperlipidemia and asthma. Health insurance penetration is bound to increase even more if the insurers actively

spread awareness about the benefits of health insurance coverage enabling people meet the untoward expenses arising out of unexpected ailments. The higher cost of medical expenses can also act as a trigger for growth in this space. This can be done through knowledge dissemination and promotion of risks and rewards of getting covered under policies. The companies can make sure that the nation gets to reap benefits of the National Health Policy (NPH) 2017 that has spoken about achieving Universal Health Coverage through promoting card-based health insurance schemes. This policy recognises the critical gaps in public health services which would be filled by 'strategic purchasing.' However, insurers should also come up with influential marketing campaigns, workshops, seminars that could be good options to achieve the same. The companies can also conduct training and skill development programmes for increasing the effectiveness of the communications made by agents who sell in policies. They can go to the roots and concentrate on the rural areas, tier II & III cities. Thus, it is clear that there is a huge scope for the sector to innovate and introduce best practices to engage and acquire new customers. By 2020, India’s insurable population is projected to reach 750 million; the life expectancy is projected to reach 74 years; and a large part of the existing market is still untapped. There are myriads of opportunities available and all one needs do is just strike while the iron is hot.

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August 2017

MARKET

MicroPort’s target eluting stent to capture 15 per cent market share in India The stent is currently used in 60 hospitals pan India SHANGHAI-BASED MicroPort Scientific Corporation's most advanced Firehawk Rapamycin target eluting stent, which was recently launched in the Indian market, is currently being used in 60 hospitals pan India. Updating about the success of MicroPort stents in India, Riyaz Desai, MD-India, MicroPort said, “Globally, MicroPort sells two million stents every year. In India, we are trying to capture at least 15 per cent of the stent market in the next couple of years.” Highlighting the features of Firehawk Rapamycin target eluting stent, renowned cardiologist, Dr Purushottam Lal, Chairman, Metro Hospital, Noida, said, "MicroPort stents

have their own unique points. The third generation premium stents (latest generation stent) in the market are not inferior to Abbott, Boston Scientific stents. There is no single patient till now who has come back to me with complaints of stent thrombosis (blood clotting). The structure of the stent is designed so well that it minimises vessel wall inflammation and the stent is designed to release the drug only to the targeted cells. The drug is released in 90 days and the polymer which is outside in specific areas of the stent is fully absorbed in nine months. So chances of blood clot is less.” Informing that Chinese stents are known for their quality, Dr Lal said, “I was invited to the International Heart Valve

Dr Purushottam Lal, Chairman, Metro Hospital, Noida

conference in China to present the first case of TAVI with Core Valve in the world done by me. I came to know about the features of MicroPort Firehawk target eluting stent. Usually,

when we use a product from a particular country, we cross check two things. First to check whether the stent is approved in that country and whether it is used locally.” Touching upon the price control mechanism on stents, Lal informed that it is undoubtedly a good move for patients, but the capping of prices has left a lot of questions in patients and caregivers. “We need to counsel the patients and inform them that price less stents are not inferior. In a way, they are better price wise and quality wise. We inform them that low cost does not lead to any compromise in patient care. My patients trust me and hence they don't have any stigma.” On February 13, the NPPA

passed a price cap of $ 108.88 (` 7,260) for bare metal stents, and $443.91 (` 29,600) for drugeluting stents, which are used in nearly 90 per cent of angioplasty procedures. More advanced, biodegradable stents were also capped at $443.91. MicroPort Firehawk stent was first used in a hospital in Mumbai, within a few days of NPPA capping. The firm has a free sale certificate in Germany and the Netherlands, and the Central Drug Standards Control Organisation (CDSCO) has approved it for sale in India. Sale of medical equipment in India is permissible if it has prior approval from drug regulators in the US, Australia, Japan or select European countries. EH News Bureau

I N T E R V I E W

India will still remain our prime focus Poly Medicure is all set to expand its business within the Indian market as well as oversees. Himanshu Baid, MD, Poly Medicure, shares the business plan with Raelene Kambli Poly Medicure is soon going to set up a manufacturing plant for nephrology products. Can you comment on the same. Yes. The operations of this plant will be commencing in September or October and the focus of the plant is to manufacture consumables in the nephrology space where we see a huge potential for growth under the Make in India campaign. You also have your business in China and Egypt. How are these market different from India? China and India have a similar population strength. However, the per capita consumption of medical devices of China is 10 times more than India. The reason behind this is that the

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Chinese government has spend around $125 billion in the last few years just to create an infrastructure for healthcare. So, they have built new hospitals and services as well as created a demand for medical equipment and devices. Whereas in India, the government's focus in this space is very minimal. Similarly, in Egypt the per capita consumption of medical devices is atleast two times higher than India. Therefore, it makes sense to us to do business in these markets. What is your opinion about the Indian market as compared to the other markets that you operate? Currently, China is a bigger market to do business. However, the larger chunk of

Yes. We are looking at venturing into Europe in order to be close to our customers. Europe is the biggest market for exports. Therefore, we aim to foray into the Western European markets, in countries namely, Germany, France, Italy and the UK.

our business comes from India, and therefore, we will continue to focus in this market. Nevertheless, India has great prospects in the future. The market and the demand for medical devices is growing . Is there any plan to venture into other markets?

Will you take the acquisition route to expand to the Western European market? Expansion in this region will have to be through acquisitions only as we do not plan to set-up a green field project. We have involved two consultancy companies based there, who will help us to shortlist companies for acquisition. What is your opinion on the

impact of GST on medical devices? I feel that GST rate should be uniform for medical devices. Currently, there is a lot of abiguity in terms of the rate for various kinds of medical devices and dignostic equipment. These products should have a minimum GST ranging between 5-12 per cent. Presently, there is a lot of confusion with regards to pricing of equipment and devices due to the application of GST. This should not disrupt the supply of products and the services. In the long run, there could be a slight price increase of medical devices. We are still reading the fine print and trying to understand its nuisances. raelene.kambli@expressindia.com

cover )

HOSPITALPHARMACIES ABOOSTTO PROFITMARGINS Hospital pharmacies are business critical to any hospital. Investing in its upliftment will ensure sustainable RoI BY RAELENE KAMBLI

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(

ear hospital executives, Have you considered viewing your hospital pharmacy services as an active generator of revenue, while scrutinising your revenue cycles? If you haven’t yet, it's time to turn your attention towards this oft-overlooked resource for it has a great potential to draw more revenue for the hospital as it seeks a more efficient and controlled means of delivering medications to its patients. It can also be instrumental in creating a value proposition for your hospital.

Let’s find out more…. What onsite pharmacies can mean to your hospital? Like all times, hospital pharmacies seem to be one of the highest cost centres within a hospital set-up. Each year, the cost incurred in this division increases due to rising drug costs and staffing needs that accounts for the majority of the pharmacy budget. Again, clinical departments of a hospital focus on gaining access to medical advances and newer, more effective treatment options to offer their patients, while the financial department prefers to maintain the status quo in terms of pharmacy spending. Consequently, hospitals tend to overlook the multiple contributions that their onsite pharmacies can offer. Nevertheless, international experts point out that the hospital pharmacy division is one such resource that can dramatically aid a hospital’s revenue cycle from the point of service to claim submission and more. They can be an integral participant in optimising several hospital processes,

FO C U S : H O S P I TA L P H A R M AC I E S

improve data management and create innovative patient programmes which in turn can be helpful in boosting overall hospital revenues. Opines Dr Suresh Saravdekar, Consultant – Medical Procurement, State of Maharashtra & IMS- BHU , Varanasi, “Hospital pharmacy essentially works to strengthen the three important pillars of the hospital. These pillars are 3Ps – namely, Patient Care, Product Care and Profit Care. As regards financial outcomes, the hospital pharmacy works in three ways: at procurement level it works for procuring quality medicines at the most economic price; at storage level it works to save on investment by blocking minimum capital in the medicine inventory and as medicines are procured on bulk basis, the cost involved in buying the medicines is minimum. So, the hospital can easily get 40 per cent RoI on its medicines sold at its retail counter and to the indoor patients. As for clinical aspects, all the medicines are procured from reputed manufacturers, having good track record of observing Good Manufacturing Practices (GMP). Secondly, the bioavailability and clinical efficacy of medicines supplied is also assured. So the clinical outcomes of all the medicines are optimal and the patient’s satisfaction is at its best.” Moreover, if this division strives for business excellence, it can guarantee a positive impact on the bottom lines, enhance patient care and reduce readmissions thereby increasing profitability for a given hospital. Experts call this a value-driven strategy for business excellence. Strategy expert, Michael Porter and innovation expert Elizabeth Olmsted Teisberg in their book — Redefining Health Care: Creating Value-Based Competition on Results write about how striving for business excellence can benefit healthcare organisations in terms of profitability and sustainability. They call it the ‘value agenda’ which speaks of creating a value-based healthcare delivery system by utilising its various resources to be financially healthy and provide the best care to their patients. This strategy in my opinion can be applied in three significant areas-revenue generation, patient outcomes and supply-chain management to explore the potential of on-site pharmacies within hospitals.

However, at first, let us learn about the global practices and the evolving role of on-site pharmacies in India.

On global front As per global practices, hospital pharmacies have been an integral unit in the entire clinical and financial functioning of hospitals. “Countries like the US, the UK and Singapore has a very good legal framework for hospitals and pharmacies. A developing country like India can learn a lot from those countries in terms of pharmacy laws and regulations. In the US, all food, drugs, cosmetics and medical devices, for both humans and animals, are regulated under the authority of the Food and Drug Administration (FDA). The Food and Drug Administration and all of its regulations were created by the government in response to the pressing need to address the safety of the public with respect to its foods and medicines. Pharmacy in the UK has been an integral part of the National Health Service since it was established in 1948. NHS pharmacies are governed and paid for their NHS work under a standard contract, which was modified in 2005. This modification-enabled pharmacy contractors to be paid for Medicines Use Reviews are conducted by pharmacists for people with multiple long-term prescriptions. Singapore’s Pharmacy Board is a regulatory body and is separate to the Pharmaceutical Society of Singapore (PSS) that represents the profession. Registration with the Pharmacy Board is compulsory in order to practice as a pharmacist in Singapore and must be renewed annually by the payment of a retention fee,” informs Mohammed Faisal, COO, Primecare India.

