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

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CONTENTS Vol 11. No 11, November, 2017

AGAINSTALL ODDS

Chairman of the Board Viveck Goenka Sr Vice President-BPD Neil Viegas Editor Viveka Roychowdhury* Chief of Product Harit Mohanty BUREAUS Mumbai Usha Sharma, Raelene Kambli, Lakshmipriya Nair, Sanjiv Das, Mansha Gagneja Swati Rana Delhi Prathiba Raju Design National Design Editor Bivash Barua Asst. Art Director Pravin Temble Chief Designer Prasad Tate Senior Designer Rekha Bisht

Improved hospital infrastructure,attractive incentives to doctors and paramedics are propelling health parameters in Chhattisgarh’s Bijapur district | P-18

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POLICY WATCH

IT@HEALTH

Graphics Designer Gauri Deorukhkar Artists Rakesh Sharma Photo Editor Sandeep Patil

MARKETING Regional Heads Prabhas Jha - North Harit Mohanty - West Kailash Purohit – South Debnarayan Dutta - East

THE PARTNERSHIP WITH HITES IS BRINGING TRUE TRANSFORMATION

Marketing Team Ajanta Sengupta, Ambuj Kumar, Douglas Menezes, E.Mujahid, Nirav Mistry, Rajesh Bhatkal, Sunil Kumar PRODUCTION General Manager BR Tipnis Manager Bhadresh Valia Scheduling & Coordination Santosh Lokare

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‘PFIZER IS A STRONG SUPPORTER OF INCREASING AWARENESS ON VALUE OF INNOVATION’

OUR VISION WITH MEITRA HOSPITAL IS TO CREATE A GLOBALLY RECOGNISED HEALTHCARE DELIVERY SYSTEM

‘DELHI GOVT’S THREE-TIER HEALTHCARE SYSTEM WILL ENHANCE PUBLIC HEALTH’

STRATEGY

FOURTH EDITION OF HEAL HELD IN KERALA

‘WE NEED DIGITAL APPROACH, DATA INTELLIGENCE AND PATIENT-CENTRIC CULTURE’

THIS DAYTHIS MONTH

SUGAR, PART WITH SUGAR!

TACKLING MALNUTRITION IN INDIA

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

CIRCULATION Circulation Team Mohan Varadkar

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.

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LETTERS

OCTOBER 2017

Check out the online version of our magazine at

www.expresshealthcare.in

HEAD OFFICE Express Healthcare® MUMBAI Douglas Menezes The Indian Express (P) Ltd. Business Publication Division 2nd Floor, Express Tower, Nariman Point, Mumbai- 400 021 Board line: 022- 67440000 Ext. 502 Mobile: +91 9821580403 Email Id: douglas.menezes@expressindia.com Branch Offices NEW DELHI Sunil Kumar The Indian Express (P) Ltd. Business Publication Division Express Building, B-1/B Sector 10 Noida 201 301 Dist.Gautam Budh nagar (U.P.) India. Board line: 0120-6651500. Mobile: 91-9810718050

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“It is easier and cost-effective to bring in healthy behaviours early, rather than changing at a later stage and spending more on healthcare costs”

“The government is in the process of putting in place dedicated, preventive and promotive strategies in schools to make India anaemia-free”

Manoj Jhalani

Preeti Sudan

Additional Secretary and Mission Director, National Health Mission (NHM)

Secretary, Ministry of Health and Family Welfare was speaking at the 11th World Congress on Adolescent Health

was speaking at the plenary session on the first day of the 11th World Congress on Adolescent Health

Fax: 0120-4367933 Email id: sunilkumar@expressindia.com CHENNAI Kailash Purohit 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 9552537922 Email id: kailash.purohit@expressindia.com BENGALURU Kailash Purohit The Indian Express (P) Ltd. Business Publication Division 502, 5th Floor, Devatha Plaza,

Residency road, Bangalore- 560025 Board line: 080- 49681100 Fax: 080- 22231925 Mobile: +91 9552537922 Email id: kailash.purohit@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 The Indian Express (P) Ltd.

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EDITOR’S NOTE

War of words on medtech pricing

hen Commerce and Industry Minister Suresh Prabhu met US Trade Representative Robert Lighthizer for the 11th round of the US-India Trade Policy Forum (TPF) in late October, he did well to stand firm on the issue of market access to medical technology products. As this was the first formal interaction between the trade authorities of the two countries after the Trump administration came to power, it was a particularly significant meeting. The minister reportedly did take note of the US' concern on price caps on medical devices like stents and knee implants but pointed out that public health is a priority issue for the Indian government and they “would have to balance between the commercial interest and the larger public interest.” He also left some room for negotiation, mentioning that a review is due early next year, during which concerns of the US would be relayed back to the reviewers. He threw the ball back into his counterpart's court by reportedly encouraging US companies to take benefit of the “Make in India” policy and establish manufacturing facilities in India which would considerably bring down the cost of the medical devices. He used the same strategy, suggesting a win-win policy framework, when he argued that if the US tightened the norms to issue H-1B and L1 visas, targeting IT professionals from India and other countries, in order to protect US workers, the reality was that this would ultimately hurt the interests of the US. He reminded Lighthizer that the US economy had reaped the benefits of the work of these IT professionals as it had improved productivity. In an effort to remind the US trade forum that India represented a huge market for US products and services, the minister also referred to orders for over 300 aircraft worth “several billions” by Spicejet and Jet Airways. But, midst the diplomatese between Indian and US governments, is patient interest still the topmost priority? The medical device pricing strategy is turning out to be one of the more stringent reforms of the current administration. To further muddy the waters, this is a policy that Prime Minister Modi himself has championed and any wavering on this issue could impact his

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In the recent war of words between the US and India trade authorities,India managed to stand firm. But midst the diplomatese between Indian and US governments, is patient interest still the topmost priority?

run for a second term. So we can expect the chorus for withdrawing or tempering price controls on medical devices to subside before it reaches a crescendo once again, just before the review early next year. Price control on medicines has already reached unprecedented levels, feel industry lobby groups. Starting with price caps on drug-eluting and bare-metal stents in February this year and following up with certain knee implants in August, the medtech fraternity is worried that more bad news will follow. Soon after the price caps on knee implants, Advanced Medical Technology Association (AdvaMed), an association representing the interests of global medtech companies, put out a statement that 'Price Control' is a blunt instrument and stress on affordability ignores the other two As, awareness and accessibility, required for "effective, appropriate and sustainable delivery of quality healthcare." Unhappy with the lack of action, it was AdvaMed members who approached the US TR to intervene and demand partial, full suspension or withdraw all India’s benefits under the Generalized System of Preferences (GSP). Along expected lines, the Association of Indian Medical Device Industry (AiMeD) countered this stance, saying that the price cap on medical devices such as knee implants and heart stents is helping the domestic medical device market grow manifold. The All India Drug Action Network (AIDAN) has drawn parallels with what it calls the 'bullying tactics of the US-based medical device industry' to the opposition to compulsory licenses on patent-protected cancer medicines by MNC pharma companies. Besides manufacturers' margins, the government is also cracking down on trade margins and costs levied by hospitals and surgeons, so the former cannot claim to be singled out. This is surely not the last we have heard on this sore point. It is a game of wait-and-watch for now. Rather than choosing sides, it would be best if all stakeholders choose patient interest as the uppermost priority.

VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com

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The partnership with HITES is bringing true transformation Reportedly one of the biggest service providers for healthcare in the US, the Sodexo Group already has a leadership position in India’s healthcare sector. On a recent visit to the country, Stuart Winters, CEO Healthcare – Asia Pacific, Sodexo Services Asia gave Viveka Roychowdhury an overview of Sodexo's healthcare business globally while Sambit Kumar Sahu, Director – Healthcare India, Sodexo On-Site Service Solution spoke about their plans to add value to public health facilities through their year old partnership with HLL Infra Tech Services Limited (HITES) How big is Sodexo's healthcare business globally? Stuart Winters: Sodexo’s healthcare business turnover globally is just under ¤ 5 billion per year. While Sodexo operates today in 80 countries, within healthcare, we operate in 38 of these 80 countries. From a labour and talent point of view, we've got just under 80,000 employees who work for us in the healthcare segment and around 6400 on the consumer side at individual sites around the world. Sambit Kumar Sahu: From an India point of view, Sodexo Healthcare’s journey in the country started around 1998. Today, we have a leadership position in India when it comes to on site solutions that we provide to the healthcare space both in the government and the private sector. We are at 45 locations spread across India. Some clients in India include AIIMS, Delhi and JIPMER. And in the private sector, Sodexo Healthcare is spread across all the brands like Apollo Group, Fortis, Manipal, Max, apart of course from the very old contracts we have with hospitals like Lilavati Hospital, Mumbai. Our services offered to the healthcare segment look after various needs of patients, visitors and hospital staff. These include management of food services, laundry services, front office management, housekeeping, patient care. We

Stuart Winters, CEO Healthcare – Asia Pacific, Sodexo Services Asia

Sambit Kumar Sahu, Director – Healthcare India, Sodexo

also manage the technical support services related to engineering. We are also venturing into the clinical technology management services which is biomedical equipment maintenance as well as infection control. Sodexo self manages these services with its own office, whether its people, process or SOPs. There are different commercial models that we have for our hospital clients.

maintenance practices in this space. Sahu: We realised that being in the leadership position in this space, there is a clear requirement with respect to patient safety when it comes to the government sector. This is a pain area, not just from a procurement point of view but post procurement. Whether it is an ambulance, CT, MRI, etc, there are enough funds being spent by the government or a health organisation but what is really very appalling is that this equipment is not being used. Either people do not know how to use it or a minor fault in the equipment leads it to being not prepared on time and finally the patient has to do without it. Today, there is a willingness in the government to outsource these services. They have realised that they themselves cannot manage it. And all these services, whether it is food

Could you give more details of your association with HLL Infra Tech Services Limited (HITES) to provide integrated facility management in public hospitals. The Gorakhpur tragedy when many babies lost their lives due to poor management clearly shows that there are many gaps when it comes to procurement and equipment

services to start with, or clinical technology management, everything has to be outsourced. That is the mandate of the government today and we are seeing this happen in the last couple of years. And Sodexo does not want to miss this opportunity because we have the right solutions, global know how, technology, and talent within the country and the region. So we are in the right position to leverage this and get those solutions here. We did not have very many government hospitals to start with. But we realised that there was an absolute synergy between HLL Infra Tech Services Limited (HITES), which is part of a Government of India enterprise under Ministry of Health & Family Welfare, and Sodexo Healthcare. They have their strengths, in terms of procurement as they are the largest procurer of biomedical and other equipment. They build hospitals and then continue to manage it or hand it over to be managed. Our due diligence showed we had synergies with HITES in the central government space. We identified value added services like clinical technology management, maintenance of biomedical equipment, laundry services, environmental services, housekeeping and patient care. These are three-four key focus areas which we are working on

together. Based on this, we signed an MoU last year. Winters: In this context, it’s important to note that today, partnerships in business are becoming increasingly important. And we see the value of these strategic partnerships all over the world. It’s about bringing the best of two, three and sometimes even four organisations together to bring a service to a client. And not restricting your ability to deliver or service a client just because you may not have that skill in-house. That’s where the partnership with HITES is bringing true transformation in the way we deliver services. One of your main clients in the public health space is AIIMS Delhi. What were the pain points, how did Sodexo Healthcare address them and what are the outcomes of your services? Sahu: At AIIMS Delhi, we started mechanised cleaning for the whole campus of around 200 acres in December 2016. HITES and Soxedo realised that the pain point was productivity of output of the cleaning services. The facility was not well maintained, there was no training of the resources which was resulting in a poor image for a premier institution like AIIMS Delhi. HITES and Sodexo's solution was to mechanise the cleaning process rather than continue with the prevailing manual cleaning method, which is

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generally used at most hospitals. We brought in stateof the-art equipment, mechanised the whole cleaning processes, got our SOPs into place. Within three months, we could see the campus turning around in terms of cleanliness of the premises of the campus. In fact, AIIMS Delhi got an award for cleanliness of the campus, which is a true recognition of the value of our services. But it doesnâ&#x20AC;&#x2122;t stop there. Maintenance of biomedical equipment, infection control protocol and management, especially in the critical areas like operation theaters and ICUs remain the key pain points. This is where Sodexo can leverage its expertise. Today, we manage six JCIaccredited hospitals and 20 NABH accredited hospitals in the country. So, we have adapted these offerings from global to Indian requirements. We are in a position to further refine and adapt these offerings for Central Government hospitals so that they can work towards accreditation as well. Winters: For us, it is about looking at it from a risk perspective especially when it comes to hospital acquired infections (HAIs), and focussing on the tools, SOPs, training, follow up ordered and as an outcome, the analytics. Anything that we deliver to the marketplace needs to have analytics behind it so that we can prove it. I want to make sure that Sodexo is known for having the best services in the market with the data and analytics to back it up. What are the other futuristic and innovative technologies that Sodexo has implemented globally and in India? Sahu: In the healthcare sector, we are an integrated facility management service provider. So any non-core activity which can be outsourced is outsourced to us and they look at Sodexo as a solution. Whether it food, laundry or patient care services across departments, it has to be seamless and integrated. Only when its integrated, will you be

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able to drive productivity, manage costs and deliver patient satisfaction to the level that you want. For this, obviously you need the right technology and tools. Sodexo has these solutions to manage the complex healthcare sector. How cost effective are these solutions? Winters: For me, it doesn't come at an extra cost. It comes as an understanding of the way services should be delivered. I look after all of Asia Pacific and I've seen pockets where the traditionalists in service delivery just cannot change their mindsets. Its a labour driven market, so its easy to get 300 cleaners, and as long as each of them has a mop and a bucket in their hands, they are satisfied. I think the world is changing. Productivity improvement is playing a very big part. Labour is becoming very difficult to acquire, train and incentivise. So the use of technology to improve labour productivity is key. So we don't talk about it as being a cost to the business but as a differentiated approach to the market, a differentiated service offering with improved outcomes. And that needs to be key. We cannot continue to talk about improvements, cost efficiencies without also talking about the improvements that new systems bring. So its a balanced approach. And governments are getting there. They are understanding the importance of productivity using technology. A cost addition in one part of the hospital could bring savings in another. So look at the total cost of operating rather than just at individual services. Could you give an example? Sahu: The biggest pain point in the healthcare sector in terms of talent management is in nursing. Hospitals report a 4050 per cent attrition level of nurses, who are very skilled staff. But if you actually break down the tasks of a nurse in India, 50 per cent of the job is non-clinical. Almost 40 per

cent of these tasks can be taken care of by patient care attendants. Sodexo trains, certifies and puts n place these patient care attendants, helping nurses to focus solely on core clinical care. This also indirectly impacts infection control because nurses are not involved in non-clinical work and Sodexo ensures that the attendants too are trained in infection control protocols. Similarly, when it comes to biomedical care maintenance. Again, this is a very specialised job, where the equipment needs to be disinfected and managed well, whether it is clinical or non-clinical equipment like quality of air, service availability of HVACs, ater supply, etc. Both, if not managed well, will increase chances of HAIs. This is again where technology comes in. Sodexo has a computerised maintenance management system. As opposed to being manually operated, this is a systems-driven process, whether it preventive or reactive maintenance. This ensures that we reduce breakdowns in the service availability of the equipment which will again reduce HAIs. Winters: A lot of people don't understand that most mistakes with medical equipment come from lack of training. We see Sodexo as a key to deliver the ongoing training, to both nurses and doctors in how to use equipment. It is amazing the value and volume of equipment that is no longer in service and put into storage in hospitals for no other reason than nobody knows how to use it properly. Incorrect use of equipment is where a lot of mistakes come in with consumer care too. This is the huge value proposition that Sodexo offers as a service provider to a range of equipment. We can provide the training and advice on how to use it to our customers and consumers. As per the fiscal 2015 figures, which is before the re organisation took place, 41 per cent of Sodexo's revenues came from North America, 31 per cent from Europe, 10 per

cent from the UK and 18 per cent from the RoW. Is there any change in this geographical distribution? And in terms of activitybased revenues, on site services was 96 per cent, where healthcare accounted for 18 per cent. Any changes? Winters: Healthcare still accounts for around 18-20 per cent of global revenues. We don't measure our revenues by geographies any more. We segmented our businesses in 2015 so that we could have an absolute focus on our clients. So we created the healthcare senior segment, corporate, education, government and agencies, justice. So, we look at segment-wise global revenues. Sodexo's healthcare business turnover globally accounts for under Â¤ 5 billion per year. How much of this Â¤ 5 billion turnover would be from Sodexo India's healthcare business? Sahu: The last five years, post segmentation in 2012, has been good for us in India. We've almost doubled our revenue, tripled our profits. The opportunity for the next 10 years is huge. Winters: That's true. The entire Asia Pacific region that I am responsible for has massive opportunities. South East Asia, India, China, has a growth potential. The adoption of new services will come at different rates and speeds. We're on a journey and it has been very successful so far. We see a large adaptation of global services especially around CSSD, biomedical engineering, and environmental services with HAIs. We see a very high level of interest in these areas in the India market. What is the focus for fiscal 2017? Would you expect the same growth rates for India going forward? Sahu: We are not going to be satisfied with the growth rate of the last five years. We are going to double it. Especially because we are entering the new space of public health facilities. The opening up to (the idea of) outsourcing opens up a huge opportunity for us.