Evolving role onsite pharmacies in India Hospital pharmacy practice in India is still evolving. “After independence, the development of pharmacy profession was mainly in the area of industrial pharmacy. Naturally, all educational institutes were and are still geared to produce industrial pharmacists and not hospital pharmacists. Therefore, unlike international practice, in India, all pharmacy colleges were / and are still attached to industries and not attached to hospitals. This led to producing the generations of compounders, having very little knowledge about real hospital pharmacy,” shares Dr Saravdekar. As per a research paper published by the US

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cover ) National Library of Medicine, “India launched the Doctor of Pharmacy (PharmD) study programme in the year 2008 which led to huge discussions about the programme and also on the role of clinical pharmacists (CPs) in the country. Before launching the study programme (i.e. PharmD), the role of a pharmacist in the nation was mostly considered to be “dispensing/manufacturing/marketing of the drugs” and clinical pharmacy education was mostly given under the study programme of Master of Pharmacy (M Pharm) (Pharmacy Practice/Clinical Pharmacy). Furthermore, there had been “almost no” professional clinical pharmacy services (CPS) provided in the country. As a consequence, the concepts of CP and PharmD are quite new in India. Adding on Dr Saravdekar says, “The concept emerged with the development of the private healthcare sector, which led to the demand for services that are of international standards and accredited. Consequently, demand for upgradation of compounders to hospital pharmacists became inevitable. Thus, only after six decades of independence, the profession of hospital pharmacy has been recognised as a profession in its real sense in India. And this opens new avenues for hospitals to offer better pharmacy services to their patients.” Hospital pharmacies currently contribute around 20-25 per cent to the hospital revenue. The division is involved in procurement of drugs and medical devices, inventory management, dispensing of drugs and patient counselling. However, there are some hospitals who engage their pharmacy services in other clinical processes as well. This role is certainly evolving and with the application of a value-driven strategy, it can transform further. According to Ron Purkiss, Clinical Director at Sheffield Teaching Hospitals NHS Foundation Trust, who writes for Royal RoPharmaceutical Society, clinical pharmacists with their unique knowledge of medicine are crucial in using pharmacoeconomic analysis to influence expenditure and distribution of resources on medicines. He further writes that hospital pharmacists need to use pharmacoeconomics to assist in making decisions involving formularies and how medicines can be used in a more cost-effective or cost-beneficial manner. This

Hospital pharmacy essentially works to strengthen the three important pillars of the hospital.These pillars are 3Ps – namely, Patient Care, Product Care and Profit Care Dr Suresh Saravdekar Consultant – Medical Procurement, State of Maharashtra & IMSBHU, Varanasi

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PATIENTCARE PRODUCTCARE PROFITCARE

in turn plays a crucial role in managing medicine demand within a hospital as well as bring down healthcare cost to a certain extent. This directs us to comprehend with the fact that onsite pharmacies can be cost savers and revenue generators.

Boosting profitability “Streamlining the formulary by cost and income,

Streamlining the formulary by cost and income, managing the formulary efficiently, along with billing help, means the pharmacy makes a contribution to the hospital’s bottom line Parveez Ahmed Executive Director, Primecare India

managing the formulary efficiently, along with billing help, means the pharmacy makes a contribution to the hospital’s bottom line. Having this information added into the billing system, it increases revenue and speeds turnover by having the initial bill correct,” informs Parveez Ahmed, Executive Director, Primecare India. A winning strategy that international experts propose consists of two steps -- capture prescrip-

At the pharmacy, we ensure that we provide streamlined counselling and communication for customers Pradnya Mane Head Pharmacy, Bhatia Hospital, Mumbai

cover ) A hospital pharmacy has the potential to become a supplementary nurse station that aids patients with information on medication

A combination of internal and external strategies to ensure that patient care is affordable and accessible to a larger population is very important

Suresh Ramu

Tony Mira

Co-founder and CEO, Cytecare Cancer Hospitals

President and CEO – MiraMed Ajuba Solutions

tions on discharge as possible, and generate revenue based on those prescriptions. If those efforts are successful, a hospital may be able to generate enough cash to grow and expand its pharmacy services, leading to ever-increasing revenue in a cycle of investment and return. Another way to cash on onsite pharmacies, is through excellent patient care and counselling. In the retail environment, there really isn't an interest in patient education and counselling. In fact, retail pharmacies may not be interested in making sure patients get the medications that they need. Therefore, hospital pharmacies can certainly leverage this opportunity to generate revenue. Pradnya Mane, Head Pharmacy, Bhatia Hospital, Mumbai, explains how her hospital utilises this advantage. “At the pharmacy at Bhatia Hospital, we take a few outlined steps for proper revenue generation. We believe that one of the mainstays of increasing revenues is to have proper communication channel with the patients. At the pharmacy, we ensure that we provide streamlined counselling and communication for customers. When patients come to us with due prescriptions, we make it a point to counsel them with the right consumption of the prescribed drugs. For instance, in case of antibiotics, we talk to them about how they need to complete the prescribed course because people have a tendency to discontinue in between. We also help them with indications on the timings -- before lunch, breakfast etc. Usually, doctors do mention these, but we try to make sure that patients have understood. We are also very particular about the availability or nonavailability of the drugs. We always maintain patient data in a register. In case, the required drug is not available, which is a rare case, we take the customers’ contact numbers. Once we procure the stock, we inform them. If they are willing to come,

it’s fine, or else we deliver to their residence,” she reveals. Going by the example of Bhatia Hospital, it brings us to knowledge that hospital pharmacies can add up to your revenue by way of various clinical and patient engagement programmes that needs collaborative efforts by every service department within a hospital.

Towards value-driven patient care and satisfaction Hospital pharmacies have a compelling role in optimising patient care by the pharmacy teams working with the physicians and nurses by providing appropriate medications and consumables as per treatment protocols. It ensures better outcomes to pa-

CHALLENGES THAT NEED FOCUS ◗ Need to upgrade the standards of hospital pharmacy services to global level

◗ Need to upgrade the skills in materials and financial management and overall administration of medicine management in the hospital. ◗ Need to learn modern communication skills to have effective communication with the patients ◗ Need to educate and update pharmacists on day today market trends, legislation, taxation, statutory requirements regarding management of medication ◗ Need to educate and update pharmacists on the use of modern technology for the overall management of medication in the hospital. (Inputs by Dr Saravdekar)

A value-based supply chain system will be strongly linked to clinical outcomes Amit Misra Head – Consulting Services, North India, QuintilesIMS

tients and thus helps hospitals exceed patient satisfaction. In 2014, the American Society of Health-System Pharmacists’ conducted a national survey of pharmacy practice in hospital settings that revealed, hospital pharmacists are taking a greater role in patient care, performing more medication-related patient transition-of-care (TOC) interventions, 24/7 medication order review and medication counselling. The report examined five areas in which pharmacists could enhance coordinated care: ◗ Medication management: Pharmacists can help patients with chronic diseases to have better medication adherence and clinical outcomes. ◗ Medication reconciliation:Pharmacists help detect and reduce medication discrepancies and increase

KEY AREAS TO FOCUS ON BEST PRACTICES PERTAINING TO VALUE-BASED SCM SYSTEM: ◗ Proper need assessment to ensure that scarce

resources aren’t wasted in excessive stocking of expensive items like implants

◗ Accurate estimation of cost, both direct and indirect, for optimal pricing

◗ Standardised protocols for product identification, ordering, billing etc. to avoid duplicity as well as effective monitoring ◗ Collaboration with suppliers for risk sharing and developing “win-win” solutions ◗ Leveraging of technology for efficient management of overall process as well as ensuring transparency ◗ Effective revenue cycle management keeping in view payable as well as receivables (Courtesy IMS Health)

IFHOSPITALPHARMACIES STRIVE FOR BUSINESS EXCELLENCE,THEYCAN GUARANTEE APOSITIVE IMPACTON THE BOTTOM LINES,ENHANCE PATIENTCARE AND REDUCE READMISSIONS 24 EXPRESS HEALTHCARE August 2017

cover ) benefits through comprehensive transition of care programmes, especially among post-discharge patients with an elevated risk of readmission. ◗ Preventive care services: Pharmacists can lead in immunisation services and identify vaccine candidates. They can also provide screening services. ◗ Education and behaviour counselling: They can provide behavioural counselling, improve medication adherence and therapeutic outcomes in patients with chronic conditions and can play a major role in other types of pharmacist interventions. ◗ Collaborative care models: Team-based care that includes pharmacists improve outcomes among patients with chronic conditions, and can alleviate demand for physician-provided care, as well as give access to primary care services related to medication management. Suresh Ramu, Co-founder and CEO, Cytecare Cancer Hospitals, draws attention towards important role of onsite pharmacies in pharmacoeconomics. “Information is the key role that a pharmacy plays within the hospital. Not just with patients but also with clinicians and nurses. Actually, a hospital pharmacy has the potential to become a supplementary nurse station that aids patients with information on medication. They can also play a crucial role in educating patients, healthcare practitioners and nurses on overuse of drugs, the interactions of certain drugs with other drugs or the diet and impact of drugs etc. Infact, the role of a pharmacist is to actually have a counter check between the clinical decision verses all other considerations that a pharmacist should make related to medication,” Ramu informed. The above mentioned survey of 1,435 pharmacy directors who worked at general and children’s medical-surgical hospitals in the US, also deployed technology to enhance patient care. It was found that the use of smart pumps, barcode-assisted medication administration, computerised prescriber order entry (CPOE) systems and electronic health record (EHR) systems, were utilised to improve patient outcomes and improve satisfaction. This is true in case of Indian hospitals as well. Digital technologies and automated equipment are utilised to get better patient outcomes and these technologies can be leveraged further to delivery better pharmacy services. Infact, digital technologies and automation can also be utilised to optimise supply chain management. Having said that, one must understand that the role of hospital pharmacies in the management of supply chain system is most imperative. In today’s cost-conscience environment, it is a must for hospital pharmacies to evolve their pharmacy supply chains and to make it more collaborative, transparent and efficient. Therefore, a value-

BHATIA HOSPITAL’S ABC ANALYSIS The supply chain management follow the universal ABC analysis (Always Better Control).ABC analysis is dividing an inventory into three categories- "items" with very tight control and accurate records, "B items" with less tightly controlled and good records, and "C items" with the simplest controls possible and minimal records.At our end, we maintain an excel sheet in which we list down the products first and enter the consumption quantity then check the average consumption.After calculating the value of consumption and the cumulative percentage we actually get the ABC categories.The A category includes drugs which have more than 70 per cent consumption, B category includes drugs with 20 per cent consumption and C category includes those with 10 per cent consumption.We ensure especially for higher consumption or A category drugs that there is never a shortage.This category also includes life saving drugs. It means we should never miss out on any drugs from this category. If there is a case that a patient comes with the prescription and the drug is not available with us, we take care from our side that the patient is provided with the correct alternative.We connect with the consultants for the alternative and try to ensure that the patient’s family and relatives are not hassled for this. In case, the consultant is not ready for an alternative, we cash purchase the drug from outside and provide it to the patient. The second category in the supply chain management is the VED (Vital, Essential, Desirable) category. For Vital drugs, we never have any stockout. Essential drugs too are extremely important, but in the rare case that they are not available, we make sure that they are with the patient at the earliest. Of course, there is always a 100 per cent availability. Desirable drugs include things like powders for example an Eno sachet to be consumed for acidity which depends on choice and can have alternatives. The supply chain management follows the FEFO system which means First expiry, first out.Whatever near expiry drugs are in the pharmacy, we ensure that they are removed immediately.These are segregated and stored in a separate area to avoid them from moving out of the pharmacy.Also, this is done to ensure that there are no confusions and mix ups- Pradnya Mane, Head Pharmacy, Bhatia Hospital, Mumbai

based supply chain strategy will be a great opportunity for hospitals to thrive. So, how can hospital pharmacies achieve this excellence?

An efficient supply chain management system Explains Amit Misra, Head – Consulting Services, North India, QuintilesIMS, “A value-based supply chain system will be strongly linked to clinical outcomes. The focus will shift from cost alone as a criteria for choice to a focus on the overall therapeutic benefit brought to the patients. An approach where therapeutic value is the basis of procurement decisions, demand planning and rationalisation will certainly be good for health outcomes.” “A combination of internal and external strategies to ensure that patient care is affordable and accessible to a larger population is very important. Quality patient care must utilise the latest technology in order to ensure credible and effective service that has a transformational effect in people’s lives. We need to ensure that this digital transition is coupled with reliable technology and qualified, dynamic professionals who ensure that the net result is always world class products and processes. With the increase in ageing population and the resulting rapidly rising health complications, patient data and diag-

nosis will be critical criteria for this industry,” spells out revenue cycle expert, Tony Mira, President and CEO – MiraMed Ajuba Solutions. Further on, Dr Mane expounds on the supply chain system followed by her hospital pharmacy division. Referring to the ABC analysis (See box), Dr Mane says, “At the pharmacy, we always take special efforts to maintain logistics like say which companies to procure the drugs from etc. We also follow good supply chain management practices. We ensure that we maintain a good inventory in such a way that there is no stock-out as far as possible. Also, there should be no over stock. For that, we always maintain an ROL, ie Re-order Level. The order is placed after calculating the ROL.”

Moving forward Well, the above mentioned techniques to prospect this unexplored good mine can only be possible if hospitals truly invest in strengthening their hospital pharmacy units and upgrading their clinical pharmacists to a leadership role. In doing so, the hospital can be rest assured of optimising the true value of its onsite pharmacies. Challenges such as, training, skill development and lack of accreditation need to be overcome. Above all, investing in its upliftment will certainly bear fruit. raelene.kambli@expressindia.com

HOSPITALPHARMACYUNITS NEED TO UPGRADE THEIR CLINICALPHARMACISTS TO A LEADERSHIP ROLE.IN DOING SO,THE HOSPITALCAN BE RESTASSURED OFOPTIMISING THE TRUE VALUE OFITS ONSITE PHARMACIES 26 EXPRESS HEALTHCARE August 2017

POLICY WATCH

World Population Day – Developing nations, empowering people Poonam Muttreja, Executive Director – The Population Foundation of India, highlights how India has taken on the responsibility of family planning as a tool that can empower people by preventing the vicious cycle of unplanned and unhealthy families that is counteractive to economic growth

he theme for the World Population Day 2017 is ‘Family Planning: Empowering People, Developing Nations’. It is the fifth anniversary of the 2012 London Summit on Family Planning.. This was the place of origin of Family Planning 2020 or FP2020, a community of leaders, experts, advocates, and implementers working together to expand access to contraceptives. Governments, civil society, multilateral organisations, donors, the private sector, and the research and development communities are working towards empowering 120 million additional women and girls. India too, as one of the most populous countries in the world, is striving to contribute towards this milestone. To achieve this, India, along with many other nations, has taken on the responsibility to support the reproductive rights of several million women and girls to decide whether, when, and how many children they want to have. Recently, the government included three new contraceptives (injectables, Centchroman, and Progestinonly pills) into the basket of choice, the Supreme Court judgement on the Bilaspur tragedy was critical in highlighting the need for a rights-based approach to family planning, and earlier this month they accelerated the roll-out and implementation of Mission Parivar Vikas, a government scheme that focuses on 145 high fertility districts in seven states. This year the theme is Developing Nations and Empowering

People. This is an appropriate time to examine the grain of the family planning debate that has so far eschewed men, making it the sole burden of woman. According to the National Family Health Survey (NFHS) III, male involvement in informed decision making on family planning is low with 22 per cent men expressing that contraception is women’s business. There is also an unequal share

in the use of modern methods of contraception among women and men in India – among the 47.8 per cent who use modern contraceptive methods, 36 per cent women opt for sterilisation in comparison with the near negligible 0.3 per cent men, as per the recent NFHS IV factsheet. It is time for us to stop referring to sexual abuse, violence and even family planning as

women’s issues. They are as much men’s issues, they are society’s issues, they are moral issues, they are ethical issues, they are issues of social justice and human dignity. India’s family planning mandate clearly needs to empower women, to assure them that the agency over their body is not up for question, but what often gets lost is the role of men in this effort. The frontline workers – ASHAs and ANMs are women in the public health system charged with family planning. Even though male sterilisation is a quick ten-minute non-invasive procedure with minimal risk, there is a greater percentage of women who choose to go under the knife and get sterilised to protect the mythical connection of a man’s strength and virility to his vas deferens. However, we have evidence to show that men are not as elusive as they may seem to be. From independent evaluation reports of Population Foundation of India’s Main Kuch Bhi Kar Sakti Hoon, an edutainment pro-

India’s family planning mandate clearly needs to empower women, to assure them that the agency over their body is not up for question, but what often gets lost is the role of men in this effort. Among the 47.8 per cent who use modern contraceptive methods, 36 per cent women opt for sterilisation in comparison with the near negligible 0.3 per cent men

gramme that was aired on Doordarshan and All India Radio we have found that men can and should be mobilised. Data shows that 48 per cent of the audience that tuned in to the show were men, and there are real-life examples like that of the men of Chhatarpur, Madhya Pradesh who were inspired by the show. These are men who were habitual wife-beaters who have now become empathetic partners; men who insisted on a boy child have opted to undergo vasectomy after two daughters. In another positive step, the state of Uttar Pradesh has recognised this gap and implemented a unique innovation that employs male family planning mentors. His role and responsibility will include dispelling the myths around non-scalpel vasectomy while also popularising the procedure and to be a depot holder for condoms. We live in a society that thrives on the intermingling of cultures and a flow of ideas that move as naturally as the currents, where technological advancements make degrees of separation irrelevant, and where partnerships and communities are created towards common humanitarian goals. This World Population Day, India has to recognise that men along with women are ready for a change and want to be free of the drudgery of an unplanned, unhealthy population. The energy is palpable and we need to unite for the cause of a healthy people and better opportunity, of women’s empowerment, and of equality.

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STRATEGY

GST: A double-edged sword Though it might usher more transparency, experts fear rise in healthcare costs due to trickle-down effec t. By Prathiba Raju

he roll-out of Goods and Services Tax (GST), touted as the country’s biggest tax reform, has evoked a mixed response from the healthcare sector. Though it is exempted from GST as a segment, experts foresee a trickle-down effect and many fear rise in medication and hospitalisation costs as some services and healthcare products are taxed at 1518 per cent. Healthcare experts from diverse segments voiced that

GST is a remarkable step taken by the government and exempting healthcare from it will help the consumer to some extent. However, they have also cautioned that input tax levied on products and services, will impact the costs for healthcare providers. The hospitals and the companies working in this domain will try and absorb the cost themselves to a certain point. However, in the long run, consumers will have to pay the service cost.

There shall be a proportionate incremental cost for the hospital.There are certain large equipment, which were taken on specific arrangement with the vendors, where the payment due to vendors was on operational cost and was broadly subject to VAT at five per cent. In the GST, the same is now defined as a service, and hence will be charged at a much higher rate at 12 per cent. Hence, the result is that the taxes on input services of a hospital will go up

The GST effect Elaborating on the new tax regime, Malyawant Passi, CFO, Jaypee Hospital, said, “The healthcare sector in terms of hospitals were exempted from indirect taxes in the pre-GST era i.e. upto June 30, 2017 and continues to be exempted under the GST regime. For the hospitals, input services which were used/consumed by the sector, like security and laundry services were earlier taxed at 15 per cent (as service tax) while it is proposed to be at 18 per cent.

There shall be a proportionate incremental cost for the hospital. There are certain large equipment, which were taken on specific arrangement with the vendors, where the payment due to vendors was on operational cost and was broadly subject to VAT at five per cent. In GST, the same is now defined as a service, and hence will be charged at a much higher rate of 12 per cent. Hence, the result is that the taxes on input services of a hospital will go up.” Patients’ bills are likely to in-

The primary issue healthcare providers are facing is on being classified as ‘exempt from GST’ by the government. Being exempt, hospitals would not be able to avail credit on inputs, primarily on service tax increases proposed by the legislation. Hence, these costs will have to be passed on to consumers of the service which will result in higher cost of healthcare

crease by four per cent as the cost of most of the drugs, reagents and disposables that hospitals use have increased at least by five per cent. High-end medical equipment, which attracted 12.63 per cent tax, is now will be taxed at 17.28 per cent. Healthcare devices and accessories such as catheters which were charged at 10.16 per cent will now be taxed at 23.15 per cent. Hospital beds which were taxed at 11 per cent, will now be taxed at 18 per cent. Lifesaving drugs and diagnostic kits will at-

Jagannath MS,

Healthcare will become expensive as the goods, products and services consumed by majority healthcare providers fall under 12-18 per cent category. Hence, in future, the end consumers will bear the extra cost on healthcare delivery due to input tax levied on them. Many companies having presence in multiple states will face challenges in statewise registrations with regards to compliances, documentation

CFO, Columbia Asia Hospital India

Amol Naikawadi, Joint MD, Indus Health Plus

Malyawant Passi, CFO, Jaypee Hospital

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STRATEGY

tract 18 per cent tax, a steep jump from 5.5 per cent. Also, the hospital infrastructure costs— for instance, comprehensive maintenance contract — has scaled up from eight per cent to 18 per cent. This will raise hospital expenditure significantly. Soon after the roll-out of GST, Prathap C Reddy, Chairman, Apollo said if there is an increase in healthcare cost by up to two per cent, hospitals would be in a position to absorb the hike, but anything more than that would have to be passed on to patients. “There is no GST for us (hospitals), but there are services and some products with GST rates ranging from 15 to 18 per cent, the cost of which should be borne by us. If the increase is up to two per cent, hospitals can absorb it, but if it is three or four per cent, then patients will have to bear it,” Reddy told the media soon after the roll-out of GST. Sandip Khosla, COO, Paras Hospital, observed that GST is a progressive step. However, he also said that it will impact all segments of the healthcare industry. “Exempting the healthcare from GST, this industry has been given the importance it deserves. The costs of several services in hospitals have gone up to 12 per cent. This is also true in the case of medicines which were earlier on a tax slab of two per cent and 5.5 per cent. Now, it is in the tax slab of 12 per cent and this will impact the end user, unless the healthcare provider is willing to absorb some of the impact on the costs. We definitely agree that the costs of the same shall increase to 10 per cent in the initial stages. However, until the complete impact of GST is not realised, it is too early to state anything. In the long run, we definitely expect relaxation and reduction in the input prices,” he said. Khosla also noted that though hospitals are exempted from GST, the input costs are still subject to GST taxation, he said, “The prices are bound to rise due to the same, however, we are certain that with the time to come and due to the robust taxation regime of GST, the economy shall benefit. We need to give time to the industry to adapt to the new taxation.