There is a lot of consolidation in the private healthcare space and they are looking for mature players like Sodexo where we can add a lot of value. The balance sheets of a lot of corporate hospitals in India are showing some stress, partly because they have taken on debt to expand and also because its always difficult to grow on a high base. How does this impact your growth potential? Sahu: I see this as an opportunity to drive efficiencies for all services. Winters: I think growth will come naturally and organically because the market is so big, it is looking for the cost savings, international methodologies, standarisation of services. So we need to remain focussed on successful roll out and adaptation of services because that will bring growth automatically. There are many new AIIMS coming up across the country. Are you involved with these new projects as well? Sahu: We are in touch with multiple AIIMS. The solutions that they are looking for are at the design stage. Which is very good because if they don't design the facility correctly then that could create future problems. HITES is in charge of building the infrastructure, which is why our association with HITES is so crucial key. We get involved at the designing stage and design it right. Winters: We bring the whole life cycle costing opportunity to the table. Constructing a hospital is one only part of the cost. Having a 20 year vision, of what it costs to maintain, how a hospital should be set up, what material should be used, etc is also important. Year two to year 20 could be significantly more costly than building a hospital if you don't get the design right. That's where we see that we could play an integral part of the front end and through the journey of the life cycle. viveka.r@expressindia.com

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‘Pfizer is a strong supporter of increasing awareness on value of innovation’ S Sridhar, MD, Pfizer, elaborates on Pfizer-IIT Delhi Innovation and IP Program, which provides a platform for innovators seeking to solve identified healthcare challenges by creating indigenous healthcare solutions, in an interaction with Prathiba Raju How does this incubation programme work and what kind of a platform does Pfizer provide for innovators seeking comprehensive support to translate their healthcare ideas into patent? The Pfizer-IIT Delhi Innovation and IP Program is a collaborative incubation accelerator, co-created by Pfizer India and Foundation for Innovation and Technology Transfer (FITT) at the IIT (Indian Institute of Technology), Delhi. Aligned to the government’s vision of Startup India, Stand up India initiative, the programme provides a platform for innovators seeking to solve identified healthcare challenges by creating indigenous healthcare solutions. The comprehensive support for the innovators provided by the Pfizer-IIT Delhi Innovation and IP Program include: For innovators ◗ Resident incubation at IIT Delhi’s bio-incubator for a period of up to two years ◗ Unencumbered funding of up to ` 50 lakhs for each innovator to take ideas through proof of concept to IP ◗ Mentoring support from IIT Delhi’s faculty and FITT nominated experts ◗ Access to infrastructure, prototyping laboratories and space for setting up an office ◗ IP search and filing services ◗ Guidance from Pfizer’s global experts ◗ Access to venture capitalists and other industry linkages For innovators who already have a proof of principle/concept and are only looking for IP related

support, the programme provides: ◗ Access to IP counseling services at FITT ◗ Funding support to cover patenting expenses Can you share few examples of the novel innovative healthcare, pharma solutions, which have already received patent via this programme? The Pfizer – IIT Delhi Innovation and IP programme is an incubation accelerator to bring healthcare ideas to life. It will support individuals and startups with resident incubation and funding through Idea to IP. The first year winners that were selected under the programme are currently in the patent filing stage. Why partnership with IIT Delhi, how does it help the programme? Will it be expanded to other IIT's as well? IIT Delhi is one of the premier institutes of the country where the spirit of entrepreneurship and innovation is encouraged and celebrated. At IIT Delhi, Foundation for Innovation and Technology Transfer (FITT) is an established industrial interface organisation that has seen some good results in the healthcare innovation space. FITT has incubated around 50 total start-ups, out of which 10 represent healthcare innovations. Pfizer is a strong supporter of increasing awareness on the value of innovation. The company always looks forward to such collaborations and will explore similar associations

with other academic institutions. Do you think the environment to pursue science and technology-based innovation has improved. Is the National IPR policy providing space for healthcare industry to encourage such innovation? Government of India has been providing substantial impetus to drive innovation in the country. Initiatives such as Start-Up India and Atal Innovation Mission (AIM) are promoting the culture of innovation and boosting entrepreneurship in India. More recently, NITI Ayog along with CII launched a mega initiative 'India Innovation Index' with an aim to make India an innovation-driven economy. The government is focussed on promoting more innovations in India. There is a consensus among various stakeholders that the innovation ecosystem must be continuously strengthened. In May 2016, the union

cabinet approved the National IPR policy, which focusses on initiatives that enhance access to healthcare and make medicines more affordable. The vision of universal healthcare in India will be possible through a sustained model wherein a scientific, economic and policy ecosystem promotes and rewards healthcare innovations. It has been observed that economies with the strongest IP protections are more likely to provide environments conducive to innovation. Furthermore, economies with IP protection in life sciences see more biomedical investment than those lacking IP protection. Aligning with the government’s increased focus of driving innovation in India, we at Pfizer are encouraging innovators to come up with creative solutions for the healthcare industry by providing them support to translate their healthcare ideas into patents. How many applicants have submitted their proposals? How was the response for the earlier phases? The Pfizer IIT Delhi Innovation and IP programme has received a positive response from the healthcare innovation community with over 100 applications submitted in the first year of the programme. The applications that were submitted had tremendous potential and were scalable innovations that could be easily deployed for the betterment of the healthcare industry. Why do you think that IPR is an important factor in

healthcare/pharma sector? How will it boost government initiatives like Start-up India and Make in India? Intellectual property rights, especially patents, are the foundation of the pharma industry as it relies on innovations that can be applied in the future. Patents help innovators protect their innovations and generate return on their investments. The need of the hour is to develop innovative solutions for better healthcare in India. Supporting innovators by granting patents will encourage them to find and develop suitable solutions for the existing problems in the healthcare sector. Pfizer is aligned to the government’s initiatives like Start-up India and Make in India and aims to contribute to these by encouraging Indian innovators and startups by providing support in IP filing. We have already seen promising results under the Pfizer – IIT Delhi Innovation and IP programme, with six innovators already having received support for IP filing services. For example, Valetude Primus Healthcare, a healthcare diagnostic solutions start-up, backed by the PfizerIIT Delhi Innovation and IP programme developed a portable, cost-effective device for early stage typhoid diagnosis within six hours, down from the usual 72 hours. Moreover, apart from the diagnostics tool being simple to manage and easily portable, its ‘cost effective’ factor, makes it a more viable option to cater to the rural masses. prathiba.raju@expressindia.com

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Our vision with MEITRA Hospital is to create a globally recognised healthcare delivery system Dubai-based social enterprise KEF Holdings has recently forayed into the Indian healthcare space. It has launched its first hospital — MEITRA Hospital in Kerala and working towards establishing its next hospital project in Coimbatore. Faizal E Kottikollon, Founder and Chairman, KEF Holdings, explains the company’s plans for India in an interview with Raelene Kambli Tell us about KEF Holdings and its offering across India, the Middle East and Singapore. KEF Holdings is a diversified holding company with operations in the United Arab Emirates, India and Singapore. We use the latest technology across our primary businesses: infrastructure and healthcare to provide innovative solutions to challenging problems in these sectors, transforming human lives and the world around us. We also have a strong investment arm that invests in technology and developing markets. Our focus is to build sustainable businesses that improve the quality of life of people and communities. One of our fastest growing verticals is KEF Infra, an offsite manufacturing company, aiming to transform the sector through strategic integration of automation and robotics and tools such as Building Information Modelling (BIM), for manufacturing hospitals, schools, hotels and homes. Last year, we opened the world’s first and largest fully integrated end-to-end offsite manufacturing plant – KEF Infra One Industrial Park in Krishnagiri, Tamil Nadu.

Health Organization. This is mainly because of the high costs and time that is taken to build healthcare facilities. Also, the quality of facilities in India is below global standards. We believe there is an opportunity to change this, and are bringing better quality healthcare, faster to India through the catalogue hospitals concept. We are pioneering a reliable solution to meet the healthcare needs of India’s fast-growing population.

Why did you choose to foray into healthcare and what are the opportunities? In India, the number of healthcare facilities is severely disproportionate to the size of the population. The country has only 1.3 hospital beds per 1,000 people, which is significantly lower than the 3.5 beds defined by the World

What are the current issues in healthcare infrastructure sector and how will you cater to it? The main challenge is the gap between the supply and demand. India’s existing infrastructure is not enough to cater to the growing demand. Many factors are contributing to this, for instance, the time

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Were there any entry barriers that you experienced? We did not face any significant barriers while entering the sector. However, the healthcare model we were introducing was unique and new to India, even though it is something that is being practiced widely in the western markets. We had to build a case study and showcase to the Indian market how we had successfully adopted this to cater to India’s needs. MEITRA Hospital our first hospital has gone a long way in dispersing any questions about our model and its remarkable success in a short time has played a prominent role to gain confidence in stakeholders across India’s healthcare segment.

and cost taken to build and deliver competent facilities. We can address this gap by our ‘catalogue approach.’ We offer a catalogue of standardised modular designs, complying with standards set by the Joint Commission International - an international healthcare accreditation service. Our catalogue hospitals range from small 15-bed to 500-bed facilities, with the number of pre-designed modules changing based on customer requirements. Thus, as per the requirement, we can set up structures in one-third of the cost and time as compared to traditional building methods. We have collaborated with Total Alliance Health Partners International (TAHPI) which has designed more than 250 healthcare facilities around the world to develop the Catalogue Hospital Format. Our formats are based on the three principles of standardisation, industrialisation and

commoditisation, leading to cost - benefits in delivery, maintenance, operations and sustainability of the healthcare facility. We have developed 50 functional planning units, as well as 500 unique rooms types - each fully specified, predesigned and engineered with multiple permutations that can be used to manufacture hospitals of any size or specialisation in 50 per cent lesser time than traditional construction. A good example of our work and expertise is MEITRA Hospital. Using offsite building technology, we manufactured the world-class 400,000 sq ft hospital within 18 months. 100 per cent of the design, by Australian Design firm, TAHPI, and 70 per cent of the manufacturing was completed offsite, at KEF Infra’s factory at Krishnagiri, Tamil Nadu using the latest technology in offsite construction. KEF Infra has successfully bridged the gap between architecture, engineering and technology while reducing considerable environmental impact. We are set to define the future of healthcare facilities manufactured in India. Whom do you consider as your competitor? This is a new and unique concept, and we do not have direct competition from other players in the market. What value proposition does MEITRA Hospital offers and how is it different from its competitors? At MEITRA Hospital, we bring hope and healing together, with

a team of world-class leading medical professionals, cuttingedge technology and state-ofthe-art IT systems, like independent ICU’s fitted with automated Draeger monitoring system where doctors can monitor patients from anywhere in the world, and a fully integrated unit dose system in the pharmacy. MEITRA Hospital enjoys an entirely paperless environment, and all records are digitally maintained to offer the best care. In the Indian context, a visit to the hospital is often an unpleasant experience for the patient and their family. At MEITRA, we have addressed this aspect by working at every touch point, to create a comforting experience not just for the patient, but for the family and bystander(s) as well. We are delivering the best possible experience at an affordable cost, the model is data-driven and standardises clinical care at the point of care setting. This helps in eliminating variance, improve outcomes, enhance the patient experience and reduce the average length of stay (ALOS). Spread across, 6.5 acre of lush green landscape, and 400,000 sq ft area, MEITRA is a super specialty hospital, with Centres of Excellence in heart and vascular, bone and joint, neuroscience, urology and gastroenterology. The hospital has the capacity for over 500 beds, launching in two phases (Phase 1, 209 Beds is complete) it also has seven state-of-theart operation theatres, 52 individual intensive care suites, 28 consulting rooms and six

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emergency units. Our vision with MEITRA Hospital is to create a globally recognised healthcare delivery system, with a superior patient experience and the best possible clinical outcomes, integrated with transparent and ethical business practices. Explain to us your strategy to sustain and grow your healthcare business in the long run? MEITRA Hospital is an excellent example of our capability, and because of the success of the project, we are already receiving interest from markets across Asia, Africa, and the Middle East regions. Within India, we are currently developing other projects in the healthcare space. We expect to see a plenty of opportunity in growing our healthcare proposition over the next years. We have turnkey models and solutions that can address the unique needs of hospital building projects and can deliver world-class facilities like MEITRA in record time across the country using offsite technology. While offsite manufacturing in healthcare is still new in India, it is widely used in western markets. It is a tried and tested method, which we have integrated into a concept model that suits the needs of the Indian market. The Western design concept for healthcare facilities puts the patient experience at the core of development, taking into account aspects such as accessibility and floor to space ratio. Offsite manufacturing and specifically BIM technology allows us to plan these elements down to the smallest detail, even from an aesthetic standpoint. For example, we equipped MEITRA Hospital with elegant and modern interiors, all of which were developed at our offsite manufacturing facility, using advanced joinery solutions. We also have strong international partnerships that we can leverage to help partners build a well-rounded healthcare experience. For example, we have partnered

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with Wipro GE Healthcare in India to combine their healthcare technology, equipment solutions, and services with KEFâ&#x20AC;&#x2122;s capabilities in offsite manufacturing technology to offer a unique value proposition to clients. At KEF, we believe

technology is the key to meet global standards across sectors. In this respect, embracing innovations such as end-to-end offsite manufacturing will help us usher in a new age of healthcare development in India.

What are your future plans? Our vision is to reshape the way healthcare solutions are delivered and managed in India. We believe that a robust and cost-effective healthcare system, available both to the rich and poor of the nation, is very critical. We want to

partner with government and healthcare providers to make this possible by using our advanced technology. Our next healthcare project is with a major hospital operator in Coimbatore. raelene.kambli@expressindia.com

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Fourth edition of HEAL held in Kerala Discussions were held on the future of healthcare and how it can be transformed from good to great THE FOURTH edition of Healthcare Excellence through Administration and Leadership (HEAL) was recently held at Baby Memorial Hospital (BMH), Kozhikode, Kerala. Research Foundation of Hospital & Healthcare Administration (RFHHA) was the Knowledge Partner and Association of Healthcare Providers India (AHPI) was the Associate Partner. The event witnessed students, healthcare professionals and dignitaries participate in large numbers and industry best practices, areas that required focus and the future of healthcare were discussed at large benefiting the enthusiastic audience in an effort to transform healthcare from good to great. Dr Vineeth Abraham, Director, BMH proposed the welcome address and Dr Soman Jacob, CEO, BMH, gave the presidential address. He highlighted the commitment of BMH and the journey of the institution from a 52-bed hospital to a 800-bed hospital. The event was inaugurated by Dr Shakti Kumar Gupta, Medical Superintendent (Dr RPC), AIIMS, New Delhi. While he started his address showering praises on BMH for their commitment and care and the leadership of Dr KG Alexander, Chairman, BMH, Dr Gupta also set the programme to a roaring start with questions to ponder which were deliberated in the subsequent sessions. Prof Mohammad Masood Ahmed, Director, Indo US Hospital, Hyderabad and Col (Dr) Saroj K Patnaik, O/o DGAFMS, Ministry of Defence, New Delhi were Guests of Honour. Dr C Vinoth Kumar, Conference Director, proposed the Vote of Thanks for the inaugural session. Prof Ahmed started the

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academic session with his talk on ‘Strategic Management in Healthcare Organizations’ in which he discussed the importance and need for strategic management in hospitals and also enthralled the audience with case studies and insightful thoughts. Dr Vijay Tadia, Senior Resident Administrator, AIIMS, New Delhi addressed the gathering on ‘Application of Lean Six Sigma in Healthcare’ in which he detailed about the application of the principles of Lean Six Sigma in Healthcare. He emphasised on the fact that defects in processes as well as variation in processes lead to sub-optimal use of the resources in any healthcare organisation. In a resource constrained country like India it becomes all the more

important to use time tested principles of Lean Six Sigma which have given good dividends in healthcare across the globe. He cited few examples of the application of these principles as well as demonstrated their applicability in healthcare during his speech. Day 1 ended up with a ‘Special Comedy Show in Healthcare’ by Dr Jagdish Chaturvedi, a medical device innovator and a renowned stand up comedian on ‘Inventing Medical Devices.’ As a doctor who has evolved into becoming an innovator of affordable medical devices designed for our Indian setting, he shared his experiences and learnings with the medical community which includes doctors, paramedical and hospital administrators. He said,

“I believe our healthcare professionals understand our healthcare needs very well and they must drive and lead new innovations to improve healthcare in our country. By giving talks on my journey and sharing lessons from my failures in the form of book – Inventing medical devices: a perspective from India, I hope to help more healthcare professionals to take up this task and improve healthcare in our country.” Day 2, started with Lt Col (Retd). Sunny Thomas, CAO, BMH on ‘Hospitals – A Tryst with Environment’ which provided figures from energy saving initiatives and measures adopted at BMH. This was followed by Dr Shakti Kumar Gupta who talked about innovation and

entrepreneurship and intelligent hospitals. He said that healthcare innovation and entrepreneurship are the cornerstone for success of any organisation. He pointed out that healthcare has traditionally lagged behind other industries in the area of innovation and entrepreneurship. He stressed that healthcare organisation that successfully foster the culture of innovation and entrepreneurship along with other management strategies will not only increase their chances of survival in a changing and challenging environment but will also be better equipped to provide cost-effective highquality services and products. Dr Sadik Kodakat, Chairman, Starcare Hospitals Group addressed the

MARKET gathering on ‘Disruptors in Healthcare : Managers & Entrepreneurs Perspective.’ He explained in details the various disruptors in healthcare with thought provoking insights and examples. This was followed by the Col (Dr) Saroj K Patnaik who addressed the gathering on ‘Role of Level Five Healthcare Leadership in India.’ He gave a blueprint for healthcare leadership in organisations, more so in the organisational setting thus enabling high standards and impactful governance. The session in the afternoon started with Sri Harsha Govardhana, MD, Sarvagnya Solutions, Hyderabad on ‘Medical Leadership: Competencies for Clinicians.’ In his address, he said, “I have interviewed and observed over 90 plus doctors who have built their practice by following highest standards of care, getting outstanding medical outcomes. I checked the validity and application of these competencies over a period of last 17 years. These doctors whom I call ‘Super Star Doctors’ rigorously demonstrate nine medical competencies that provide excellent clinical outcomes in Indian healthcare setting.”

Sri Harsha went to explain the competencies in detail. These competencies are clinical excellence, team building and collaboration, doctor-patient relations, management skills, learning and development, health and well being promotion, professional behaviour, governance and compliance and technology adoption for personalised care using precision medicine. This was followed by Saji Mathew, Chief, IT & HR, BMH on ‘The Employee Experience is the Future of Workplace.’ In his talk, he said, “Healthcare is considered the most ‘human’ of all endeavours. The performance of healthcare professionals such as physicians and nurses directly affects the physical and mental well-being of patients. Research has clearly identified links between healthcare work attitudes and patient outcomes. In the digital age, employee experience is an important concept worthy of attention to drive positive customer experience.” The last session of the day saw Prof (Dr) Anand Gurumurthy, IIM, Kozhikode who delivered a talk titled ‘Can car making methods be applied to

hospitals?’ His talk dealt with how the concepts of Toyota Production System (TPS) can be applied within the healthcare setting such as hospitals to improve the efficiency of the various processes and thereby reduce the overall cost, which would enable healthcare services to be more affordable and accessi-

ble. He highlighted the similarity in terms of the objectives for TPS and healthcare institution such as hospital. For example, the car maker would consider the ‘safety of the customer using the car’ as the foremost priority, while in the case of a hospital, the safety of patients matters most. Similarly, for both the

car maker and hospital, the factors such as quality and cost are also important. Apart from this, he also highlighted about the increasing labour cost and shortage of skilled people in the healthcare setting, which also warrants the need for car making methods. Then, he explained how there are seven

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MARKET wastes identified by Taiichi Ohno, Chief Architect, TPS is also prevalent in healthcare with a funny video and noted that these wastes has to be reduced. To accomplish the same, he also suggested some of the tools and techniques of TPS such as ‘Value Stream Mapping,’ 5S, Sphagetti Diagram, Kaizen, Changeover time reduction, etc., which can be used to reduce these seven wastes. Lastly, he demonstrated the application of the same using a case of Viriginia Mason Medical Centre, a multi-speciality hospital in the US, which has pioneered the implementation of TPS in healthcare setting. He also advocated the use of these concepts in Indian hospitals and healthcare setting to reap various benefits such as reduced cost, reduced patient stay, increased utilisation of hospital equipment, reduced waiting time, increased customer satisfaction. The vote of thanks was proposed by Rohith G, Joint Organizing Secretary, HEAL 2017. The two-day session gave

new directions and ideas that can be incorporated in healthcare practice to the healthcare professionals and a ringside view to the students community. The audience

participation was appreciable with various queries to the speakers after each session and aptly addressed by the speakers. The thoughtful session made the audience crave

for more and has provided the drive and direction for the organisers in making HEAL 2018 even bigger. For now, it is a long wait and time to chew on the learnings,

interpret and realign healthcare practice for greater good and organisational excellence. EH News Bureau

18th edition of Medicall held in Mumbai Apart from exhibition, interesting sessions were lined up for visitors to brush up their knowledge on various factors that come into play while deciding on healthcare business strategies MEDICALL, ONE of India’s largest B2B medical exposition, was recently held at Mumbai’s Bombay Exhibition Centre. The three-day exhibition saw visitors from all segments of the healthcare fraternity be it doctors, equipment manufacturers, service providers, hospital owners, healthcare administrators, marketing professionals, healthcare consultants. The 18th edition of the medical equipment exhibition was organised by Medexpert Business Consultants and promoted by Dr Manivannan, Joint MD, Kauvery hospital, a 750-bedded Hospital group in South India. Medicall serves as a marketing platform wherein the

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MARKET equipment companies showcase their products to hospital owners and decision makers. A broad category of exhibitors were present ranging from healthcare IT solutions to refurbished equipment. Along with the medical device exhibition there were interesting sessions lined up

The 18th edition of the medical equipment exhibition was organised by Medexpert Business Consultants and promoted by Dr Manivannan, Joint MD, Kauvery hospital for the visitors to brush up their knowledge on various factors that come into play while deciding on the business strategies. The first day of Medicall deliberated on how to purchase the right medical equipment. Specialists Venu Isukapalli, Director, Materials Management, American Hospital of Dubai, UAE; Chandrasekaran J, Technical Director, Biomedical Engineering Company; Shrirang Tambe, Founder and CEO, ORIGA, discussed points to consider while purchasing radiology equipment. Discussions were held on the pros and cons on whether to buy or lease equipment. Day two of Medicall focussed on hospital projects and digital hospitals while discussing intricacies of common pitfalls in hospital planning and construction, NABH in-

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frastructure requirements, sustainable green hospitals, hospital design that increases operational efficiency, seismic base isolation system for hospitals, IT Infrastructure. Speakers included Dr Manivannan S, JMD, Kauvery Group of Hospitals; CJ Kosalraman, MD, Infrabees Project

Management Consultants; Madhulika Pise, PrincipalDesign & Sustainability, FreeSpanz; Joy Chakraborty, COO, PD Hinduja Hospital and Ratish Jain, MD, Resistoflex Dynamics; Niranjan Ramakrishnan, CIO, Kauvery Group of Hospitals; and Aniruddha Nene, Founder &

Director, GraOne Solutions. On the last day, experts discussed appropriate and effective low-cost strategies including PR, digital and social media marketing for hospitals. Dr Alok Khullar, Chief Business Officer, Kauvery Group of Hospitals and Vivek Shukla, Senior Advisor, Frost

& Sullivan concluded the exhibition with sessions on branding and marketing for hospitals. The 19th edition of Medicall is scheduled to be held in Hyderabad from February 2325, 2018. mansha.gagneja@expressindia.com

cover )

Against all odds Improved hospital infrastructure, attractive incentives to doctors and paramedics are propelling the health parameters in Chhattisgarh’s Bijapur district BY PRATHIBA RAJU

mong the thick forests and rough terrains in the interior districts of Chhattisgarh, thousands of tribals and locals lead a complicated life due to the internal strife of Naxalites. They are deprived of basic healthcare facilities due to shortage of doctors, staff nurses, proper hospital infrastructure. Things are changing for better and people residing in those areas now have access to better healthcare amenities. The public healthcare facilities in these Naxal stronghold areas like Bijapur, Dantewada and Sukma are showing signs of improvement. Till a year ago, pregnancy meant complication for tribal women of the interior districts of Chhattisgarh, as many pregnant women were carried in dhola (a palanquin) to the nearby District Hospitals (DH). Many a times, the deliveries took place in the village itself, as the local population faced sudden bandhs, roads blocked by tree trunks and trenches dug to prevent people’s movement. With wellequipped DH and a decent hospital infrastructure, sufficient number of doctors, specialists like gynaecologists,

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BIJAPUR Highly Naxal affected.! ◗ 74 per cent tribal population.! ◗ Four local languages: Dorli, Halbi,Gondi, Telugu.! ◗ Seven hours from nearest airport or railway station.! ◗ Population of 2.5 lakh and scarcely populated with density: 39/sq km.! ◗ Literacy: 40 per cent.! ◗ No mall/cinema theatre.! ◗ BSNL is the service provider. ! ◗ Not a single private practitioner.!

paediatrician, nurses — available round the clock and follow-ups by them in Community Health Centres (CHC), Primary Health Centres (PHC), many tribal women from various districts of Chhattisgarh are opting for institutional deliveries. Among them, Bijapur district, one of the top five naxal affected, home to 2.5 lakhs, got its first gynaecologist in July 2016. The DH has registered total delivery of 766 from January to September 2017. By the year end, it set to cross the 1,000 mark. Meanwhile, Sukma, home to 2.6 lakh people, mostly tribal families, got its first gynaecologist recently from Telangana. Achieving this progress in Bijapur was a step-by-step process, informs Dr Ayyaj Tamboli, District Collector, Bijapur, “The district known as the hotbed for naxal violence, with 74 per cent tribal population and not a single private practitioner, reviving the public health infrastructure, bringing in doctors, was not an easy task, but it was not impossible as well.”

Building a robust public health system The process of making healthcare available and deliv-

( ery for the tribal region made a humble beginning in May 2016. The district started with its available local funds and the vision was to provide comprehensive health improvement of tribal populations into action; and get ‘mélange’ of specialist doctors who are willing to serve in this region. To achieve this mandate, the Government of Chhattisgarh initiated Chhattisgarh Health Systems Strengthening Project (CHSSP) for providing quality healthcare to tribal populations of the Bijapur, Sukma and Bastar region. “The project was a joint effort by the Directorate of Health Services (DHS), Govt of Chhattisgarh (GoCG) in collaboration with UNICEF and Public Health Foundation of India (PHFI) and the main agenda was to attract and retain specialised Human Resources (HR) for health in districts of Bijapur and Sukma in Bastar region. At the time of inception of the project, almost 80 per cent of posts of specialists, including surgeons, obstetrics and gynecologists, physicians and paediatricians, were lying vacant in DH and CHCs across the Bastar region. However, after the implementation of project, Bijapur recruited 13 specialist doctors against zero before the project and Sukma recruited nine specialist doctors against zero,” a PHFI official informs. A national-level workshop with different stakeholders from the state governments, elite medical institutions, state and national health system resource centres, NGOs providing specialists care in the region showcased that most people had very limited understanding of the districts of Chhattisgarh and believed on media hyped stories. The workshop addressed the myths and highlighted that creating an enabling environment could motivate medical officers or specialist doctors to work and sustain in such regions.