Hence, we are not looking in for amendments to the GST regime, but time for adaptation.” Giving his opinion, Jagannath MS, CFO, Columbia Asian Hospitals India, said, “The primary issue healthcare providers are facing is of being classified as ‘exempt from GST’ by the government. Being exempt, hospitals would not be able to avail credit on inputs, primarily on service tax increases proposed by the legislation. Hence, these costs will have to be passed on to consumers of the service which will result in higher cost of healthcare. As far as hospitals are concerned, though industry bodies requested the government to either look at a five per cent GST for hospitals services or consider a zero rate of GST. If this happens, increases in input taxes can be offset with the output GST or in a case of ‘zero’ tax hospitals can avail a refund. So, rationalising the tax structure in case of hospitals would help resolve the problem. Amol Naikawadi, Joint MD, Indus Health Plus, reiterated, “Different GST structures have been fixed for many utilities that are used in the healthcare sector, making it easy for the finance department to levy tax. However, healthcare will become expensive as the goods, products and services consumed by majority healthcare providers fall under 12-18 per cent category. Hence, in future, the end consumers will bear the extra cost on healthcare delivery due to input tax levied on them. Many companies having presence in multiple states will face challenges in state-wise registrations with regards to compliances, documentation.” Explaining the domino effect in the cost structures for healthcare sector due to GST imposition, Ameera Shah, MD and CEO, Metropolis said, “Hospital services are exempted from taxes under GST. The outsourced services, aesthetics and outpatient pharmacies are subject to GST imposition. In the pharma landscape, the five per cent tax rate on life-saving drugs that treat diseases like malaria, HIV-AIDS, tuberculosis, and diabetes are expected to marginally increase the prices of medicinal drugs, leading to a domino effect

in the cost structures for healthcare sector. The decision of the government to exempt healthcare services from GST has been good news for start-ups as well as established healthcare businesses. However, for the end-consumer, the costs could rise, given the increase in input costs as proposed by GST. It will create a risky situation for the common man as the tax charges are tweaked up to a substantial number. It is observed that the GST is more likely to affect the healthcare industry. While this shift is dramatic enough, I am glad that the GST council has decided to make the transition as smooth as possible for India, by not moving the tax needle too drastically on the healthcare related goods and services. Many healthcare entrepreneurs voiced that they will observe the actual impact on input cost for sometime. They further said if the percentage is small they will absorb the cost, and if it increases, then it will passed on to the consumers.

GST PROS

CONS

For healthcare industry as a whole (taxable), the biggest advantage is single nation single tax, which means tax liability is same across the nation which was different in pre-GST era.

Healthcare services being exempt from the levy of GST, all taxes paid on input remains a cost.

To a certain extent, cascading effect of taxes will be eliminated with the introduction of GST as earlier for trading activities, taxes paid on services was huge along with the VAT on goods.As all the credits are allowed in the GST regime this cascading will not be there.

Adapting to GST In the past few months, the GST has been the sum and substance of many debates and speculations within the healthcare industry. The impact of the new tax regime on business processes, be it small, medium and big hospitals, shall remain the same, irrespective of the size of business, according to healthcare entrepreneurs. “Small hospitals have to ensure that they don’t deal with unregistered vendors/suppliers as the same would result in tax payment under Reverse Charge Mechanism. Large hospitals, which provide taxable services like plastic surgery for beautification, need to ensure that all the expenses directly related to such activity shall be segregated as tax credit of the same could be availed 100 per cent and for unsegregated expenses, proportionate credit is available. Large and medium hospitals have to be careful in availing these credits based on their last year performance and should finally reconcile it in March 2018, based on actuals,” Passi informed. Supporting his view, Jagannath said, “The impact may not be very different between

For import of medical equipment as Countervailing Duty and Special Additional Duty besides the basic custom duty is replaced by IGST, there will be seamless flow of taxes which should bring down the cost of such imported machinery or material. Multiple registrations were required in the pre-GST era like VAT, Service Tax and Excise Duty. Each had their own typicality’s/conditions. In GST, these multiplicity of registration will not be required.

Leasing arrangement of equipment which were charged under VAT @ 5 per cent earlier and shall be treated as a service under GST and at a higher rate of tax @12 per cent and shall have an impact on the bottom line. Some medicines for which the tax rates have been revised upwards will also have an impact on the bottom line. For the pharmacy business, though tax credit will have a positive impact, the compliance cost in terms of returns etc. shall increase. For manufacturers of medical equipment, which supplied these equipment across the country would need to change their supply chain management as stock transfer are also subject to tax, which will have a huge impact on working capital requirements. As a Service Provider, in the Pre-GST era, business could avail centralised registration (Under Service Tax), however, in the GST era whatever you propose to supply from, you need to get registered in the specific state. Advertisement under print media is taxable at 5 per cent under GST which was exempt under Service Tax.

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STRATEGY

We definitely agree that the costs of the same shall increase to 10 per cent in the initial stages. However, until the complete impact of GST is not realised, it is too early to state anything. In the long run we definitely expect a relaxation and a reduction in the input prices Sandip Khosla,

The decision of the government to exempt healthcare services from GST has been good news for start-ups as well as established healthcare businesses. However, for the endconsumer the costs could rise, given the increase in input costs as proposed by GST. It will create a risky situation for the common man as the tax charges are tweaked up to a substantial number

COO, Paras Hospital

Ameera Shah, MD and CEO, Metropolis

smaller and bigger hospitals in terms of percentage increases. However, hospitals which operate under ‘Headquarter-branch’ model, where the HQ and branches are in different states, GST on HQ benefits received by the branches would increase the input cost of the branches. Typically under this model, a HQ functions as a cost centre with centralised functions like finance, accounts, treasury, legal, HR, tax, IT, etc. While all these centralised functions are performed within the HQ, the benefit thereof is received by all branches. The GST law envisages that costs should follow the benefits, i.e. that if the branches avail the HQ services, then they should also be passed on to the relevant HQ costs as are apportioned/allocated to them. The said cross-charge (being a consideration for provision of HQ services by the HQ to the branch) would constitute a taxable service and would attract GST. As the hospital service is exempt, such tax on the intercompany service would have to be absorbed by the branch hospital and thus would increase the cost of healthcare. However, GST would also usher in certain positive changes. For instance, throwing light on starting new business and new ventures, Khosla, said, “There have been different tax rules in different states which have impacted new startups or expansion to other places in complicating processes. A centralised registration system will

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make all these easier and impact the economy also. With the government looking at an increase in the exemption limit to ` 25 lakhs under the GST which was at ` 5 lakhs earlier, this will impact a large and significant percentage of new venture capitalists and entrepreneurs to give them opportunities of expanding their businesses. The reduction of the tax burden will certainly have a positive impact. Delivery of services and goods will be impacted as they will improve in logistics as well. Under this game changing bill there is no entry tax. This will encourage entrepreneurs additionally. Systems will be transparent and this will lead to no tax evasion paving the way for more facilities and services for the end user or consumer. GST is said to create a levelplaying field for healthcare companies, irrespective of their geographical location within the country. The medical devices sector urges the government to support ease-of-doing business, reduce cost of compliance and provide entrepreneurial impetus via GST.

Medical device – urge for compliance Medical devices are either manufactured in India or imported, and they have two arrangements with the vendors i.e. buying the equipment or leasing the equipment on the specific terms and conditions. Before GST on imports, there was Centre Value Added Tax (CENVAT) available for CVD paid on imports against

excise duty and SAD (In lieu of VAT) were subject to refunds. In the GST regime, there will be IGST charged on the imports and if the hospital is acquiring the asset, there will be an incremental cost for the hospital. Assets taken on lease on certain terms and conditions attract 12 per cent service charge now; earlier it was five per cent under VAT. Medical Technology Association of India, an association of research-based medical technology companies, has informed that the current GST dispensation for healthcare that keeps the hospital services exempt from GST and fixes rates that range from five to 28 per cent on medical devices will do little to lower the existing medical costs for the common man. “It would have helped if the medical services were zerorated, similar to exports, where full tax credit against inputs would be refundable, and all devices were taxed at a standard rate of five per cent GST. On the contrary, many medical devices have seen higher GST rates than the embedded tax earlier. The increase ranges from about 1.5 per cent (for devices attracting six per cent CVD earlier) to 4.5 per cent (for devices under nil CVD). Besides, the maintenance cost of the Capital Equipment went up by three per cent, owing to an increase in GST to 18 per cent versus previous Service Tax rate of 15 per cent. There was an across-the-board increase in custom duties board in early 2016 as well. A successive in-

crease in GST will force the suppliers to raise prices of devices. This will only add to the cost of medical services. A lower and uniform GST rate of five per cent, when combined with the anti-profiteering law would have helped to bring down the cost of medical service to patients, and also attract investments to the sector and expand reach,” MTaI urged. Giving an overall perspective of medical equipment industry, Naikawadi said, “GST has lowered tax burden for medical equipment industry. Now companies working in this domain need to pay one uniform tax which will ease the process of operating business and there will be no double taxation.” Not just medical devices, GST has also moved the healthcare space towards a ‘digital economy’. It is helping the industry to be completely transparent with respect to all transactions under the tax net and bringing in a level playing field for the players. Healthcare is expected to benefit because of this macro change.

Going digital The biggest change is compliance in digital platform. Post GST, every organisation has to go through compliance modification in their IT systems and software. Everything from back-end processes, filing, documentation, etc. have to be GST enabled. Listing out the changes made by Columbia Asia Hospital India, Jagannath said, “We have made several changes to the software

to manage invoices and related forms, billing, returns and MIS required for the purposes of fulfilling the statutory requirements under the GST. Also, we are developing interfaces to connect with third party vendors for filing purposes.” As for Paras Healthcare, Khosla stated that the HIS system of the hospital has become GST compliant and it has been done on a priority basis to ensure that the patients receive the benefit, there is no confusion and the entire healthcare becomes compliant to new taxation regime.

Wait and watch As a whole, the hospitals welcome the fundamental premise of the GST legislation, which is to avoid cascading effects of indirect taxes and thereby bring about lower costs of products and services which is a key consideration in framing the National Health Policy. However, rise in healthcare costs emerge as a major concern. The healthcare sector experts find the new tax reform as a good step, but also suggest that the roll-out of GST needs to be given sometime, as the complete impact of GST is not yet realised. Khosla sums up, “We sincerely believe until the complete impact of GST is not realised, it is too early to state anything. In the long run, we definitely expect a relaxation and a reduction in the input prices.” prathiba.raju@expressindia.com

STRATEGY I N T E R V I E W

â&#x20AC;&#x2DC;India has the expertise and technology but delivery of care is a huge challengeâ&#x20AC;&#x2122; Recently, representatives from the Cleveland Clinic visited Indian experts for a knowledge exchange. Raelene Kambli catches up Dr Umesh Khot, Vice Chairman, Department of Cardiovascular Medicine, COO, Section of Clinical Cardiology, Cleveland Clinic, to understand his perspective on the opportunities and threats in cardiac science for India Excerpt.... Brief us about the global Cardiovascular disease (CVD) burden. The CVD epidemic started off in the US and Europe in the 1950s which started to slow down with the availability of better treatment but the explosion has shifted to lower and middle income countries in particular, India. The highest risk of heart disease in the world rests with the Indian population. We are seeing an explosion of heart diseases both heart attacks and heart failures and the most dramatic things is that it happens at a very young age. The average age of heart disease in India is almost 10-20 years younger than the people in the US. Indians are genetically predisposed to heart disease. Can you explain this further? This is not completely well understood. Indians are very sensitive to smaller weight gains than an American population. So if an Indian would gain around 10 kg of weight, that person would suddenly become diabetic as compared to a caucasian population. There are a lot of theories surrounding this subject and scientists are still researching on the genetic connection of heart diseases among Indians. What is your opinion on

sation to treat heart attacks and the treatment is accessible even in the rural areas. We have started this initiative in the state of Tamil Nadu and its success story has been published in an American journal which shows how they have reduced the death rate using this technique.

heart transplants? It is nice to have the technology and facility to have heart transplants but in my opinion I feel that patients should not reach that level that they require a transplant. We need to look at preventing heart attacks. So, what are the opportunities and threats for cardiac sciences in India? The scenario has changed in India in the last 10-15 years with the availability of technology. This opens up a lot of opportunities for cardiac sciences. The biggest challenge that India faces is the delivery of care. India has the expertise and the technology but delivering that care at the right time to the patients is a huge challenge and this is something that we need to work upon. How can we turn these challenges into opportunities? Well, that is why I am here. I work with this group called StemiIndia, which stands for ST Elevation Myocardial Infarction (STEMI). We have worked together to design a heart attack system for India.This system is designed specifically for India as the situation is quiet different here as compared to the US. Here, we use a combination of thrombolysis drug with a heart catheri-

The scenario is changing in India in the last 10-15 years with the availability of technology. This opens up alot of opportunies for cardiac sciences

Which technologies can be leveraged to improve cardiac sciences in India? One nice thing about India is that, the country is focusing on information technology and is leveraging the digital space very well. People in India love their smart phones and are utilising it to the best use. Even doctors in India are utilising smart phone technology much faster than us. Therefore they have more advantage in several areas. This will take India ahead of other countries especially in terms of mobile technology and transmission. Infact, I came on the whatsapp platform because of my counter parts in India. Things don't function here without it and in one way it build communities and drives faster communication. So, you see that's the advantage and influence these technologies can have. So are you involved in helping Indian doctors to

conduct research in cardiac sciences? Yes, we have done a research on the heart attack system for India and published it in the Indian Heart Journal where we wrote about how to design a heart attack system for India. And over the last five years, we have taken that message across the country. We started with Chennai, Bengaluru, Mumbai and Hyderabad. This year we went to Vijaywada and next year we will be going to the north. What is Cleveland Clinic's vision for collaborating with India? Cleveland Clinic has a long stand international perspective and because India's healthcare system has grown so much, we wish to partner with Indian physicians by providing them training, exchange knowledge. We would also like to partner with the governments in many ways. What is your message to the cardiac science fraternity in India? There is a need for organisation of cardiac care across the country. The Indian healthcare providers need to connect the dots and how care can be provided to every patient at the right time and at an affordable cost. raelene.kambli@expressindia.com

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KNOWLEDGE I N T E R V I E W

'Study shows fairly strong correlation between GDP of a state and prevalence of diabetes' Dr V Mohan, Chairman, Dr Mohan’s Diabetes Specialities Centre and President, Madras Diabetes Research Foundation and Dr RM Anjana, MD, Dr Mohan’s Diabetes Specialities Centre, in an interaction with Mansha Gagneja, talks about ICMR – India DIABetes [INDIAB] Study and the growing prevalence of diabetes in urban and rural India The ICMR – India DIABetes [INDIAB] Study, the population-based crosssectional study, is aimed to estimate the national prevalence of diabetes and pre-diabetes in India. Could you elaborate on the takeaways from the study? The ICMR – INDIAB Study is one of the largest epidemiological studies on diabetes ever done and certainly the largest on diabetes done in India. It is also the first study in India to look at whole states of the country. In the publication in Lancet Diabetes Endocrinology, the prevalence of diabetes and prediabetes in 15 whole states of the country were reported. The results show several findings. 1. There are huge variations in the prevalence of diabetes and pre-diabetes in different states of India. Some states like Bihar and Jharkhand still have relatively low rates of diabetes while states like Tamil Nadu, Punjab and Chandigarh have very high rates of diabetes. In some of the states where the diabetes rates are low, the prediabetes rates are high suggesting that the genetic tendency is there, but they have not yet converted to diabetes. 2. The study also showed that there was a fairly strong correlation between the GDP of a state and the prevalence of diabetes showing that as the state become more affluent, diabetes rates are increasing. This is probably related to obesity levels increasing as well as physical activity coming down as well as possibly changes in dietary habits of the people.

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Dr V Mohan

Dr RM Anjana

As diabetes is a major constituent of growing NCDs in India, is there an action plan in place to approach the policy makers to devise strategies to control diabetes? The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) was started by the Government of India in the year 2010. It’s a comprehensive programme which looks at the control of diabetes at different settings, i.e., at the primary care setting, secondary care setting and the tertiary care settings. The programme emphasises on changing life styles, preventing obesity, increasing physical activity and healthy eating. There is also some emphasis on stress reduction through yoga and meditation and relaxation techniques as well. This kind of primary prevention measures is adopted, will help to control, not only diabetes, but also other metabolic NCDs like obesity, hypertension, dyslipidemia and coronary artery disease.

diabetes epidemic seems to be maturing in the more economically advanced states of India. What are the factors influencing the growth in various states? Do these factors overlap ? The ICMR – INDIAB Study has shown clear evidence of epidemiological transition. In more economically developed states of India, there is not only an increase in the prevalence rates of diabetes but also a shift in the burden from the high and middle income group to the lower income groups, especially in the urban areas. Thus in urban areas of Tamil Nadu, Punjab, Maharashtra and Chandigarh, poor people seem to have more diabetes than the middle and the higher income groups. However, in rural areas of all the states studied, the more affluent people suffered from diabetes. The advantage of the ICMR – INDIAB Study is that since each state has its data on diabetes, pre-diabetes and other NCDs, health being a state subject, each state can then prioritise what policies need to be adopted to curtail the diabetes epidemic.

The study states that

Factors influencing the growth of diabetes are similar in various states. There is a clear increase in diabetes with affluence because with affluence, mechanisation in the way of motorised transport becomes available. So, instead of walking or cycling, people now use two wheelers or cars which brings down the physical activity considerably. They also tend to eat food which is rich in calories, carbohydrates and fat, all of which are obesogenic and thereby lead to increased diabetes rates. Examining the factors, would you recommend a general or a customised plan of action? To control the diabetes epidemic, may things need to be done. The first is primary prevention of diabetes. For this, a generalised plan encouraging people to increase their exercise levels, ie., 30 minutes of brisk walk, atleast five times a week and cutting down on carbohydrate (eg., polished rice or wheat) in the food and replacing this with plenty of green leafy vegetables and protein. It was shown that this can reduce the diabetes incidence by more than 30 per cent as shown in the Diabetes Community Lifestyle Improvement Program (DCLIP) carried out by Dr V. Mohan and colleagues at the Madras Diabetes Research Foundation (MDRF) in collaboration with Dr Venkat Narayan and his team at the Emory University. This can be called as a ‘population-based approach’ or a ‘generalised approach’. In addition, those who are at ‘high risk’, for example those who have the

family history of diabetes or obese or physically inactive or have other NCDs like hypertension, dyslipidemia, etc., are at much high risk of getting diabetes, should undergo early screening to detect diabetes and most intensive life style changes to prevent diabetes. In the study, it is evident that the prevalence of the disease in urban India is twice that of rural India. What are the learnings needed to be incorporated from the rural setting in order to curtail diabetes? Yes, it is true that in all the 15 states studied, the prevalence of diabetes was higher in the urban areas compared to the rural areas. However, the rural areas of India are fast urbanising and the habits of people in urban areas. Example, less physical activity, eating junk food, etc is fast being introduced in the rural areas of India as well. The lessons learned from urban India can be transferred to rural India. This is important because 70 per cent of India’s population now still lives in rural areas and even a small increase in the prevalence of diabetes in rural areas can result in millions of people in India developing diabetes. The Chunampet Rural Diabetes Prevention Project (CRDPP) is a study conducted by Dr V Mohan and colleagues in Chunampet in Kanchipuram district and this has been widely acclaimed as a good model to prevent diabetes in rural India. mansha.gagneja@expressindia.com

STARTUP CORNER I N T E R V I E W

CCU to break-even for any new territory in three months Rajiv Mathur, Founder, Critical Care Unified, elucidates on the need to provide home healthcare services in an organised and structured manner. He also shares his start-upâ&#x20AC;&#x2122;s objectives and strategic plans to fill the gap in a conversation with Mansha Gagneja What led you to establish CCU and what is the main focus of this venture? Personal experiences and those of friends and relatives, with regard to cost and inconvenience associated with post-operative or continuous care, clearly built a case for services at home to address critical care, outside the ambit of hospitals. Critical care needs a high level of medical expertise, along with equipment and medical electronic, to be provided and managed in the home of the patient. Informal arrangements do not work as the family and friends of the patient cannot devote dedicated time and attention required in critical cases. Therefore, there is a need for an organisation that provides these services in an organised and structured manner. CCU's objective is to fill this gap by providing all elements required to manage critical care at home. Elaborate on the Investments involved. What is your strategy for growth? There are two main areas that involve investment: Technology: For monitoring the patient's parameters as well as allowing growth of the organisation and extension of services into smaller cities Training and development: The home healthcare industry is in a nascent stage in India. Not enough professional and trained

CCU, when it was set up, was to focus on unit economics. This has led to a profitable operation from the very first month in Delhi/NCR region. Focus on unit economics has not only led to above average industry gross margin, but a tight control on indirect expenses has resulted in positive net margin. CCU lays down a clear objective for any new territory â&#x20AC;&#x201C; to break-even at the end of three months.