FO C U S : D I G I TA L T EC H N O LO G Y

We identified that the infrastructure support and basic comfort of an individual or a family was the key component that will make the doctors opt to work in insurgency-hit areas, just like the army personnel and civil servants. So, transit hostels with good infrastructure were set up for them R Prasanna, Commissioner Health and Mission Director, National Health Mission, Government of Chhattisgarh (GoCG)

If similar packages are given in locations like Raipur or Haryana, then it will distort the complete market, as many doctors would prefer them. The discrepancy of the differential factor should be maintained based on the difficulty of the terrain Dr Ayyaj Tamboli, District Collector, Bijapur

We don't have any specific timings, we keep getting patients wheeled in with different complications. But here the patients respect us so much, I don't think this much respect can be earned if I work in any other location Arun Choudhary, Gynaecologist, District Hospital, Bijapur

The officials found that it was not about incentives, but additional facilities like employment for spouse, school admission for kids and additional marks in PG courses are some of the perks that would attract the doctors and specialists opt to work in the Naxal heartland. “We identified that the infrastructure support and basic comfort of an individual or a family was the key component that will make the doctors opt to work in insurgencyhit areas, just like the army personnel and civil servants. So, transit hostels with good infrastructure were set up for them. Apart from it, they are given additional marks, in their PG courses, if they opt to work in such areas. Now we are planning to tie up with well-known universities so the doctors can avail their advanced studies. In certain tribal districts getting ANM, Asha workers are a challenge because of certain reservation. So, we are identifying certain tribal women who are interested with the government funding. We give them coaching and training so that they can come back and serve their own community,” says R Prasanna, Commissioner Health and Mission Director, National Health Mission, Government of Chhattisgarh (GoCG). Social and recreational support avenues were created for doctors to have a positive social life in the calm of nature. Establishing these social avenues together with grievance-redressal mechanisms for alleviating individual and system level barriers were the paramount attraction and retention of specialist doctors. Explaining how the district revived the grappling public health system in the district, Tamboli, said, “We focussed on improving and creating a good infrastructure and other social support for the doctors, specialists. We converted a building inside the premises of DH into a transit hostel, which had fully furnished rooms, TV,

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cover ) gym, common laundry area and mess. Doctors can access the officers club, which have facilities like swimming pool so that they can feel working in a corporate set-up. Before recruiting doctors, we enrolled hospital staff and nurses, as most of the day-today operations are done by the nurses. The funds are made available from the District Mineral Fund (DMF) mandated under the Mines and Minerals (Development and Regulation Act), which pay a part of their royalty to the district for the development of areas and people affected by mining. Bijapur district receives a corpus of `40 crore per annum. With this fund, I recruited 45 staff nurses in DH alone, apart from CHC and PHC.” According to officials, in 2007, Bijapur DH had only one MBBS doctor and seven staff nurses. In 2013, it was increased to seven MBBS doctors and 10 staff nurses. Currently, 40 doctors work in DH, which includes 16 specialists — the surgeon is from Tamil Nadu; gynaecologist, pathologist and anaesthetist are from Uttar Pradesh; ophthalmologist from Maharashtra; Microbiologist from Andhra Pradesh and ENT doctor from Telangana. As on March 31, 2016, 42 of the 55 sanctioned posts of super specialists and medical officers were vacant at Sukma. Within six months, the vacancies were down to 18 there and 20 in Bijapur. Since April 2016, efforts by the district collector and Directorate of Health Services (DHS), Government of Chhattisgarh (GoCG), over 84 super specialists and medical officers have signed up to work in Sukma and Bijapur, where you can find CRPF camps in every five kilometeres, but not a single private hospital or clinic. “Overall, we have done 153 cesarean operations, 514 major surgeries and minor surgeries during the last seven months. We are seeing an increase in OPD, IPD, Institutional deliveries and FP

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SUPPORTING STAFF Highly Naxal affected.! ◗ Only 10 staff nurses in DH in May 16 ◗ Contractual appointment ◗ Recruited 73 staff nurses for DH, CHC and PHC from DMF ◗ Pay scale same as of NHM salary ◗ Lab tech, pharmacists and OT technician from DMF and Jeevandeep

services at DH,” Tamboli says. Bijapur district in Chhattisgarh has now turned out to be a model which has elevated the healthcare availability and delivery of the tribal region, and this is now turning out to be an example for other Left Wing Extremist states and districts, inform officials.

Designing attractive incentives As per officials, Naxals impede three developments — construction of roads, installing mobile phone towers and buildings with permanent roofs. With such restrictions to woo the doctor fraternity to these areas, attractive and negotiable pay package were designed. Apprising that the focus was to fill the shortage of specialist doctors and medical officers, Tamboli gave details on how a lucrative salary package was designed and says, “For a staff nurse in Raipur, a non-tribal and non-naxal and completely urban area, is paid ` 12,500. And, if it is a non-tribal, nonnaxal rural area, the package is ` 14,000, for tribal and nonnaxal, hilly areas, it is ` 16000, ` 18,000 for tribal and naxal infested areas and ` 20,000, if it is a severe naxal infested area and ` 24,000 for the most inaccessible naxal-affected areas. Similarly, in Raipur a specialist gets ` 84,000; at the same time, working in Bijapur, the package offered was 1.87 lakhs. Thus, the differential salary is based on the difficult terrains -- on how deeply naxal infected area they are willing to work. These were basic packages, but some experienced doctors and radiologists, orthopedicians, expect more, so we kept a negotiable salary bracket. Currently, we have a surgeon who is paid `2.2 lakhs and was given an incentive on his performance after six months.” The package was a shared effort by the district, state government and National Health Mission (NHM), and the central government. “Initially, for the Human Resource (HR) 60 per cent

cover ) funds were from DMF, 40 per cent NHM and state component. Now, it is in the ratio of 50:50. Apart from HR, NHM funds are used to get equipment. Some additional funds from Rashtriya Swasthya Bima Yojna (RSBY), state governments were used for upgrading mortuary, blood banks, OPD set up,” Tamboli informs. In order to make the recruitment process fast, smooth and easy in such under-served districts, Tamboli shared a SOS WhatsApp message on medico groups and Facebook (check the image for the SOS message). “We received over 100 responses – both from specialists and general practitioners. We asked them to send there CVs via Whatsapp and Gmail. Once they had sent, we shortlisted them and asked them to visit the facility and then decide to join, and when they reached, they were assured about the safety,” he adds. Doctors and specialists who work for the district seem to be happily serving the community, as they inform that it is not just the incentives and perks but the people and the community respect them, which is unlikely if they work in urban areas.

Providing healthcare in naxal bosom Straight roads with mine-clearing vehicles, covered by thick forests on either side and incessant rains, black-topped roads snaking into the distance, 29year-old, Arun Choudhary, a gynaecologist, from Aligarh Muslim University, was was baffled by the serenity of the place “I got an offer to join DH Bijapur, from my Head of the Department (HOD), Seema Hakim. Initially, I was under the impression that it was Bijapur in Karnataka, but later got to know that it is Bijapur located in Bastar region. I had no apprehensions, rather the environment with no hustle bustle was pleasant. Accompanied by my wife, I wanted to check the DH facility before joining in. Soon after reaching the DH, a civil surgeon asked me to help him in the OT (operating theatre) as a mother in labour and her baby were in critical condi-

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ATTRACTING SPECIALISTS

NAXALITE MENACE - BIJAPUR 2015

2016

2017 (till July)

Policeman killed

Residents killed

Explosives recovered

Bomb explosion

S.No

Doctors

2016-17

2017-18

Doctors (MBBS)

Sanctioned – 44 Posted -15

Sanctioned – 33, Posted -30

Specialist

Sanctioned – 40 Posted - 1

Sanctioned – 84 , Posted - 44

Staff Status S.No

Paramedical staff

2016-17

2017-18

Staff Nurse

Sanctioned – 114 Posted -16

Sanctioned – 114 , Posted -108

Pharmacist

Sanctioned – 21 Posted -10

Sanctioned – 21, Posted -14

Lab Technician

Sanctioned –30 Posted -7

Sanctioned – 30, Posted -15

ANM/2nd ANM

Sanctioned – 176 Posted -111

Sanctioned – 176 , Posted -150

MPW

Sanctioned – 92 Posted - 21

Sanctioned –92 , Posted -40

Source : District administration, Bijapur

tion. The heart rate was dropping, I had no time to think. Though I was not an official employee, I immediately got into action, and after few hours, I was happy that we managed to save both the mother and the child. When I first took the baby in my hands, I decided to serve this locality,” Choudhary says. Informing that the team of nurses are outstanding and they manage any kind of complex situation with such ease, Choudhary said, “We don't have any specific timings, we keep getting patients with different complications. But here the patients respect us so much, I don't think this much respect can be earned if I work in any other location.” Vector borne diseases and anemia are the main concerns here.” Choudhary’s wife, an English post graduate, now works as a teacher in government school in Bijapur. Talking about the hospital infrastructure, Dr Kushal Sakure, obstetrician-gynaecologist, says, “The OT in Bijapur is better than the one at JN Medical College in Aligarh.” Now, the DH has a new blood bank, operation theatres, 150 beds and a 50-bed maternal and child healthcare section. “A month prior to the project, we used to have 32 to 44 deliveries now we conduct 104 –132 deliveries a month. Earlier, when blood was required, we used to get it from Jagdalpur, 162 kms away and only 10 to 12 blood transfusions used to happen in a year. Now we have 400 to 500 transfusions in a month. New born care units, neonates, even with birth weight of 862 grams are surviving,” Tamboli informs.

Miles to go Trying to combat the fear factor instilled by the insurgency, getting doctors and paramedics to the rebel belt and filling the shortage with flexi-funds from National Health Mission (NHM), state government, district mineral funds (DMF), the official said that it is a 100 per cent public health contribution and the private sector or the Public Private Partnership

( (PPP) has not been explored. In terms of medical care, we don't have a single private practitioner in the district, Tamboli says. “We don't have any MBBS operating privately as there is no such robust private sector to invest or donate to the DH. We are getting CSR funds from the National Mineral Development Corporation (NMDC), which contributes ` 10 to 15 crore per annum for all the components like education, health, infrastrucutre like roads and electricity in Bijapur. Overall, we get about ` 1 crore or 50 lakhs with which we procure lab equipment,” he adds. Meanwhile, elucidating the work done in interiors of Jharkhand, another Naxalinfected state by Philips healthcare and Health MaP Diagnostics, Niraj Arora, CEO Health MaP Diagnostics, inform that they have a PPP with the Jharkhand government under which they provide tele-radiology serving an approximately 700 patients per day, and this number is growing on a daily basis. “It is not easy to get trained medical staff in certain pockets of Jharkhand where we are operating. Also, it is tough to motivate the staff from other regions to move to these locations. However, which ever locations we have managed to find staff for our services, we have had no issues in running the medical services as on date. Availability of trained paramedics is still manageable but getting doctors for locations besides the three to four key towns is a challenge. Across two states where we are working currently, i.e. Haryana and Jharkhand, we have seen strong initiatives from the respective governments to deliver better healthcare across all key segments like nephrology, cardiology, radiology, etc . However, this will become super successful only if all the segments of healthcare delivery right up to the PHC level are engaged through PPP or an appropriate mode of delivery. In association with National Rural Health Mission (NRHM), the governments are building specific programmes for pro-

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viding specialised services to the patients,” Arora says. However, officials are worried that there will be a problem if such negotiable salary packages are replicated in plain areas, a perturbed Tamboli said, “If similar packages are given in locations like Raipur or

FO C U S : D I G I TA L T EC H N O LO G Y

Haryana, then it will not attract doctor’s to cater to areas which are under naxal threat. The discrepancy of the differential factor should be maintained based on the difficulty of the terrain. We have miles to go to bring in a robust public healthcare system in these under-served dis-

tricts.” Informing that Bijapur model being successful, the same is being replicated in Sukma and Dhantewada and similar model is looked upon by the Odisha government for Malkangiri district, Tamboli adds that this model can be fur-

ther extended to similar, other remote and naxal-affected districts and conflict zones in India. He adds that the real challenge, would be ensuring its localised success. Picture courtesy: (District administration Bijapur) prathiba.raju@expressindia.com

POLICY WATCH I N T E R V I E W

‘Delhi govt’s three-tier healthcare system will enhance public health’ Satyendar Jain, Minister of Health and Family Welfare Department, Government of NCT of Delhi, who is donning several other portfolios of Power, PWD, Industries in Aam Aadmi Party (AAP), in a candid and free-wheeling exclusive interaction with Prathiba Raju, elucidates about Delhi government’s three-tier healthcare system, mohalla clinics, polyclinics and multispeciality hospitals and how it is improving the healthcare infrastructure of Delhi Can you list out the various initiatives taken by AAP government towards betterment of healthcare sector in the NCT? The most important achievement on the health front made by us is the starting of mohalla (neighbourhood) clinics in Delhi. These clinics have been conceptualised as a mechanism to provide quality primary healthcare services accessible within the communities in Delhi at their doorstep, and help decongest crowd within government hospitals. We have set up 158 clinics so far and will open 1000 clinics soon. Next to mohalla clinics, we have multi-speciality polyclinics, which focus on secondary healthcare in the form of OPD consultation by specialist doctors, including diagnostics. We have opened 25 clinics and our target is to have 150 such polyclinics. Right now, the mohalla clinics and polyclinics are functioning upto 10 to 15 per cent only, but if they are fully functional it will help de-congest government hospitals. Unlike any other metros, Delhi’s government hospitals are facing huge crowd. In 2015, the government hospitals in Delhi registered 30 million OPDs. In 2016, it was 40 million OPDs and in 2017, we will cover atleast 50 million OPDs. We are providing free of cost medicines and tests, so many are coming from

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nearby states as well. Increased OPDs itself showcases that the services have been enhanced. For example, the Delhi government has tied up with certain private labs which conduct MRI, PET scans and ultrasounds for free for its citizens where we pay for them. Till now, over 5,000 scans have been conducted in these labs per month.

The number of out patients in Delhi’s government hospitals is increasing manifold every year. Earlier, the ratio of patients visiting from outside Delhi was 50 per cent, but nowadays over 70 to 80 per cent patients who approach Delhi government hospitals are outsiders

According to you, AAP's mohalla clinics have gained huge achievements. Do you think the rationale behind this initiative is met? Thanks to the BJP and Congress, we are facing a lot of hurdles in coming up with the mohalla clinics. The government is not providing land for mohalla clinics, for which we are approaching every department. Despite all these hurdles, setting up 158 clinics in two years is a big achievement and 1,000 is an ambitious target. We are sure that we will achieve it. Compared to earlier governments in Delhi, which have just set up about five to seven dispensaries per year, I hope we are serving better to our citizens. Many don’t understand the concept of mohalla clinics. It is a simple concept developed by AAP, which is being explored by many others now. The idea was to provide diagnostics and treatment of simple ailments to people and reduce the footfall in tertiary care

hospitals. These clinics within a 5 km radius from their home offer over 100 essential drugs and 212 diagnostic tests which are absolutely free. The doctors in these clinics treat minor ailments such as fever, headache, diarrhoea, skin problems, respiratory problems etc., first aid for injuries and burns, dressing and management of minor wounds and referral services. With this, doctors in government hospitals can focus on complicated diseases and surgeries. Services are good in every mohalla clinics. In Delhi, we are lucky that we have enough doctors as it is the only metro in India which has a better doctor-patient ratio with 50,000 doctors around. As for cost, construction of 1000 mohalla clinics is estimated at ` 200 crore and its operation per year costs ` 400 crore. For existing 158 clinics, the operation cost comes to around ` 30 crores. On an average, how many patients from outside Delhi do government hospitals caters to? It is very difficult for us to manage increasing crowd in hospitals. The number of patients visiting any government hospitals in Delhi is increasing manifold every year. Earlier, the ratio of patients visiting from outside Delhi was 50 per cent, but nowadays over 70 to 80 per cent patients who approach Delhi government hospitals are outsiders. The rush has doubled and the Centre is not providing any help. They don’t even pay share from the income taxes collected in Delhi. As far as the upcoming new AIIMS are concerned, it is over three years since BJP has won the elections. Whatever they had to deliver in five years has not been done, they are trying to open AIIMS here and there. Let's wait and see what they manage to deliver. Delhi's budget of ` 5,736 crore for healthcare is appreciable. But how have you utilised it? What is the

progress so far? Delhi government’s prime sectors are education and health. We are spending 25 per cent on education and over 12 per cent on health and our budget reflects it. Already, 17 hospitals are in various advanced stages of renovation and their infrastructure is being upgraded. Right now, we have 10,000 beds in these hospitals but we are trying to add 15,000 new beds. We expect to cover all the hospitals in the next two years. The three-tier healthcare system, mohalla clinics, polyclinics and multispeciality hospitals is improving healthcare infrastructure of Delhi. Can you explain about the new Good Samaritan Policy?

(CGHS) rates. As private players have their own lab space and they have installed their scanning machines, we are utilising their services and paying them CGHS rates and not paying any capital expenditure. We have started scheme of operations in private hospitals. If a patient is waiting for over a month for a surgery in Delhi government hospital, he/she will be referred to any of the enrolled 50 private hospitals which is NABH accredited and have CGHS facility. Right now, we have a list of 52 surgeries, which are performed by private hospitals. The Good Samaritan Policy, which is an accident victim scheme will have over 330 private hospitals, nursing homes as our partners. I hope these can be the best examples of

of 10? I would give four or five out of 10. Our target is 10 and we are working on it. What is your take on NEET? Do you think it will help in medical education? National Eligibility Entrance Test (NEET) exam will eliminate corruption because in most of the states local examinations are rigged in large scale and people take medical seat by paying money. Many politicians don't like this idea because most of the medical colleges are run by them. But Delhi government supports NEET. What initiatives have been taken to control vectorborne diseases? For vector-borne diseases, we had started our campaign in March. This year, there is only

Overall, on health front, I would say AAP government is working on all the promises it made in its manifesto, certain promises have been fulfilled and we assure that the rest will be achieved within the next two years We will implement Good Samaritan Policy by the end of this year. The reason and need for implementing it is to encourage people to help road accident victims. Every year on an average 1600 deaths occur on Delhi roads. Many don’t reach hospital on time. Under this policy, monetary incentive of ` 2,000 and appreciation certificate will be given to those who help road accident victims reach hospitals. If a victim is admitted in a private hospital, the hospital expenditure will be borne by the Delhi government. What is your view on Public Private Partnership (PPP)? We do PPPs in a smart way. For example, we collaborate with various private players and pay them in Central Government Health Scheme

PPPs in healthcare. If you have to pick few states for its best healthcare services pan India, which ones would you mention and why? I would say Kerala and Tamil Nadu. As everyone knows about Kerala’s health indicators where they have the least infant mortality rate and maternal mortality rate (MMR). The atmosphere of government hospitals in Kerala is calm and there is no stress. Moreover, the state has high literacy rate, which compliments better healthcare delivery. Tamil Nadu is another state, which has also done reasonably good in healthcare. If you have to rank Delhi for health performance, how much would you give out

one death in Delhi due to dengue and chikungunya cases are 90 per cent less. About 200 cases are registered for swine flu, but no death has been registered, correspondingly many states have registered many deaths in various vectorborne diseases. You seem to be surrounded by controversies. What do you have to say about the appointment of your daughter who was put in charge of Delhi mohalla clinic and designated as an advisor to the health secretary-cum-mission director of the National Health Mission? I fight with big, powerful people and they gift me controversies. For example – we started giving free medicines scheme for many people in Delhi, the diagnostic

tests rates, test rates for vector-borne diseases like dengue, chikungunya, swine flu are 3/4th lesser. We initiated the scheme for free diagnostic test for all the residents of Delhi and banning the chewable tobacco products are some of the steps not liked by many individuals or groups. It is a major lobby here. As far as the issue regarding my daughter is concerned, it is very unfortunate. She is an architect and got admission in IIM Indore. It was I who asked her to work for a year as a volunteer in mohalla clinics, as she had good administrative skills. She joined as a volunteer in Delhi Health Mission to help mohalla clinics. Even when she went for a week’s training with 70 other people in Ahmedabad, the expenses were from my pocket. Here, I think, the voluntary services are not regarded as it should be, people have very negative approach. I don't know why people or media don't question about ministers appointing close relatives as their OSDs. Her name was tarnished in the national media, but I think it is not her loss but the project has lost a good volunteer. Union health minister JP Nadda informs that health is a state subject and there is no dearth of funds from the centre to the state. He added that the state governments should do rightful utilisation of this budget. Your comments. Ask the union health minister to list out funds they have given to each state. If such a list is put out, Delhi will be the last in the list. First of all, I would like to ask the centre to gives us a free hand to run our health schemes. Overall, on health front, I would say AAP government is working on all the promises it made in its manifesto, certain promises have been fulfilled and we assure that the rest will be achieved within the next two years. prathiba.raju@expressindia.com

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STRATEGY

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STRATEGY

Tackling malnutrition in India India is among those countries in the world with the highest recorded numbers of undernourished and malnourished people. As the country aspires to fulfil its economic and social development goals, how will we solve this humongous problem? By Raelene Kambli

ndia, a progressive nation is said to have immense potential to lead the world in many ways. Its science and technological advancements, infrastructure development, burgeoning business environment, increasing foreign relations and trade collaborations, growing political influence over many emerging markets, education and lifestyle progress have all been great contributors to its growth story. Howbeit, experts believe that the disparity in health economics can act as a serious deterrent to this progress. Disparity in terms of rural-urban health infrastructure, differentiating health indices within states, rising NCDs, disproportionate nutrition level, varying social determinants that impact health outcomes, etc., are poignant concerns. Amongst these, nutrition related conditions such as under-nutrition—obesity and malnutrition is said to be a major cause of concern that stunts India's economic growth ambitions. Source: The Indian Express photo archives

Socio-economic impact of malnutrition Ironically, in our country we have both forms of malnutrition- under nutrition and overweight obesity and as per various studies, and expert reviews both these forms co-exist with multiple micronutrient deficiencies. For instance, India houses the second highest number of obese children in the world at 14.5 million after China, which has 57 million. Also, we have the highest population of stunted (low height for age) kids - 48.2 million. Similarly, statistics compiled by the Food and Agricultural Organisation (FAO) show that while the SubSaharan countries of Africa

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have the highest prevalence of hunger, in absolute terms, India has the highest number (one quarter) of undernourished (hungry) people in the world (194.6 million or 15 per cent of India’s total population during 2014-16). In 2015-16, 38.4 per cent of Indian children below the age of five were stunted, according to National Family Health Survey data. States which are having high malnutrition (Children under five years who are stunted) rates are Bihar (48.3 per cent) , UP (46.3 per cent), Jharkhand (45.3 per cent), Meghalaya (43.8 per cent), Madhya Pradesh (42 per cent), D&N Haveli (41.7 per cent) and

Rajasthan (39.1 per cent). Moreover, every one per cent loss in adult height due to childhood stunting is associated with a 1.4 per cent loss in economic productivity and stunted children earn 20 per cent less as adults compared to non-stunted individuals, as per IndiaSpend reported in July 2016. Therefore, loss of human potential means a a huge economic loss to the country. Dr Shweta Khandelwal, Associate Professor, PHFI and Senior Public Health Nutritionist and member of FSSAI informs, about a UNICEF report that reveals, stunting in early life is linked to 0.7 grade loss in

schooling, a seven-month delay in starting school and between 22 and 45 per cent reduction in lifetime earnings. The Global Nutrition report 2016 pegged malnutrition related economic losses to be around 11 per cent of GDP per year in Asia. It has been estimated that because of undernutrition, India will suffer an economic loss of about $40 billion by 2030, which might perhaps be the highest loss of human potential ever. Malnutrition has an enormous effect on the socio-economic aspects within the country as well. For example, Dr Khandelwal points outs, “The first 1000 days (conception to two years of age) are very cru-

cial to curtail malnutrition. Thus, factors like poverty, social taboos, unhealthy diets, poor access to healthcare, lack of education, financial dependency etc., exacerbate the malnutrition effect on an individual. It is estimated that half of all child stunting occurs in utero. In general, malnourished women and girls of reproductive age have higher chances of giving birth to smaller babies (weight and height), continuing the cycle of malnutrition into future generations. Child stunting also impacts brain development and results in impaired motor skills.” Dr Rajan Sankar, Program Director- Nutrition, TATA

STRATEGY Trusts, propounds,“Poverty and undernutrition are locked in a vicious cycle of increased mortality, poor health, and retarded cognitive and physical growth, diminished learning capacity and ultimately lower work performance, productivity and earnings. As this vicious cycle threatens health and survival, it simultaneously erodes the foundation of economic growth — peoples’ strength and energy, creative and analytical capacity, initiative and entrepreneurial drive. It is right to say that malnutrition slows economic growth and perpetuates poverty. Mortality and morbidity associated with malnutrition also represent a direct loss in human capital and productivity for the economy. The effects of malnutrition are long-term and trap generations of individuals and communities in the vicious circle of poverty. Improving nutrition is therefore essential to eradicate poverty and accelerate the economic growth of low- and middle-income countries.” Sharing the experience from MSF’s Darbhanga project, officials inform that out of over 14,000 children under five treated in, 87 per cent belonged to the poorest and the most marginalised castes and more than 60 per cent were found to be female thereby indicating a distinct social and gender slant in those suffering from malnutrition. The MSF team also observed that breastfeeding practices varied across cultures.

Understanding the cost of malnutrition Malnutrition also adds to overall healthcare costs to a patient and his family as well as the country at large. Experts explain how malnutrition amounts to human and healthcare cost. Dr B Sesikeran, Former Director, National Institute of Nutrition (ICMR), FSSAI says, “Due to long-term illness and prolonged medication expenses caused by malnutrition, parents of malnourished children have to constantly spend a lot of money on medicines and healthcare services driving them into poverty. “In India, it has been estimated that the economic cost

Kelavani Yatra for saving the precious lives of mothers and children, fighting against malnutrition, taking care of primary education and particularly education of girl child. In order to improve the current status of nutrition, it was felt that the preventive and curative strategy needs to be very clearly evolved keeping in view the various stages of desirable interventions namely adolescence, nine months of pregnancy to first two years of age (critical 1,000 days) and for children up to six years. Hence, the Gujarat State Nutrition Mission was formulised.

of micronutrient malnutrition amounts to between 0.8 per cent and 2.5 per cent of GDP.” Referring to a Cost of Hunger in Africa (COHA) report, he says, “The cumulative effects of malnutrition lies in its grave impacts on cognitive and physical development of children as well as medical costs. The costs of malnutrition have been studied to vary from two per cent to 16 per cent of GDP depending upon location and sector.” He explains further, “As per an analysis based on surveys by the National Nutrition Monitoring Bureau during 1988-90 and 1996-97, it is indicated that 30 per cent of households in India consume less than 70 per cent of energy requirement. This was based on the presumed parameter of an average wage of ` 60 per Indian per day for eight hours of work. Therefore, work hour lost per day per person because of inadequate calorie consumption was four hours of moderate work and 7.5 hours of heavy work. Loss of money because of malnutrition related low productivity was approximately ` 30 per day per person. Direct nutrition interventions, such as promoting breastfeeding, and indirect nutrition interventions, such as social protection, investments in agriculture, and ensuring access to safe water and sanita-

tion, can address malnutrition’s underlying causes. Hence, investing in nutrition is key to unlock the potential of a generation of children.” Expounding on the interrelation between improved nutrition and economic growth and its significance to understand human and economic development, Dr Sankar says, “It is a two-way relationship. On one hand, an inclusive economic growth that can contribute towards reductions in the prevalence of malnutrition and on the other hand, reductions in malnutrition can have a transformative effect on economic potential of individuals and whole society. The World Bank suggests that malnutrition results in 10 per cent lower lifetime earnings. It is estimated that each dollar spent on nutrition delivers between $8 and $138 of benefits and another study shows that preventing one child from being born with a low birthweight is worth $580.23. According to the Copenhagen Consensus, ensuring good nutrition is the single most important, cost-effective means of advancing human well-being and advancing on the Millennium Development Goals. Evidence suggests that improved nutrition not only drives stronger economic

growth but is tremendous value for money,” Sankar adds.

Eliminating malnutrition needs a multi-pronged approach The government in the past and is at present continues to initiate efforts to control malnutrition in many ways. The national schemes/programmes include the Integrated Child Development Services (ICDS), National Health Mission (NHM), Mid-Day Meal Scheme, Rajiv Gandhi Schemes for Empowerment of Adolescent Girls (RGSEAG) namely SABLA, Indira Gandhi MatritvaSahyogYojna (IGMSY) as direct targeted interventions. Besides, indirect multisectoral interventions include Targeted Public Distribution System (TPDS), National Horticulture Mission, National Food Security Mission, Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS), Swachh Bharat Abhiyan, National Rural Drinking Water Programme etc. Mentioned below are the good initiatives taken by some states: Gujarat: The state has already implemented various schemes like Chiranjeevi Yojana, Bal Bhog Yojana, Vitamin Yukta Poshan Ahar Yojana (nutritious food with vitamins), Kanya

Following are the preventive aspects of Gujarat state nutrition mission ◗ Acceleration community mobilisation for strengthening comprehensive nutrition programme through extensive behaviour change communication (BCC) ◗ Strengthening ongoing nutrition supplementation programmes through MAMA diwas and Annaprashan Diwas ◗ Strengthen infrastructure of intensive nutrition care centre as “ganishth poshan abhiyan Kendra,” child malnutrition treatment centre as ‘bal sewa Kendra’ and nutrition rehabilitation centre ‘Bal Sanjeevani Kendra.’ Other programmes and schames to tackle malnutrition in the state are ◗ Bal Shaka Scheme ◗ Bal Amrutam ◗ Kasturba Poshan Sahay Yojna ◗ Mission Balam Sukham ◗ Mamta Ghar ◗ Doosh Sanjeevni Yojan ◗ Mission Shakti Rajasthan: In Rajasthan, a joint-initiative of the departments of Women and Child Development, and Medical and Health, with technical support from UNICEF – Rajasthan, the Rajasthan State Nutrition Mission called for convergence of all concerned departments and sectors actively involved in addressing the multiplicity of causes and the multiple determinants of nutrition. Planned in a phased three-year approach (2006-08), in the first phase, the mission focussed on 13 districts, including five with

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STRATEGY tribal predominance, followed by the remaining 19 districts. The community-based Management of Acute Malnutrition (CMAM)— a project undertaken by the government in December 2015 — has helped to treat 9,117 children below five years who were suffering from severe acute malnutrition (SAM). India with a large population that still living in accute poverty needs a multi-pronged approach to tackle malnutrition. According to Médecins Sans Frontières (MSF) the following can be done: Give priority to the 1000-day period: A child’s first 1000 days since birth are critical for his/her survival, growth and intellectual development. This is also a period when the child can potentially suffer from problems like infections or diarrhoea or is underweight. During this period, breastfeeding practices play a vital role in preventing infections and ensuring child survival. Breast milk is the best source of nutrition and immunity for a newborn infant, especially during the first six months of its life. Prevention vs treatment: It is crucial that programmes to treat malnourished children are not considered a solution that removes the need to take preventive strategies seriously. It should not be a choice between preventive strategies versus those that offer medical treatment. Malnutrition cannot be eliminated without adequate information, awareness and preventive measures. Need for credible data and evidence: Collecting reliable data can help understand the prevalence of undernutrition. This would mean investing in obtaining appropriate data including regular nutrition surveillance at the district level. As mentioned before, among the over 14,000 children (under five-year-old) treated, 87 per cent belonged to the poorest and the most marginalised castes and more than 60 per cent were found to be female thereby indicating a distinct social and gender slant in those suffering from malnutrition. This kind of nuanced information is of immense value for generating awareness, plan-

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THE COST OF MALNUTRITION Malnutrition costs $3.5 trillions per year to the global economy

Undernutrition and micronutrient deficiencies cost up to $2.1 trillion per year

ning appropriate interventions and sharing information. More than just health: Nutrition needs to be considered while devising policies for food security, agriculture as well as water and sanitation apart from just being addressed within health. This is important to address critical problems such as, what happens to severely malnourished children when after treatment they go back to the same environment of chronic food insecurity. Understanding the link between health, social welfare and community perception can play a valuable role in the success of malnutrition programmes. Investing in the community: MSF’s experience in Darbhanga has taught them that communities are the most vital in implementation of malnutrition projects. Community health workers help us bridge language and cultural barriers with the community and make treatment more accessible. Empowering the community with information can reinforce the importance of addressing malnutrition and make them partners in successful implementation of programmes. While malnutrition is a national problem, it is critical to engage with community resources and knowledge at the most grassroot level. Investment in health sector: The Integrated Child Development Services (ICDS) system is like the central nervous system of all nutrition programmes and strategies. The ICDS, which comes under the Ministry of Women and Child Health, cannot singularly be tasked with this burden of reducing malnutrition since it is

The cost of obesity and over-weight related non-communicable diseases was estimated at $1.4 trillion in 2010

overburdened, underfinanced and poorly managed. What is important is to invest in nutrition as a priority, by allocating resources or providing institutional mechanisms to combat the problem of malnutrition. The national nutrition mission was framed in 1993, followed by more guidelines and specific policies. There is a need to review these policies in today’s context and developments, while at the same time holding the government accountable to the implementation and political commitments around nutrition financing and governance. Additionally, Dr Khandelwal recommends nutrition specific interventions. “Women education and empowerment as well as their financial independence are important areas. There are three main segments which need to be acted upon simultaneously – nutrition specific interventions (feeding programmes, access to healthy foods, breastfeeding etc); nutrition – sensitive interventions (like women empowerment, education, agriculture, sanitation) and enabling environment (like governance, subsidies, tax reforms, policy etc). We can’t focus on only one dimension and expect any sustainable development or progress in getting rid of malnutrition. This framework dovetailing all three pillars of action against malnutrition need to be recognised and implemented in harmony. For this decision makers, bureaucrats, academia/researchers and programme implementers need some level of capacity building in their respective areas of work. We also need motivated and trained front line health workers for effective action against malnutrition,” she informs.