The important objective of CCU, when it was set up, was to focus on unit economics. This has led to a profitable operation from the very first month in Delhi/NCR region talent is available. Therefore, significant investment needs to go into building up a resource base that can deliver high quality and world class services. The strategy for growth entails both vertical growth of critical care services as well as horizontal growth

covering more geographies, including overseas. Appropriate plans are being chalked out for expansion towards the end of 2017. What is the current status of profitability in the organisation? The important objective of

How will leveraging technology assist in bridging the gap in home healthcare? There is already significant and increasing use of IT, globally, within medical services. However, with advancement in medical electronics and IoT, integration of these technologies provides tools for much sharper monitoring and care of patients, as well as, enhanced positive experience for the stakeholders â&#x20AC;&#x201D; the patient, the treating doctor and other clinicians as well as the patient's family. Therefore, use of technology will play a key role in user acceptance of critical care services at home; rendering of services that assist treatment based on continuous feed of data and analytics; expansion and monitoring of these services in smaller cities at an affordable cost. Home healthcare is usually associated with higher

cost. Is that still a concern or have you managed to make these services cost effective? Home healthcare services need to deliver value for money. The alternative to home care is care in a hospital as informal arrangements with help of friends and relatives are getting less and less viable. When compared to the cost associated with care in a hospital, home care is significantly cheaper, ranging from 30 per cent to 75 per cent, depending on the level of care, with much lower inconvenience for the patient and family members. Greater availability of trained manpower and achieving a critical mass will enable home healthcare to be a viable and affordable alternative. In doing so, would you be partnering with hospitals? Hospitals are and will continue to remain the most important element in the value chain of healthcare, especially in cases of critical care. Therefore, partnering and integrating with hospitals in the care continuum is not only germane but fundamental to success of home healthcare. CCU not only partners with hospitals but also implements a model of coordination right from the point of discharge, transition to home and then ongoing care. Robust processes and SOPs drive this endeavour mansha.gagneja@expressindia.com

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August 2017

IT@HEALTHCARE I N S I G H T

Aparadigm shift and the wayforward DrSuchita Markan, Asst. GM, BCIL, speaks on the compelling need to integrate IT into healthcare to foster and deliver efficient healthcare

ealthcare is the world’s largest and fastest growing industry. In India, public healthcare system is responsible for spending of one per cent of GDP (effectively about `1000 per capita). In contrast, approximately three per cent of the GDP (an average of `3675 per capita) per annum is spent in the private sector on healthcare. With the demand for public healthcare far exceeding supply, there arises the need for devising ways and means to increase the productivity of the public healthcare systems with limited resources. The best way to increase the productivity of any system/sector is its integration with the latest advancements in technology, more particularly Information and Communications Technology and healthcare is no exception. We have a new buzzword healthcare IT. To define healthcare IT, it refers to the use of IT services, products, software, and solutions by healthcare organisations to integrate and streamline various processes. In healthcare, IT is used to develop a secure environment and maintain a uniform flow of information. It improves the quality and efficiency of the services delivered and helps in reducing errors in the healthcare industry. To enable healthcare industry to foster and deliver efficient healthcare to cater to the huge demand, integration of IT into healthcare is a compelling need. This need can further be appreciated in light of the following healthcare challenges being faced by our healthcare sector which are also opportunities

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August 2017

for healthcare IT sector: ◗ Huge urban-rural gap: Rural India accounts for 70 per cent of the Indian population but 80 per cent of the health infrastructure is in the private sector. The medical insurance coverage is a mere five per cent, limited almost entirely to the urban, educated, middle classes in India’s larger cities. This gap makes out a strong case and represents a huge opportunity to deliver healthcare services from urban to rural areas through use of IT tools such as Telemedicine as India has very good mobile coverage in the rural areas. ◗ Inadequate trained and skilled manpower: As per WHO report, India is placed in the category of critical shortage of health service providers with 0.7 doctors and 1.5 nurses per 1000 people. The WHO average mandate is 2.5 doctors per 1000 people. According to

the Planning Commission (now NITI Aayog of India,) we are short of 1.54 million doctors and 2.4 million nurses to match the global patient to doctor ratio. This offers itself as an opportunity for integration of IT with the healthcare ecosystems wherein limited skilled manpower in Indian healthcare sector must be ITenabled to increase their efficiency for effective healthcare delivery to the patients in remote locations.

data is difficult in the health sector in our country. This is despite the presence of many agencies ranging from NASSCOM to the Registrar General of India to diseasespecific programme-based systems to survey malaria to HIV. Data is incomplete (in many cases it excludes the private sector) and many a time, it’s duplicated. This embarks another opportunity for the IT sector to bridge the gap.

Fragmented Health Information Systems

Weak primary healthcare sector

To strategise, develop and implement any healthcare solution into the system, requirement of reliable and adequate data is the starting point to appreciate the quantum of unmet needs and market opportunities. The data about disease burden, birth and death rates is not up-to-the mark in India. Getting quality, clean, up-to-date

Although the public healthcare sector has made strides in recent past with various new initiatives and schemes to benefit the patients, there is a huge shortfall of primary healthcare centres and community health centres viz a viz the population. Healthcare IT sector can take this as an opportunity for public and private sector alike

DR. SUCHITA MARKAN Asst. General Manager in BCIL

wherein IT enabled solutions can deliver efficient services to make-up this deficit. The Indian healthcare IT market has a huge potential. It is valued currently at $1 billion and is expected to grow 1.5 times by 2020 as per NASSCOM. The rising number of healthcare institutions and the emerging need to modernize the same is contributing to the growth of healthcare IT. Today, IT is being used in most of the hospitals in work force management, patient record keeping, billing, finance, administration and pharmacies. In large corporate hospitals, IT is being used in telemedicine (in some cases), hospital management information system, electronic medical record keeping etc. Next wave of IT adoption in healthcare sector will include data management by cloud computing, wireless technologies, BIG data, teleradiology, picture archiving and communication systems(PACS), real time monitoring systems etc. Adoption of IT into the healthcare systems can have several advantages including the following: ◗ The quality of service can go up and hospitals can turn more efficient in terms of reach and delivery of service. ◗ Integrated electronic medical records facilitate quality research as data is made available in structured manner which helps in studying trends and identifying disease outbreaks etc. ◗ By means of creation of electronic patient record, each patient’s blood group, reports of investigations etc. would be documented and available which prevents manual errors.

IT@HEALTHCARE ◗ IT also facilitates remote diagnosis of patients through data exchange/telemedicine. As a result, people in rural areas can also have access to consultation from speciality doctors. ◗ It can also enable Customer Relationship Management (CRM) as this is a very important facet for specialty hospitals and chain hospitals, in terms of patient loyalty. ◗ IT also helps patients move seamlessly across different geographical locations. ◗ IT provides the flexibility to procurement and billing. ◗ IT also provides accounting framework and therefore help with entire billing, inventory management, store management, laboratory management, etc. ◗ By virtue of streamlined processes and efficient management, hospitals will also experience better return of investments made by them. Recognising the immense potential and importance of e-Health or IT in healthcare, Government of India has also launched various initiatives in this sector. An important landmark in the healthcare sector in the country is formal release of National Health Policy 2017. The Policy has been recognised as a historic milestone in the Indian healthcare sector as it has been finalised after lot of deliberations and brainstorming, fifteen years after the issuance of earlier policy in 2002. It demonstrates the endeavour of Government to create a healthy India where everyone has access to quality healthcare and the policy specifically mentions about commitment of government towards settingup digital health technology ecosystem in the country. Recognising the integral role of technology (eHealth, mHealth, Cloud, Internet of things, wearables, etc) in the healthcare delivery, a National Digital Health Authority (NDHA) will be set up to regulate, develop and deploy digital health across the continuum of care. The policy advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system. The

policy aims at an integrated health information system which serves the needs of all stake-holders and improves efficiency, transparency, and citizen experience. Delivery of better health outcomes in terms of access, quality, affordability, lowering of disease burden and efficient monitoring of health entitlements to citizens, is the goal. Establishing federated national health information architecture, to roll-out and link systems across public and private health providers at State and national levels consistent with Metadata and Data Standards (MDDS) & Electronic Health Record (EHR) will be supported by this policy. The policy suggests exploring the use of ‘Aadhaar’ (Unique ID) for identification. Creation of registries (i.e. patients, providers, services, diseases, documents and events) for enhanced public health/big data analytics, creation of health information exchange platforms and national health information network, use of National Optical Fibre Network and use of smartphones/ tablets for capturing real time data are key strategies of the National Health Information Architecture. The policy advocates scaling of various initiatives in the area of tele-consultation which will entail linking tertiary care institutions (medical colleges) to district and subdistrict hospitals which provide secondary care facilities, for the purpose of specialist consultations. The policy will promote utilisation of National Knowledge Network for Tele-education, Tele-CME, Tele-consultations and access to digital library. The policy also envisages to leverage digital tools for generation and sharing of information about AYUSH services and AYUSH practitioners, for traditional community level healthcare providers and for household level preventive, promotive and curative practices. ◗ Other important initiatives in this direction include initiatives such as E-health initiative which is a part of Digital India drive launched by Prime Minister Mr Narendra Modi

in 2015 and aim at providing effective and economical healthcare services to all citizens. The programme aims to make use of technology and portals to facilitate people maintain health records and book online appointments with various departments of different hospitals using eKYC data of Aadhaar number. The broad aim of e-health is to provide effective, economical and timely healthcare services to all individuals, and especially to those people who have little access to health-

care services. An eHospital App has also been launched with an Online Registration System (ORS). This initiative allows us to skip the hassles of registration and other formalities required at hospitals. ◗ Government of West Bengal has introduced G1 Digital Dispensary which aims to provide people from rural areas access to primary healthcare services. ◗ A unique initiative for healthcare 'Sehat' (Social Endeavour for Health and Telemedicine) has been

launched at a government run Common Service Centre (CSC) to empower rural citizens by providing access to information, knowledge, skills and other services in various sectors through the intervention of digital technologies and fulfilling the vision of a ‘Digital India’. ◗ Various other e-Health initiatives which are being implemented in various states of the country include- Drug Logistics Information & Management System (DLIMS) which handles procurement,

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IT@HEALTHCARE storage and distribution of medicines, drugs, injectables, surgical goods and medical equipments, e-Aushadhi- a supply chain management application for bringing transparency in purchase, inventory management and distribution of various drugs, Birth and Death entry application system, E-Olakh, EMamta, Blood Bank management system, Beti Vadhaao, E-Mitra, Asha Soft, Pregnancy, Child Tracking and health Services Management System, Computerised Human Resource Information System (CHRIS), Hospital Information System, Mobile Kunji, M-sehat etc. to name a few.

Digital AIIMS- A laudable initiative in public healthcare sector Although the policy initiatives by the GoI will reap its noticeable results in due course of time, there have been few noticeable success stories in health IT adoption in the country which can be emulated country wide e.g. The Digital AIIMS project, with nearly 45 lakh beneficiaries, has had the highest footfalls of Digital India Projects. AIIMS has been felicitated by the Ministry of Electronics & Information Technology for reaching the milestone of India’s first fully digital public hospital. The Digital AIIMS project, implemented as part of the Digital India Initiative, has been widely termed as the First Digital Revolution in Healthcare in India. It has two components – the e-Hospital Project and the AIIMS Transformation Project. It has reduced patient wait times by six hours per visit and freed up clinicians’ OPD timings, brought transparency and streamlined patient records. Till date, its online registration has benefitted 45 lakh patients. The Aadhar-linked online registration system enables the patients to develop online OPD cards and has a linkage with Pay Gov portal for making online payments. The Prime Minister in his 2016 Independence Day address commended the Digital AIIMS project and ex-

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horted for its replication on a pan India basis. The Digital AIIMS project can benefit about 3 crore patients if successfully replicated on pan India basis and is in the process of implementation.