Child and maternal malnutrition is by far the largest nutritionrelated health burden in the world

Equivalently, Dr Sankar cites from a 2013 report published by Food and Agriculture organisation of the United Nations that examines the cost of malnutrition and ways to resolve the cost issue. India can take some learnings from this report as well. The report says, “The cost of malnutrition is high, but investing in solutions can improve nutritional outcomes long term. Recent research shows that investing $1.2 billion annually in micronutrient supplements, food fortification and biofortification of staple crops for five years would generate annual benefits of $15.3 billion, a benefit-to-cost ratio of almost 13 to 1, and would result in better health, fewer deaths and increased future earnings (SOFA 2013).” (http://www.fao.org/zhc/detailevents/en/c/238389/)

Can nutrition fortification be an answer? In many ways, experts agree that nutrition fortification is a good way to enhance nutrition related interventions. “Food fortification refers to the addition of micronutrients to processed foods. In many situations, this strategy can lead to relatively rapid improvements in the micronutrient status of a population, and at a very reasonable cost, especially if advantage can be taken of existing technology and local distribution networks. Since the benefits are potentially large, food fortification can be a very cost-effective public health intervention. Fortification of food with micronutrients is a valid technology for reducing micronutrient malnutrition as part of a food-based approach when and where existing food

supplies and limited access fail to provide adequate levels of the respective nutrients in the diet. In such cases, food fortification reinforces and supports ongoing nutrition improvement programmes and should be regarded as part of a broader, integrated approach to prevent micronutrient malnutrition MNM, thereby complementing other approaches to improve micronutrient status,” states Dr Sankar. In a manner corresponding to the FSSAI, food fortification has a high benefit-to-cost ratio. Likewise, Copenhagen Consensus- a project that seeks to establish priorities for advancing global welfare using methodologies based on the theory of welfare economics estimates that every one rupee spent on fortification results in 9 Rupees in benefits to the economy. “It requires an initial investment to purchase both the equipment and the vitamin and mineral premix, but the overall costs of fortification are extremely low. Even when all program costs are passed on to consumers, the price increase is approximately by 1-2 per cent, which is less than the normal price variation”, explains Dr Khandelwal. Following are the benefits of fortification of foods according to FSSAI: ◗ Nutrients are added to staple foods since they are widely consumed. Thus, this is an excellent method to improve the health of a large section of the population, all at once. ◗ It is a safe method of improving nutrition among people. The addition of micronutrients to food does not pose a health risk to people. The quantity added is small and well under the Recommended Daily Allowances (RDA) and are well regulated as per prescribed standards for safe consumption. ◗ It is a cost-effective intervention and does not require any changes in eating patterns or food habits of people. It is a socio-culturally acceptable way to deliver nutrients to people. ◗ It does not alter the characteristics of the food like the taste, aroma or the texture of the food.

STRATEGY Food fortification practice in India

be prepared at home,” he said.

Currently, food fortification is endorsed and supported by governments as well as by international agencies such as the World Health Organization (WHO), the Food and Agricultural Organization of the United Nations (FAO), and the United Nations Children Fund. Staple foods including salt, flour, oil, rice and sugar are the main vehicles chosen for this application. India too has acknowledged this and set requirements for the fortification of staple foods. Following publication of a draft regulation in October 2016, which failed to include mention of a product known as ‘standardised milk’ the text was updated and a new version of the regulation published on May 19, 2017. (Refer to the Table 1: Food fortification by FSSAI in 2017) “The government in future is also planning to roll out a strategic phased operation in order to make its nutrition programmes more efficient. The first phase of the endeavour will focus on public funded food programmes which will include supplying fortified food and scale up the programme to various regions and the second will focus on opening market channels through effective communication and public awareness,” disclosed Dr Khandelwal. Besides this, Dr JB Prajapati, Principal & Dean, Faculty of Dairy Science, SMC College of Dairy Science, Anand Agricultural University, speaks about the need to promote fermented food products which are natural and can be prepared and supplied at a low cost. “Fermentation is a natural process and has more nutritional value. For example, when milk is fermented into curds, you will find that curds are more nutritional than milk. Going this route will also save us cost on buying fortified food. At our institute in Anand, Gujarat we have developed an iron fortified butter milk which is rich in nutrients such as iron, fibres and vitamin C and can be made easily available to school going children especially young girl. We are soon going to come up with a booklet of such fortified food stuffs which can even

The role of private sector in supplying fortified foods Well, no endeavour can be complete without the efforts of its multiple stakeholders and the private sector indeed plays an important role in the supply of fortified food. The FSSAI has taken initiative to promote food fortification and with its efforts a number of enterprises have begun adding premixes of micronutrients to launch fortified foods. Dr Sankar reveals, “Big enterprises like General Mills India, ITC, Hindustan Unilever and Patanjali will launch wheat flour and Adani Wilmar, Marico, Borges India, and Kaleesuwari Refineries are working on oil whereas LT Foods, DCP Food and KKR Food will launch rice products. Other brands will join Tata, which already has a double fortified brand in the salt segment. Milk cooperatives in Haryana,

Punjab, Rajasthan, Assam and Maharashtra are fortifying their products too. Targeting children, Rajasthan, Madhya Pradesh, Haryana and Himachal Pradesh governments have begun using fortified oil for their mid-day meal schemes. West Bengal and Andaman and Nicobar Islands are now distributing fortified wheat flour through public distribution system, and Maharashtra government has already started a pilot project. Recently, the key MinistriesWomen and Child Development, Human Resource Development Departments, and Consumer Affairs, Food and Public Distribution have issued guidelines to provide fortified foods: Oil, wheat flour and double fortified salt through the ICDS, MDM and PDS.”

A strategy that is well meaning The government is doing its bit. As per an industry source, the

government will come up with guidelines for CMAM (Community-Based Acute Malnutrition Model) to tackle this issue. The private sector as well is extending its efforts in this space; however, the fact remains that malnutrition cannot be resolved just by fortifying foodstuff. It needs a 360 degree approach. “Food fortification is just one aspect to tackle malnutrition, the country certainly requires a multi-pronged approach wherein all aspect of this condition and situation is covered. We as regulators will continue to streamline our policies to the benefit the people so that no consumer can be mislead by any manufacturer or marketer,” maintains Ashish Bahuguna, Chairman, Food Safety and Standards Authority of India. Adding to this, Dr Khandelwal shares, “All depends on effective enforcement. Manufacturers/retailers at all levels

should comply and honestly meet the norms, since the FSSAI plans to get local flour mills to add premixed nutrients. Our PDS should be strengthened and made corruption free. Awareness generation campaigns to encourage people to adopt a diversified and wholesome diet should be run simultaneously. Junk food advertising should be curtailed. Also, the issue of affordability should be placed as a central concern, because unaffordable fortified food would defeat the very purpose of fortification.” At the end, malnutrition cannot be eliminated in a country like India without a political will as well as concerted efforts of all stakeholders. Strategies to resolve the issue of malnutrition needs to be designed keeping in mind that food security and access to healthcare needs to be a basic human right. raelene.kambli@expressindia.com

TABLE 1: INDIAN STANDARD FOR FORTIFIED FOODS BY FSSAI IN 2017 Micronutrients

Food commodity

Level of micronutrients

Iodine

Salt

Manufacture level: Not less than 30 mg/kg dry basis Distribution channel: Not less than 15 mg/kg dry basis

Iron content (as Fe)

Salt

850 – 1100 mg/kg

Ferric salt

Atta, Maida, rice

= 20 mg/kg

Ferrous salt

Maida

= 60 mg/kg

Zinc

Atta, Maida, rice

= 30 mg/kg

Vitamin A

Milk (standardized, toned*, double toned or skimmed milk)

= 770 IU/L

Vegetable oil

= 25 IU/g

Atta, Maida, rice

= 1500 ug/kg

Synthetic vitamin A

Vanaspati

At the time of packing: not less than 25 IU/g

Vitamin D

Milk (standardized, toned*, double toned or skimmed milk)

= 550 IU/L

Vegetable oil

= 4.5 IU/g

Folic acid

Atta, Maida, rice

= 1300 ug/kg

Niacin

Atta, Maida, rice

= 42 mg/kg

Vitamin B1

Atta, Maida, rice

= 3.5 mg/kg

Vitamin B2

Atta, Maida, rice

= 4 mg/kg

Vitamin B6

Atta, Maida, rice

= 5 mg/kg

Vitamin B12

Atta, Maida, rice

= 10 ug/kg

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November 2017

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

â&#x20AC;&#x2DC;We need digital approach, data intelligence and patient-centric cultureâ&#x20AC;&#x2122; Sanjay Joshi, CTO, Life Sciences and Healthcare, Dell EMC, elucidates how linking Aadhaar data can give better healthcare outcome to India, in an interview with Prathiba Raju

What is the role of data and how will it elevate the Indian healthcare system? There is a lot of development going on in the Indian healthcare space. Particularly, Aadhaar, the nation-wide biometric card, which even includes retina scans, is an interesting and robust set of data. Right now, if the government actually wants to understand the national scale of diverse health issues be it maternal or child health, air and water quality issues, it can analyse the Aadhaar data. To begin with, every state government should monitor these data closely. 70 percent of people reside in rural India and with one doctor per 2000 citizens, the Indian healthcare system can he helped by digital approach, data intelligence and a patientcentric culture. Engineering-based Dell EMC, Centers of Excellence (CoE) in Bengaluru and Pune, are providing healthcare data and cloud solutions. How to combat NCDs via technology and what does Dell EMC offer? Rising incidents of lifestylerelated, non-communicable diseases like cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD) is a great challenge. According to the Institute for Health Metrics and Evaluation (IHME), an independent global health research center at the University of Washington, CVD is the top killer in India. However, the second largest killer is COPD and the largest source of this is air pollution and smoking. We need to address these issues with

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November 2017

technology and growing pool of digitally-empowered patients. The government is working on smart cities, but I would say that without healthy cities we cannot have smart cities. Dell EMC, an infrastructure company is service-oriented and we are also looking to make data centres more efficient and let the people who move the business forward take care of the business part rather than taking care of hardware management and IT infrastructure. For example, if my data is in 10 different places,it can be seen in a given time with solutions like Elastic Cloud Storage (ECS) and Isilon (it is an unstructured file-based data system). We need to focus on healthcare data because 20 years down the line, the primary healthcare will disappear, as everything will be replaced by data and information, and it will be useful for rural economy. As Dr Leroy Hood, famous futurist, Systems Biologist and Seattle native, wrote in Nature journal that healthcare will be seen as 4Ps: Predictive, Preventive, Precision and Participatory. Hence, India needs to put in more effort and money to scale up in healthcare. Can you share the details on pan-cancer genome projects? Initially, six countries were working on cancer projects, which, has now scaled up to 16 countries. India is looking into specific cancers like pancreatic cancer, head and neck cancer, breast and ovarian cancer. I have talked about it to many scientists,

push the technology forward.

who believe that there is a viral vector to cancers and many are working on it. Do you think tele-radiology could benefit the current healthcare industry? As a tele-radiology believer, I would say telemedicine is definitely going to be the largest transformative change for healthcare, especially in places that lack access. Technology has always been there but we need the government's understanding to move IT forward by having more and more innovations. For this, both the central and state governments should interact with each other. Our goal ultimately is to get to a point called Vendor Neutral Archives (VNA), like addressing communicable disease or simple things like typhoid, diarrhoea, dermatological care and skin

problems. VNA is a central imaging archive, we need a larger adoption of it as it can scale up the value-chain for telemedicine. It consolidates multiple imaging departments into a master directory, associated storage and lifecycle management of data. Besides, modalities like radiology and pathology will be the key delivery areas in tele-medicine; for example, bringing in portable ultrasound for mother and child health. Our focus is to say how physicians can understand the modern medicines as it is happening. The stethoscope which was invented in 1800s is now wireless, a couple of Indian star-ups are working on it. Tele-medicine can help elevate rural health ecosystem if we collaborate with small start-ups and governmental agencies. And, since telemedicine is critical, we need to

The Global Data Protection Index commissioned by Dell EMC informs only 24 per cent of public healthcare providers in Asia are very confident of fully recovering systems and data to meet business service level agreements in the event of a data loss incident. Your comments? The core tenets of building a secured information and recovery platform is the access control. We need to look into who is coming into your data or information system and how can you authorise the right people to look at the data. An identity manager is important and critical for healthcare for which Aadhaar can be used as it comprises unique IDs and can be attached to a patient ID as well. Nevertheless, we need to have robust security system for the same as future warfare are going to be in biology. Other than Isilon, Dell has acquired RSA, which is one of the largest security companies. Data protection and people who handle data are need to be regularly trained, globally, Germany and France are the two countries, which give lot of importance to data protection. How important is it for the public health system to invest into IT? From a public healthcare perspective, the biggest issue for Indian healthcare system is 1:2000 doctor and population ratio. As the doctor has no information about the patient history, countries like Taiwan, Japan, South Korea have public health cards. Some of the technologies

‘We need digital...

INSIGHT

How IoTis transforming the healthcare industry? Tim Sherwood,Vice President,Mobility & IoTSolutions,Tata Communications shares his insights on the opportunities unleashed by IoTto boost efficiency and productivity in healthcare organisations In the face of ever-increasing competition and evolving demands of patients in different geographies, healthcare service providers need to innovate and plan for digital transformation. In the developed world, they need to be equipped to treat an increasingly ageing population whereas in the developing world, a big challenge still is how to reach more and more people in regions and communities with not enough healthcare staff. Given these varying demands, more and more healthcare organisations are investigating machine-to-machine communications and the Internet of Things (IoT) to stay ahead. Looking at the Internet of Medical Things (IoMT) market, a report by Frost & Sullivan estimates that this segment is expected to grow at a 26.2 per cent compound annual growth rate (CAGR) to reach $72.02 billion by 2021. This is a huge increase for a market that was worth ‘just’ $22.5 billion last year. Furthermore, according to Deloitte and NAT Health report, healthcare industry in India is expected to be worth $145 billion by 2018 and over $280 billion by 2025. It’s highly likely that digitisation will be an accelerator for this growth in the coming years. While patients are already used to decentralised treatment centres, self-diagnosis portals and even telemedicine, this is just a beginning. Process management and cloud-based applications are unleashing new ways of working such as remote monitoring and support of patients, and delivering innovative ways for customers to access healthcare services. The supply chain is changing too, with more and more collaboration across the entire ecosystem to bring down costs, accelerate the digitisation of medical records and introduce more patient-centric treatment

models. This brings very real benefits to the quality of patient care, as local practitioners have more up-to-date data on their patients and their conditions at their fingertips, enabling doctors and nurses to make better informed data-led decisions with regards to remedies and patient care. Now the IoT looks set to change the healthcare sector once again. It’s worth investigating four key factors that are going to be crucial during this next evolution.