DocsApp: Doctor in your mobile Another interesting success story in the private sector domain is the story of two IIT Madras alumni Satish Kannan and Enbasekar D about DocsApp. DocsApp is an online specialist doctor consultation mobile app. The thought behind the entire concept is to make the healthcare industry more efficient and accessible to the commoners. Their mantra is #NoAppointment #NoTravel #NoWaiting – for doctor consultation. So no more waiting in line, or travelling long distances to meet the specialists. The doctor is just a click away. DocsApp has a lot of features that will make you want to download the app and start using it instantly. They have specialist doctors from depts such as gynaecology, dermatology, general medicine, paediatrics and psychiatry who provide consultations on DocsApp. Other advantages that this app offers include: ◗ Patients can get consultation through Chat or Call mode and also upload pictures of affected areas or medical reports. It is like Whatsapp for patients and doctors. ◗ Patients can also get diagnostic tests done at home. ◗ On DocsApp, patients can consult a doctor from the comfort of the home and receive the same quality consultation. ◗ Diagnostic tests are also arranged at home through the app and the reports get automatically uploaded into the app. Patients can save time, effort and money by consulting online. DocsApp is a huge success and it has received an amazing response till now. This app has connected patients not just in cities but from every nook and corner of India to top doctors in Bangalore, Bombay and Delhi. Currently, they have six million patients from all over the country and

a team of 1200 specialist doctors from various fields having different specialties. Apart from this, they have partnered with more than 1000 diagnostics lab centres across India to do home pick up of samples and medicine delivery in about 110 cities. Other noticeable cases include- Technologies Private Limited, a Chennai-based healthcare technology firm which has raised $ 10 million in a Series B funding from Qualcomm Ventures and Norwest Venture Partners in order to expand its digital healthcare solutions from the current 200 hospitals and laboratories to 25,000 such facilities globally. Pluss, a Gurgaon based on-demand medicine and healthcare products delivery service start-up has raised US$ 1 million in pre-Series A funding from IDG Ventures, India, M & S partners, Singa-

pore and Powerhouse Ventures, US. The company would use the funding to upgrade its technology and expand presence in five cities.

Healthcare IT- current status and way forward IT has become an integral part of healthcare service delivery, patient and operations management in tier-I cities and in private hospitals wherein it has become an integral part of process management, patient record management and hospital management information systems (MIS/HMIS). It is bringing huge efficiencies into their systems and provide necessary avenues for instant information retrieval. The Healthcare IT sector is facing its own set of challenges including issues related to initial investments, lack of in-house IT expertise,

manpower training requirements, reluctance by the staff to change management systems and lack of confidence in adoption of newer technologies etc. Although, majority of the private sector has adopted technology and IT as an integral part of their operations for efficient service delivery and there are also few success stories to cherish, however, there is a strong need to upscale IT adoption in healthcare system in India in both public and private sector alike and full integration of systems to unleash the immense potential that this sector offers. India, being the world's largest sourcing destination for the IT industry with established legacy in IT sector needs to marry healthcare sector with IT to bring about systemic changes and transform this sector into digital healthcare sector.

LIFE I N S I G H T

Leadership for nurses in India: Afuturistic perspective

ROSAMMA JOSE Head Nursing, BLK Super Speciality Hospital

Rosamma Jose, Head Nursing, BLK Super Speciality Hospital, gives insights on the evolving role of nurses in the healthcare sector and the need to boost the nursing profession in India

ursing has assumed a pivotal position in healthcare today. This profession is on the cusp of a paradigm shift. It is no more a marginal profession. However, it still occupies subliminal space and is in need of robust leadership to get a fillip and occupy centre stage in healthcare. Nurses form the backbone of patient care in the health sector. They are engaged in the treatment, safety and recovery of ill or injured people, health maintenance, and treatment of life-threatening emergencies in a wide range of healthcare settings. Nurses may also be involved in medical and nursing research and have to perform a wide range of non-clinical functions necessary for the delivery of healthcare. They develop a plan of care, in collaboration with physicians, therapists, the patient, the patient's family and other team members. So, nurses play a very crucial role in the medical system. The relation between a nurse and a doctor is similar to that of a general and a soldier. Like a soldier, the nurse has to do most of the work as they spend more time with patients. Nurses are the frontline soldiers while doctors are the generals. But sadly, in India, this important component of healthcare is in dire straits. Nurses are highly exploited, with lack of respect and dignity at workplaces. They are paid extremely low salaries without any job security. Nurses are not only responsible for their clinical function, but also adequate care for patients who deserve appropriate and safe care. They act based on the values they have been selected on. These values form a framework to evaluate

their activities, influencing their goals, strategies and function. These values can also be counted as a resource for nursesâ&#x20AC;&#x2122; conduct toward clinical ethical competency and their confrontation with contemporary ethical concerns. Values conduct human life priorities and form the world we live in. They act as one of the most basic parts of human life. Ethical values are inseparable components of the society and, as a result, of nursing profession too. Nursing is governed through the National Indian Nursing Council (INC) and State Level Nursing Councils (SNCs) The INC advises the government on nursing matters prescribes national nursing education syllabi and specifies minimum quality criteria for educational institutions. SNCs inspect and accredit training institutions, conduct examinations, monitor rules of professional conduct and maintain an active register. Trained Nurses Association of India (TNAI) was formed in the year 1908 and the INC was established in the year 1947, which thereafter upgraded the basic educational qualification requirement for candidates desiring to undergo nursing education. Women from the Christian community undertaking the nursing profession were more in number than women from other communities, since, as a profession, nursing did not have a proper status in the eyes of the society.

Great demand for nurses As the nursing profession, being entirely job-oriented, there is great demand for qualified nurses all over the India. Since many corporate hospitals are being established and many more avenues like medical

tourism, home nursing, industrial nursing etc. are available to better qualified and efficient nursing personnel, so migration of trained nurses to overseas countries, especially in the Gulf countries for higher salary and perks. It is a clear indication of increased demand for nurses. However, in reality, nursing and midwifery profession is not honored as an autonomous body in spite of the fact that they are fully developed, qualitatively and quantitatively. The services rendered by them to ailing patients do not receive proper recognition from other health professionals in the medical field and even by the society at large. They are not accepted as leaders or administrators in their own fields without assigning any justifiable reason for such lack of recognition for the nursing profession.

Challenges to growth The absence of direct links between the education sector and employment in the domestic sector is a major problem. The nurse who completes the course expects to be employed in India, but often finds herself underpaid and faced with poor working conditions. This gap between nursing education and employment is a conse-

quence of poor planning. For decades, nurses from India, especially from states like Kerala, have been going off to foreign countries. The demand from nursing aspirants reportedly began in mid-2000. Nurses report misconceptions about job availability in India and abroad as one reason for their career choice. Nursing aspirants believed that the developed countries would experience a shortage and recruit nurses from India. According to recent statistics, the total number of nurses available in India is 1,431,000 (+4.3 per cent) while nearly 30 lakh-qualified nurses are required in India. Compared to global standards there is huge gap between Indian and foreign nurses. Nursing education is at the crossroads in India. There has been a growth in the number of institutions of nursing education, but it has been unevenly distributed across regions. States where institutions have mushroomed need stricter monitoring mechanisms because the quality of training is often questioned. There is a lack of good quality nursing teaching faculties. Regularisation and standardisation remain the greatest challenge for Indian nursing. Social and administrative responses to the nursing sector have varied across India. The sector will continue to grow, and in order to get the best results out of the system, regulatory bodies should function for the advancement of nursing education and the nursing profession. The WHO defines health promotion as a process of enabling people to increase control over and to improve their health (WHO, 1986). To facilitate that process, we must

provide people with appropriate information. Nurses have a key role in providing that information in the form of health teaching. Nurses are highly educated, experienced health professionals who are accessible through many settings. Telehealth Ontario is a great example of how anyone can access the expertise of a nurse. Anyone can call in with a question, concern or health issue and gain information while being advised of a plan of action right over the phone. Of course, without being able to use hands-on assessment skills, this can be limiting when it comes to dealing with an acute scenario. Telehealth is not for resolving situations that require immediate attention. Nurses can direct people to local resources and give out health and wellness information. It would be useful when parents seek well-baby/well child information, information on vaccines, smoking cessation, addiction counseling, adolescent mental health resources, nutrition information etc. These are examples of situations where access to accurate health information can assist people in staying healthy. A degree in nursing does guarantee a job, considering that the nurse-patient ratio in our country is still very poor, but one needs to acquire handson skills. They can be acquired by working in a good hospital for atleast three to five years. This is how one can become an efficient nurse and progress in life. Also, a huge gap exists between theory and practice when it comes to the curriculum of nursing colleges. A lot needs to improve. Nurses have to go through rigorous on-the-job training and put in more effort to unlearn traditional practices.

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LIFE BOOK REVIEW

The Act That Wasn't Dr Bobby George critiques both the lawmakers and law breakers in his book, The Act That Wasn't and manages to deliver on his promise of being 'an insider's view on healthcare laws, loopholes and reforms. By Viveka Roychowdhury

ith an intriguing title like The Act that Wasnâ&#x20AC;&#x2122;t, author Dr Bobby Georgeâ&#x20AC;&#x2122;s book is sure to hook anyone who is researching the legal framework prevalent in India. Focusing on legislative measures impacting the healthcare and pharma sectors, the author also lays out the loopholes along with suggested reforms. As Vice President & Head Regulatory Affairs, Reliance Life Sciences, the author has spoken on these topics at various fora and has published in quite few journals. This book adds to his already sizable work on this subject and manages to delivers on its promise of being 'an insider's view on healthcare laws, loopholes and reforms'. Published in March this year, with a foreword by Justice KT Thomas, former Judge of the Supreme Court of India, and testimonials from Dr Eswara Reddy, Joint Drugs Controller of India and Dr YK Gupta, Prof & Head, Department of Pharmacology, AIIMS, New Delhi, the book comes highly recommended by some of the doyens who have been involved with shaping the very laws and their implementation that George critiques in his book. As Dr Gupta points out, the author describes the background and details of the Acts (laws) put in place, as well as reviews the acts (wrong deeds) of the industry. He also details how regulators have engaged with stakeholders while formulating these policies and regulations. Priced at around ` 400 and accessible on e-commerce sites, the slim volume consists of 12

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chapters, each focusing on key legislation ranging from the Clinical Establishment Act to fixed dose combination drugs and biosimilars. It also analyses laws regulating referrals, surrogacy, organ transplants, etc. While analysing the nuances of the Acts, the book also details the unsavoury practices that the laws seek to control. For instance, in the fourth chapter titled Blood Borne Acts, the author starts with the technicalities of blood banking and transfusion, then goes on to detail the menace of unlicensed blood banks, the shortage and wastage of blood products even as there is rampant 'trading in blood/components/plasma' and overpricing. George ends each chapter with recommendations to government on how the laws can be strengthened as well as some advice to industry stakeholders. The common refrain, not very different from other writers on this subject, is that while the laws are in place, their implementation lacks sustained and systematic vigour. But this is a book that will hopefully trigger renewed effort from both regulators and industry to meet on the same page and protect the interests of the patient. The author's exhaustive analysis of global laws, juxtaposed with the scenario in India, will prove to be invaluable to both industry professionals tasked with compliance within their organisations. It will also serve as a research guide for health policy researchers as well as students hoping to make a career for themselves in this vital yet much abused sector. viveka.r@expressindia.com.

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DiaSys Diagnostics India Pvt. Ltd. Plot No. A -821, TTC, MIDC, Mahape, Navi-Mumbai - 400 710. Maharashtra, INDIA. Toll Free number : 1800 120 1447 | Email ID : info@diasys.in | www.diasys.in

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E mail: sales@hemantsurgical.com, info@hemantsurgical.com

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TRADE AND TRENDS

Carestream receives best radiology company of the year award According to Sushant Kinra, MD, Carestream Health India, with this honour, the company will strive to provide superior products and services to the clients AT THE 7th Elets Healthcare Leaders Forum held recently, Carestream Health India, the worldwide provider of medical imaging systems received an award for the best radiology company of the year. Organised by Elets Technomedia, the forum honours some of the best healthcare initiatives and organisations that work towards making quality health services more affordable, accessible and inclusive. K Rajeswar Rao, Joint Secretary, Health and Family Welfare, Government of India, presented the award to Carestream at a recently held function in New Delhi. Carestream India is a global leader in medical imag-

ing and is known for introducing innovation in the industry. The company is renowned for its extraordinary customer service and its ability to leverage people, processes and tools to provide world class service to its customers with a range of products and solutions that are best fit to serve the Indian market. “We are honoured to receive this award and sincerely believe that it would not have been possible without the support of our customers. We are passionately committed to doing whatever it takes to help our customers be successful and this award amidst a prestigious list of nominations only seconds our faith in ourselves.

HEAD OFFICE Express Healthcare® MUMBAI Douglas Menezes The Indian Express (P) Ltd. Business Publication Division 2nd Floor, Express Tower, Nariman Point Mumbai- 400 021 Board line: 022- 67440000 Ext. 502 Mobile: +91 9821580403 Email Id: douglas.menezes@expressindia.com

Mobile: 91-9810843239 Fax: 0120-4367933 Email id: gaurav.sobti@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.

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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,

With this honour, we would always strive to provide superior products and services to our clients, said Sushant Kinra, MD, Carestream Health India. The Elets Healthcare Leaders Forum is a premium platform that brings together the government, elite hospitals, diagnostic centres, medical equipment manufacturers, pharmaceutical companies and related organisations under one roof. The forum offers top healthcare professionals, agencies and consultants a conducive environment for recognising and rewarding excellence. Contact details www.carestream.in

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 KOLKATA Ajanta Sengupta

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

TRADE AND TRENDS

Lindstrom India launches its 11th production unit The unit in Visakhapatnam will cater to pharmaceutical, food processing etc LINDSTRÖM INDIA, subsidiary of Lindström Group headquartered in Finland and India’s leading workwear service company, is celebrating 10 years of operations in India as it launched its 11th production unit in the country. Nina Vaskunlahti, Ambassador of Finland to India inaugurated Lindstrom India’s newest production unit in Visakhapatnam. The new production unit will cater to the pharmaceutical, food processing, retail, automotive and engineering, seafood processing, electronics industries in Visakhapatnam. Anupam Chakrabarty, MD, Lindstrom India, said, “We see a huge potential in Visakhapatnam with its flourishing business environment and believe our professional

sador of Finland to India, “Lindstrom India has completed 10 glorious years in India and we believe it will add value to its customers in Visakhapatnam, as it has in other areas in India.” Established in 2007, Lindstrom India provides a reliable, flexible, carefree and economic way for companies to look after their workwear, releasing time and resources for core business. With its workwear services Lindstrom ensures that clean workwear is delivered to employees’ lockers at its customers’ premises in a timely and efficient manner.

and organised workwear services are best suited to compa-

nies aligned with international standards, creating

world class products.” Nina Vaskunlahti, Ambas-

Contact details www.lindstrongroup.com www.lindstromgroup.com/in

SCHILLER launches DIAGNOSTIC STATION DS20 In addition to physician offices, retirement homes, hospitals and clinics, the DS20 is a useful tool for routine check-ups in occupational medicine

SCHILLER’s DS20 is self-explanatory and very little training is needed. The large interactive touch screen supports the highest user-friendliness.

SCHILLER HAS launched DIAGNOSTIC STATION DS20, the most comprehensive diagnostic station with unique features: resting ECG, PWA, and Spirometry. It is designed for spot measurements and routine check-ups of non-critical patients. In addition to physician offices, retirement homes, hospitals and clinics, the DS20 is a useful tool for routine checkups in occupational medicine. DS20 enables physicians to perform tasks in five minutes with one device which may otherwise take 20 minutes with multiple devices. It is an ideal tool for patient induction process in a hospital, as the patient’s vital parameters are quickly checked on a single platform and the data can be automatically transferred and stored to the hospital information system

One touch to the measurement

through HL7 protocols. One of its important features, the advanced Pulse Wave Analysis (PWA) helps in easier understanding of hemodynamic and the process of arterial aging within minutes with graphical indication, which is useful in screening patients for early evidence of vascular disease and monitoring the response to the therapy given.

Simply touch the large, high-resolution colour display and you are in the business recording, and selecting the highest quality ECGs. ◗ Perform ◗ Review ◗ Store or export wherever you want

Connected DS20 simplifies daily work ◗ Main vital signs and physical assessment tools united in one device ◗ Ideal for arrhythmia and atrial fibrillation screening: one resting rhythm channel for display, storage and printing with three electrodes ◗ Large, interactive touch screen ◗ Intuitive guidance and ease of use

Fast and easy to use The DS20 immediately detects connected sensors and automatically displays the corresponding value. This fast operation allows for easy addition or removal of parameters. Thanks to its intuitive user guidance

The DIAGNOSTIC STATION DS20 is a networked device. Seamless connectivity to EMR, PACS, HIS or SCHILLER’s SEMA3 Cardiology Information System is possible and bidirectional communication allows for easy data access, while Wi-Fi with strong security enables direct and fast transmission.

Expandable Easily add new functions and other devices or future technological developments. The DS20 is ready for the most common functions and will satisfy new requirements. ◗ DS20 on trolley - easy transport between rooms ◗ DS20 on wall mount - saves space ◗ One-time patient data entry saves time and reduces data errors ◗ Large display (18.5”) - all information at a glance, no submenus ◗ Touchscreen and intuitive icons - one touch to measurement ◗ Interface to scales - automatic weight, height and BMI measurements Contact details V Balakrishnan Phone:022 61523333 Email: bala@schillerindia.com/ media@schillerindia.com Website: www.schillerindia.com

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TRADE AND TRENDS

Growing need of fully automated systems Sachin Singh, Head Strategic and Operational Marketing, DiaSys Diagnostics India, elaborates more on the need to make dedicated investments in terms of sophisticated analytical technologies, skilled human resources, equipment and reagents LABORATORIES DESIGNED for processing specimens have specialised machinery designed to measure different chemicals in a number of biological samples and tests. The first biochemistry analysers were mainly used for routine repetitive analyses. Over the years, they have been replaced by discrete working systems, which use lower reagent consumption. These new instruments automate repetitive sample analysis steps which would otherwise have been done manually by a technician. In vitro diagnostics market has showcased several emerging trends over the past few years. Some of the most definitive trends have been the advent of decentralised testing, mounting automation in laboratories, increasing consolidation, and preference for early detection of diseases. Several pathological labs have resorted to invest heftily and have been adopting fully automated systems for diseases diagnosis. In light of this, the accuracy of test results has increased, while the turnaround times have been re-

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duced significantly. Automating the process used in biological samples is extremely advantageous especially in high throughput laboratories. In general, automation improves throughput, decreases error within and between tests, and generates a report of the steps performed. As todayâ&#x20AC;&#x2122;s assays require smaller and smaller volumes, doctors require accuracy and CV data to be available for an increasing number of tests. Nowadays, the aim is to give a fast and reliable result with minimal human assistance. These new technologies have enabled a better understanding of disease processes. The introduction of userfriendly automated devices has minimised human effort and increased the efficiency of diagnostic procedures. Automated instruments are expanding system capabilities and introducing technological advancements to provide comprehensive testing solutions that facilitate efficient, accurate and streamlined laboratory procedures. The factors contributing to the growth of automated instruments and

SACHIN SINGH Head Strategic and Operational Marketing, DiaSys Diagnostics India

reagents market in India include the consolidation of diagnostic laboratory chains, major hospitals and laboratory chains opening new centres in Tier-II and Tier-III cities, increasing government/private sector expenditure in healthcare, public awareness, and affordability. Laboratory management in India is a super-specialised arena. The need of the hour is to make dedicated investments in terms of sophisticated analytical technologies, skilled human resources, equipment and

reagents; comply with stringent accreditation guidelines; and provide excellent customer service such as exhaustive test menu, along with short and accurate reporting times. In order to overcome these challenges, the market is moving toward automated systems. Upgrading the laboratories to totally computerised fully automated systems has made a big difference in the bottom lines of many laboratories, by cutting down the cost of consumables and less requirement of qualified and trained technicians. These factors have prompted lab managers to go in for automation. Customers are placing a lot of weightage on the quality of service backup they receive. The emphasis is on getting complete solutions from a single company. High-end laboratories opt for automated integrated systems. Developments of software programmes have also allowed the integration of various workflows of biochemistry analysers for better control and operational efficiency One of the major factors driving the growth of the market is the advancement in

technology. The increase in automation of biochemistry instruments is the key advancement in technology for high-throughput analyses of biochemical entities. Highthroughput analyses consume less time and generate results quickly. The use of automation in clinical labs has progressed significantly, from the first random-access analyser to total lab automation (TLA). Laboratories now desire complete solutions from a single provider, like closed system reagents with calibrators and controls, and viable software. Additionally, the fully automated analysers market is moving toward testing consolidation, which is creating demand for integrated systems with expanded capabilities, thereby securing the future of next-generation laboratory analysers. Given the trends being observed among biochemistry labs today, automation will play an even larger role in the future, going beyond operational effectiveness to also positively impact clinical effectiveness and ultimately help improve patient outcomes.

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