Healthcare will go global Health organisations need to take digital transformation on board to extend their services and reach in areas and communities where there aren’t enough healthcare professionals to treat a growing number of increasingly elderly patients. To succeed, they’re going to have to get the right strategy in place. Large healthcare groups are international, so connectivity services need to be international too. It’s no longer possible to think on a purely domestic basis. Healthcare providers need a reliable communications network partner that can provide end toend mobile and cloud connectivity as well as data management services. Only by offering excellent service, both in a domestic setting and across borders can they win and keep new business.

Continuous collaboration Multi-platform collaboration across employees, partners and patients is the next step for healthcare organisations. By

giving everyone access to the data and applications they need, wherever and whenever they’re needed, healthcare organisations can boost productivity and drive efficiency. Let us consider the advances that telemedicine has already introduced. Remote treatment of patients is estimated to have delivered savings of $132 billion in the EU alone. One trend we’re bound to see is ever-better connectivity, as hospitals and organisations link up their care estate and supply chains to deliver a truly seamless service.

Connected healthcare experiences for everyone Today’s connected consumers – and patients – increasingly expect their healthcare provider to offer them a similar digital experience as they are accustomed to when it comes to managing their finances through online banking, or ordering goods online. Patients want real-time data on their health and the ability to communicate with their doctor or nurse whenever, wherever. More and more clinics are already offering appointments via self-service portals, and alerts through simple application-to-person (A2P) messaging to remind patients of their appointment. Given the pervasive nature of SMS, there is scope for healthcare providers to extend the use of A2P messaging to, for example, remind their elderly patients to take their medications too. Furthermore, the increasingly sophisticated nature of IoT-enabled healthcare devices means that we’re only starting to scratch the surface of the potential of remote healthcare provision and monitoring. However, healthcare organisations don’t simply need to start providing their patients with a seamless experience, they also need to consider how best

to interact with partners too. Hospitals, diagnostic labs, consultants, researchers – they should all expect an omni-channel experience to deliver the best possible service. Furthermore, all parts of the healthcare ecosystem – hospitals, research facilities, pharmaceutical companies, clinics and patients – should be able to communicate and work together more easily, with a more seamless flow of information (with the patient’s consent of course). Patient data is critical, yet connectivity could introduce a security risk. Organisations may also find it difficult to scale solutions as demand fluctuates. That’s why they have to make sure they’re choosing the right partner for their infrastructure solutions.

Trustworthy and reliable As they take advantage of digital transformation, healthcare providers are going to have to take positive steps to manage to risk. That means protecting patient records and other data and applications against external threats. It also means ensuring service continuity and zero disruption in the event of a breach: it is not inconceivable that cyber criminals start to target millions of IoT-enabled healthcare devices to stage huge attacks which could put people’s lives at risk. That is why healthcare organisations need to adopt an adaptive security strategy.

A healthy transformation It’s time for healthcare providers to offer a cross-border service, with a global network infrastructure and global connectivity. Only an international partner that offers global mobile network access and connectivity agreements is going to meet the requirements to deliver services such as tele-medicine, remote diagnostics and eHealth services.

look upon a card which is used for both transport, health and fixing appointment with the physicians. There comes the role of Internet of Things (IoT), which will shape the future of many industries, including healthcare. Therefore, healthcare organisations must first get their data strategy right, so that these new technologies can add value to patients by increasing survivability and life expectancy or providing predictive and prescriptive indicator for diseases. How Dell EMC is unique from other IT companies and what are the digital transformations you are working on? The US has invested in digitising healthcare records. Similarly, India's Aadhaar card can be a good role model for digitising public healthcare system. Public and private healthcare should be integrated but looking forward, it is a huge challenge, as integration of structured information in the medical records is important. We need to know things from the infrastructure perspective; for example, statistics on smoking pattern among patients, Computerized Patient Order Entry (CPOE), drug reconciliation -- which monitors the drug a person takes. Moreover, EMC is present in more than 50 per cent of the US hospitals and partnered with Independent Software Vendors (ISVs) like Siemens, Philips and GE. From national scale perspective, I would highly recommend that India should consider building nationalscale imaging archive and the state governments should control their own archives. Dell EMC would like to join hands with the Indian government in building up a national-scale pandemic disease infrastructure. We can create disease registries for communicable and non communicable diseases and showcase how big data can help. prathiba.raju@expressindia.com

EXPRESS HEALTHCARE

November 2017

THIS DAY THIS MONTH

Sugar,part with sugar! With diabetes bringing along a spectrum of ailments as co-morbidities for women, management of the disease needs to involve tackling precursors which will aid in preventing it. Mansha Gagneja talks about the strategies that can be put to use

aving its roots in the mid 16th century, diabetes mellitus has been growing rapidly. Among all non-communicable diseases prevalent, diabetes mellitus ranks in the top few which seek serious attention in both highincome as well as developing countries. In India, it is quickly gaining the status of a potential epidemic with more than 70 million diabetic individualshalf of them women, currently diagnosed with the disease. This reckons us to look at the management strategies to cope with diabetes. Currently, the management strategies used for both men and women are mostly common, even when the ailment is much more complex in women leading to multiple consequences. Thus there is an immediate need to focus on devising tailor-made approaches particularly for women so as to tackle the disease. World Diabetes Day is celebrated every year on November 14 and this year’s theme ‘Women and diabetes - Our right to a healthy future’ aims to draw attention to the complexity and magnanimity of the issue. In a country like India, where socio-economic factors and gender bias are prevalent, women on many levels are still portrayed as the caregiver and in the process neglect their own health. Hence, major strategies to aggressively manage the disease need to be devised particularly in favour of women as diabetes’ effect grows multifold in this segment of the society.

Plethora of ailments With the advancement of technology, there has been a radical change in the lifestyle of every individual and women are no exception. Also, in Asian

EXPRESS HEALTHCARE

November 2017

Source: International Diabetes Federation

countries, including India, the risk factor is relatively higher due to the genetic predisposition towards diabetes adding to the grave situation that already exists. Amitabh Nagpal, Founder and CEO, Lifeincontrol.com, a diabetes management programme, highlighted about a 2016 study conducted by the Department of Science and Technology (DST) and re-

vealed that the incidence of diabetes is increasing among urban Indian women, leading to premature mortality due to increased vulnerability to other diseases like cardiovascular diseases, glaucoma, neuropathy and skin infections. The report found that the prevalence of the disease condition is 17.7 per cent among urban middle class women while it is 10 per cent in rural areas.

Risk factors for diabetes The management of diabetes in women does not differ much from that in men. However, there are certain peculiarities that women with diabetes have as the disease causes various other ailments. Sedentary lifestyle along with increase in unhealthy patterns of life act as catalysts in diabetes growth. There are precursors that act as risk factors leading to diabetes.

PCOS: According to a PCOS study, one in ten women has Polycystic ovary syndrome (PCOS) which is a high risk factor for women to develop diabetes in future. Dr Duru Shah, Scientific Director, Gynaecworld, informs that almost 50-60 per cent of these women develop insulin resistance which is a pre-diabetic state. She emphasises on how constantly monitoring these patients will prevent them from developing more incidents of diabetes. Gestational diabetes: Women, majorly PCOS patients are at a higher risk of developing diabetes during pregnancy due to the rise in sugar levels which results in gestational diabetes. According to the report ‘Women in India with Gestational Diabetes Mellitus Strategy (WINGS): Methodology and development of model of care for gestational diabetes mellitus (WINGS 4),’ prevalence of Gestational Diabetes Mellitus (GDM) has dramatically increased by 16–127 per cent in the past 20 years among various ethnic groups. The International Diabetes Federation (IDF) stated that there is a notable difference in the prevalence of GDM, with the South East Asia Region having the highest prevalence (87.6 per cent) of all the low- and middleincome countries (LMICs), where access to care is often limited. Asian women are more prone to develop GDM than European women and Indian women have 11-fold increased risk of developing glucose intolerance in pregnancy compared to Caucasian women. Studies conducted in the 1980s have shown that the prevalence of GDM in India was 2 per cent, which subsequently increased to 16.55 per cent in 2000.”

EXPRESS HEALTHCARE

November 2017

THIS DAY THIS MONTH Obesity: Obesity is a neuroendocrine disease that is itself associated with numerous metabolic complications. In addition, it has a strong relationship with diabetes and insulin resistance and so it is an important determinant of the long-term risk of developing type II diabetes in genetically predisposed individuals. Consequently, overweight or obese women begin their pregnancy with insulin resistance and increased predisposition towards GDM. An excess of weight gain during pregnancy would further worsen these phenomena and increase the risk of GDM as well, even in women with normal prepregnancy weight. Let us now look at a few comorbidities of diabetes that get aggravated if the timely prevention and management of diabetes is not taken seriously. Hypertension: According to the report ‘Hypertension in India: A systematic review and meta-analysis of prevalence, awareness, and control of hypertension’ about 33 per cent urban and 25 per cent rural Indians are hypertensive. Only 25 per cent rural and 38 per cent of urban Indians are being treated for hypertension. Uncontrolled diabetes is a major risk factor for hypertension and thus unmanaged diabetes will drastically increase the burden of diabetes. Cardiovascular disease: Diabetes is a powerful risk factor for heart disease in women. These women also experience more complications after developing a heart disease. Dr V Mohan, Chairman, Dr Mohan Diabetes Specialties Centres states that normally, women in the reproductive age group i.e. up to menopause are protected from coronary heart disease. However, when women get type II diabetes at a young age, this protection from the heart disease disappears and they have the same, if not higher risk, of developing heart attacks as men with diabetes of the same age group.

Management of diabetes in women There is a need for prevention, monitoring and controlling di-

EXPRESS HEALTHCARE

November 2017

abetes in women at multiple levels. The key to managing diabetes better is through education and awareness. Spreading the word about symptoms and measures to be taken at different levels will certainly bring about a change in the statistics. Currently, many initiatives have been set in motion. For instance, Dr Mohan highlights that the government has initiated the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS). This programme includes prevention and control of diabetes at several levels i.e. at the school level, community level and worksite under the primary, secondary and tertiary prevention of diabetes. The private sector has been extremely active in diabetes and India has one of the largest number of diabetologists in the world. One such programme by institutions like Dr Mohan’s Diabetes Specialities Centre is large scale capacity building in the field i.e. training doctors and other paramedical personnel to diagnose and treat diabetes well. Another pro-

gramme, D-CLIP studied 600 people with pre-diabetes and put them on intensive lifestyle management programme i.e. diet and exercise and weight reduction were appropriate. The results were very impressive. Upto 32 per cent of people with pre-diabetes could be prevented from developing diabetes. Programmes such as these are needed to be expanded throughout the country. Dr Mohan also suggested that if we start focussing on young girls and prevent obesity in them, we can prevent and control PCOS and thereby prevent gestational diabetes. By this process, we can also bring down the incidence of type II diabetes and cardiovascular disease in women in the future. Routine screening of all pregnant women to rule out gestational diabetes has now become mandatory and if this is followed right from the first trimester of pregnancy, gestational diabetes can be diagnosed early and hence the associated morbidity both in the mother and the child can be prevented. Dr Shashank Joshi, Consul-

tant Endocrine and Metabolic Physician, shared a different perspective. He said there is a need to promote physical activity like cycling and aid such programmes. Another way of preventing diabetes is by formulating strict laws for food labelling so as to curb the unhealthy foods to promote better lifestyle.

The way forward… India is the world capital of diabetes. The disease contributes substantially to many deaths that are ultimately ascribed to other causes, such as cardiovascular disease. Diabetes causes special problems during pregnancy, and the rate of congenital malformations can be five times higher in the offspring of women thus causing tremendous increase in cost of healthcare. If some of these resources can be directed towards research of the ailment , it will help us level up in fighting the disease. Much has been learned about the basic biology, epidemiology and treatment of diabetes, yet immense scope exist to understand, treat, cure, and prevent

diabetes. Research in the field of regenerative medicine to cure and prevent diabetes may also help in managing the burden. Dr Prabhu Mishra, CEO, Cofounder, StemGenn Therapeutics, states, “Another revolution aiding the removal of diabetes is regenerative medicines witnessed through stem cell therapy or bone marrow harvest. It directly heals the ailing pancreas and regenerates it. It prevents vascular complications and one would be liberated from the constant jabbing of the insulin needles. Diabetes severely affects multiple organs, puts us at a greater risk of kidney failure, blindness, heart attack and is a breeding ground for other infections as well.” Many more efforts need to be put in the form of initiatives, awareness programmes and advance research so as to achieve the shift from merely diabetes care and management to the issue of attaining a better quality of life through prevention and curing it. mansha.gagneja@expressindia.com

RADIOLOGY I N T E R V I E W

“AOCR 2018 is a perfect showcase to see the latest in machine advancement and technology in India' As the radiology sector in India gears to witness one of the largest gathering of experts from this field in January 2018, Express Healthcare speaks to Dr Sanjeev Mani, Organising Secretary IRIA 2018 and Secretary, MSBIRIA, to understand what’s in store for radiologists during the four-day event Tells us about the latest trends in radiology world wordover? Continuous advances in radiology are taking place across the world. With better resolution, faster machines, more of multi-modality imaging is coming to the fore. The ultrasound goalpost has also been widened with superb 3D & 4D imaging and a more common use of contrast in ultrasound imaging. The AOCR 2018 is a perfect showcase for delegates to see the latest in machine advancement and technology in India. What are the business opportunities that the Indian radiology industry can look up to in 2018? The radiology industry is rapidly growing with a significant penetration of advanced machines now extending to tier-II and tier-III towns. With availability of such equipment through all India distribution, people across India are likely to benefit. Radiologists and entrepreneurs from across the country are likely to see the best technology available in India. This is likely to fuel purchases across India, and hence growth of radiology across India over the next few years. What are the current issues that the radiology sector in India is grappling with? Radiology in India is currently in a good space; however, ongoing issues with regards to the PC PNDT Implementation, turf erosion and trade coordination are

some areas where the current IRIA office bearers team is involved to solve issues across these levels. Tell us us about the preparations for IRIA and AOCR 2018? What should the industry expect from AOCR 2018 clubbed with 71st Annual Conference of IRIA? The 17th Asian Oceanian Congress of Radiology and the 71st Annual Conference of the Indian Radiology and Imaging Association (IRIA) will be held at Renaissance Mumbai Convention Centre Hotel, Powai, Mumbai from the January 25- 28, 2018. With four days of lectures spread across six halls, five halls for presentation of scientifc papers, E posters on screens across the conference arena, more than 20,000 sq feet of space for scientific exhibits, Mumbai Chaat Street, three consecutive nights of topnotch social events, and stay available at the venue itself for those taking the residential package, the event is packed with tremendous academics and enjoyment for all delegates who will attend AOCR 2018, an event reaching Indian shores after a gap of 25 years. A strong participation from AOSR group of countries is expected for this event, with a heavy dose of international and national faculty that will make this a not-to-miss event in the annals of radiology conferences in India. We have geared ourselves to showcase an academic and cultural extravaganza and look forward to your presence at this event. We will leave no

expecting? We expect more than 4000 radiologists to take part. More than 2500 have already registered for the conference upto October 31, of which more than 30 per cent are radiology students. The participation is expected to cross 4500 delegates, if we include trade, industry and AOSR representatives. Our focus is on making it a great learning experience for radiology residents.

The 17th AOCR and the 71st (IRIA) will be held in Mumbai from January 25-28, 2018 stone unturned to ensure a wonderful experience for the delegates. It is a great opportunity to meet friends, network, watch legends give cutting updates, see budding talent amongst indian radiologists, be a part of exciting on site quiz contests, see new equipment showcased at the trade exhibit, and enjoy wonderful cultural events that showcase India’s rich heritage across three social events during the course of the event. How many radiologists and allied industry representatives are you

What is the focus for this year? The focus for this year is advanced imaging across Asia. The conference is being held in association with the Asian Oceanian Society of Radiology (AOSR) by the Indian Radiological & Imaging Association (IRIA), and more than 25 international speakers are expected to share their experiences from across the Asian Oceanian region. How will this year’s gathering be different from the previous ones? Six dedicated halls for scientific sessions, and five halls for paper presentations have been planned at this event. The six session halls will have LED screens with digital screening of all lectures. We are planning a green conference with minimal use of paper and all updates and notifications on our mobile App via SMS. Mumbai is the commercial capital of the country and the Local Organising Committee (LOC) is working hard to cover all facets of the event to make it successful. We are

already primed to be the highest attended conference of radiology ever in the country. More than 1000 papers and posters are expected for this event. A huge registration of radiology students and resident doctors is expected, and the interest from your radiology blood is heartening to say the least. Three social events will be held, and will also include high voltage performances by stars from Bollywood, and culminating with a entertainment performance on Saturday night. What are the scientific programmes focussing on? What are the kind of topics that will be covered? All modalities of radiology under all subsections will be covered by international, Asian and the best of Indian faculty. Topics across neuroradiology, chest radiology, abdominal imaging, OBGY imaging, and all other important subsections of radiology will be covered. Are there any learnings from the previous years that you would like to incorporate this year? Our focus this year is on a dynamic website and Mobile app (AOCR 2018) that has already been launched. We will be providing live feeds of key moments of the conference through our live updates section on the Mobile App. Our Facebook page also showcases the event as we countdown to January 25, 2018. EH News Bureau

EXPRESS HEALTHCARE

November 2017

RADIOLOGY

17 AOCR and 71 IRIAto be held in Mumbai from Jan 25-28,2017 th

The conference will have four-day of lectures spread across six halls, five halls for presentation of scientific papers THE 17 TH Asian Oceanian Congress of Radiology (AOCR) and the 71 st Annual Conference of the Indian Radiology and Imaging Association (IRIA) will be held in Mumbai from January 25 – 28, 2018. With four-day of lectures spread across six halls, five halls for presentation of scientific papers, E posters on screens across the conference arena, more than 20,000 sq feet of space for Scientific Exhibits, Mumbai Chaat Street, three consecutive nights of top-notch social events, and stay available at the venue itself for those taking the residential package, this event is packed with tremendous academics and enjoyment for all delegates who will be attending AOCR2018, an event reaching Indian shores after a gap of 25 years. A strong participation from AOSR group of countries is expected for this event, with international and national faculty that will make this a not-to-miss event in the annals of radiology confer-

ences in India. The conference is open to IRIA members of India, and members of the AOSR. Dr Bhupendra Ahuja,

the conference. The members of IRIA are requested to attend this mega academic event in large number and make it a grand success.”

2018, the most important scientific and educational event of AOSR. AOCR is traditionally designed for your to explore and experience new de-

A strong participation from AOSR group of countries is expected for this event, with international and national faculty that will make this a not-to-miss event in the annals of radiology conferences in India.The conference is open to IRIA members of India, and members of the AOSR President, IRIA said, “The organising committee is putting in tremendous efforts to make this event a great academic feast. The scientific programme is being planned keeping in mind of residents’ teaching and more of clinical radiology, which is a demand of today. I am sure that this congress will be a resounding success and delegates will go back with fond memories of

YI-Hong Chou, President, AOSR said, “As the President of AOSR, I would like to welcome all members of AOSR to this biennial congress of AOSR. On behalf of the Executive Committee of the AOSR, I shall thank all members of the Organizing Committee of AOCR 2018, the strong team from IRIA, for their hard work and very warm hospitality in organizing the AOCR

velopments and clinical applications of radiological science. The scientific programme is studded with lectures by eminent international faculty from various international societies and also from various countries of Asian-Oceanian region on the latest trends in radiology. I hope you will also take some time to interact with your peers and colleagues, ex-

change your experiences and knowledge with the internationally recognized experts/professors. One of AOSR’s missions is to expand the opportunities for radiologists throughout Asian and Oceanian region and the world to practice in newly developed technologies through the scientific and education programmes. Our goal is to enhance the level of patient care through medical imaging, one of the most exciting and progressive disciplines and the frontier in current medicine and healthcare.” The organising chairmen are Dr Jignesh Thakker and Dr Bhavin Jankharia; vice chairmen, Dr Suresh Chandak, Dr Suresh Saboo, Dr Rajesh Kapur; organising secretaries, Dr OP Bansal, Dr Shailendra Singh and Dr Sanjeev Mani, Joint Secretaries, Dr Lalendra Upreti, Dr Aniruddha Kulkarni and Dr Mrudula Bapat, treasurers Dr Pramod Loniker and Dr RK Sodani. EH News Bureau

Carestream introduces easy, affordable upgrade to DR New wireless tablet control delivers exceptional flexibility; saves time and money Carestream Health makes converting to DR easy and affordable with the launch of its CARESTREAM DRXTransportable System/Lite. This system equips facilities to convert room-based or mobile imaging systems to DR through use of a wireless tablet PC that gives users complete control of the X-ray system and displays diagnos-

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November 2017

tic images as they are acquired. Control from the wireless tablet eliminates the need to interface with a generator and use a cable connection, which delivers exceptional flexibility and saves both time and money. An access point in the detector communicates with the access point in the tablet to create a flexi-

ble solution that enhances workflow. This new system is available in the US, Canada, Europe and selected countries around the world. It will be displayed at the Radiological Society of North America meeting (Booth #6713). “The ability to quickly and easily convert CR systems to DR with the use of Care-

stream’s wireless tablet offers dramatic advantages for healthcare providers,” said Sarah Verna, Global Marketing Manager, Carestream, Xray Solutions. “The lightweight wireless tablet equips users to capture DR exams from any room-based or mobile imaging system while moving freely throughout the radiology department and

the hospital.” This system uses a virtual access point in the DRX detector to manage image capture and display images on the tablet. The tablet PC is self-powered and rechargeable. It has a 12-inch touch screen and weighs just 3.6 pounds. EH News Bureau

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TRADE AND TRENDS

Key trends in urinalysis market Harshad Bhanushali,Product Manager,Instruments DiaSys Diagnostics India, gives an insight about the growth story of urinalysis market URINALYSIS TESTING is used as the frontline diagnostic tool in the diagnosis of various metabolic abnormalities and UTIs. It is also used as a disease management tool for the treatment of chronic diseases such as diabetes, Chronic Kidney Disease (CKD) and urinary bladder cancer. Rising kidney diseases owing to change in food consumption habits accompanied by growing concerns from geriatric population are among major industry drivers. As urinalysis plays an integral role in the diagnosis of such diseases, the urinalysis market is expected to grow significantly in the near future. The growing prevalence of these target diseases and the introduction of technologically advanced, rapid,

non-invasive and user-friendly tools for urinalysis are estimated to be the major growth drivers of this market. Asia Pacific urinalysis market share is expected to witness growth of over 7 per cent CAGR up to 2023, mainly due to demand across India and China. Increase in adoption of advanced urine analysers coupled with large number of untapped population is forecast to present attractive growth opportunities. The urinalysis market is broadly classified into product type, test type, applications end- user and region. On the basis of product type, it is subdivided into consumables and instruments. The consumables segment accounts for the largest share of the global mar-

ket. Key reasons to influence demand of consumables segment leading to global revenue are increasing test strips and reagents usage due self-awareness. Dipstick, disposables and reagents are the major consumables in the industry. The major-end users of urinalysis systems include hospitals and clinics, research laboratories and institutes, diagnostic laboratories and home care settings. Clinical laboratories are the dominant segment and account for around 35 per cent of the global share. Growing concerns pertaining to hygiene and cleanliness accompanied by increase in number of hospitals and healthcare centres should positively drive the demand. Based on applications, the

global urinalysis market is segmented into disease diagnostics and pregnancy tests. The disease diagnosis application segment is projected to witness the highest CAGR in the coming years due to factors such as increasing research for the development of new urinalysis tests for better, early diagnosis of chronic diseases and increasing incidences of chronic diseases. DiaSys Diagnostic India offers QDx Urinalysis solutions: ◗ QDx Urine strips (DS 10, DS 11 MAU, DS ACR and DS 4 MAU) giving reliable results, free from ascorbic acid interference and high sensitivity for all parameters. ◗ Urine analysers (DS 100 & DS 500) which are versatile and suitable for DS 10/10+, DS 11

MAU & DS 11 ACR parameter strips with convenient customer usage. ◗ DiaSys introduces QDx DS Mini- a portable hand held Urine Analyzer suitable for DS 10, DS 11 ACR and DS 4 MAU strips with a convenient user friendly GUI. Contact details DiaSys Diagnostics India Plot No A-821, TTC Ind Area, Mahape, Navi Mumbai - 400710 Mobile: +91 9029023012 Fax: +91 (022) 3371 4333 E-mail: harshad.bhanushali @diasys.in

PPPs in healthcare: Need of the hour Vivek Tiwari, Founder and CEO, Medikabazar, elaborates on how collaboration between the public and private sectors of the healthcare industry would foster PPPs and encourage investment in India's healthcare sector HEALTH OF the nation is the lifeline for its well being. It is the aggregation of the health conditions of its citizens. The Indian healthcare sector is one of India’s largest sectors, in terms of revenue and employment, and the sector is expanding rapidly. It has emerged as one of the most challenging sectors in India and is expected to reach $280 billion by 2020 with an annual growth of 17 per cent. The Indian healthcare delivery environment is facing distinctive challenges. Inadequate infrastructure and inefficient healthcare delivery process further intensifies the complexity. It is estimated that almost 15 per cent of India’s population, has absolutely no access to healthcare services, either due to unavailability or economic reasons. Around 75 per cent of doctors practice in urban areas and 23 per cent in towns, while only 2

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per cent practice in rural areas leading to very low availability of healthcare in rural areas. The Indian healthcare system consists of players from public sector, private sector and other informal networks. The very size, scale, and spread of India are a huge challenge. The industry is largely fragmented with independent and privately run hospitals and health centres. It operates in a largely unregulated environment, with minimal controls on the type of services to be provided. This is further complicated by the usual Indian tendency to lack of standardisation and minimal compliance though there are norms and guidelines. These challenges can be addressed efficiently through combined efforts of both public and private sectors by forming suitable public policies especially for healthcare delivery and incen-

tivising financing and provision of healthcare, and thereby increase healthcare access to the people. The collaboration between the public and private sectors of the healthcare industry, would foster Public Private Partnerships (PPPs) and encourage investment in healthcare sector to shape the future of Indian healthcare Industry. There are five major indicative areas where PPP could be introduced as a synergistic model to achieve the objectives

of Indian healthcare sector and the business objective of running a beneficial healthcare facility. The five areas where PPP contribution can prove very valuable are: ◗ Infrastructural development - Development and improvement of healthcare infrastructure to ensure that services are evenly distributed geographically and at all levels of healthcare (primary, secondary and tertiary healthcare) ◗ IT Infrastructure of the industry – Establishing IT as the backbone of healthcare in the industry for easy data management and easy and uninterrupted access to healthcare. ◗ Systematic operations and management – Involvement of PPP in operations will ensure efficient services and quality operations and management of healthcare facilities. ◗ Education and training –

Education for formal education and continuing education of professional, paraprofessional and ancillary staff engaged in the delivery of healthcare ◗ Financing mechanism Creation of voluntary as well as mandated third-party financing mechanisms. The private sector investments in healthcare have been driven by free market economy, and the pricing of healthcare services has been largely influenced by investment cost. Consequently, these services have remained out-of-reach of a large majority of our population due to cost consideration. In order to make PPP as a sustainable common ground for both public and private sectors and to evolve successful PPP models, it is essential to have clarity of the public and private sector positions and develop unambiguous criteria for assessing PPP models.

Importance of QC and medical standards for image diagnostic devices Ing Juergen Heckel, VP, Medical Business, Sales & Marketing, Global, Certified Medical Device Advisor, EIZO Corporation, gives an insight about contents of quality control process ACCURACY AND stability are the most important targets we have to achieve in healthcare industry for the best patient treatments. The visibility of cancer is very difficult and depends very much on the visible image contents and used equipment at the hospital. The doctors are only able to diagnose what is visible in special on the medical grade monitor so called image diagnostic device. Why Quality Control (QC) is important and what exactly will be controlled? For image diagnostic devices quality control means to check the ‘stability or also called constancy’ of the image device. Medical diagnostic monitors are already pre-calibrated at the factory side to DICOM Part 14 GSDF Standard in an optimum reading room environment (mainly dark rooms of 0lx). Most of the medical monitor manufactures offer their own optional special QC Software and sensors to periodically control and adjust the device onsite. Such QC is mandatory and highly recommended and unfortunately often forgotten. Having only the medical certification like CE mark label for medical or FDA510K certification does not replace the need of QC. It just shows the device is declared as medical device but does not show the accuracy. Let us understand step by step the contents of the QC process. At first the ‘Acceptance’ test will be performed. This is the test when the medical monitor will be installed at the first time and also depends on the working environment. Here the room ambient light will be measured and set between 0 and 100lx (Lux) for diagnostic. (for mammography it should be even darker between 0-50lx). By knowing the exact ambient room-light the bright-

ness of the monitor will be set as next via calibration. This means it is not enough just to unpack the new medical monitor and expect that the device works perfect in all environments all the time. The client environment is maybe different to the one the device manufacturer used at the factory side. For calibration there are various sensors available (inbuilt or external). After such calibration process is done the acceptance test can be performed. The test includes a visual check (here various DICOM test patterns will be shown to check the geometry but also contrast visibility), a greyscale test (the DICOM GSDF greyscale levels will be measured), a luminance test (the calibrated luminance will be controlled if reached or not) and finally the uniformity test (it controls the corner to centre uniformity of luminance and greyscale). Such an acceptance test is required one time at the first installation and will be repeated again only in case the working environment will be changed or in service cases. For dual monitor solutions the uniformity test also compares the performance on one and to both medical monitors to each other. The second QC control function is called ‘Constancy’

test. With the constancy test the stability of the medical monitor could be understood. Here the actual performance of the medical monitor will be checked and compared with the one done during the acceptance test and aligned with the selected medical standard (e.g. AAPM, IEC or DIN). Constancy tests include more or less the same four steps as the acceptance test but require this periodically (at least every six months). In case the medical monitor does not pass the constancy test, the medical monitor requires some adjustment also so called ‘Calibration.’ With the calibration procedure, the medical monitor will be re-adjusted and corrected. Normally after such adjustment method the medical mon-

itor pass then the needed requirement following the selected medical standard. Medical monitors have several components embedded which deteriorates over the life time and because of such parts a ‘maintenance’ and calibration is mandatory to keep the accuracy for diagnostic purpose. Some components are, say for example, the LCD panel module and backlight. If such calibration and QC testing process are missed, the brightness may drop or the uniformity decrease which will end in a dramatic impact on the medical DICOM image and small details may not be seen anymore. It can cause a misreading from the doctor. In such cases, the doctor has no chance to proceed an accurate patient treatment. QC is also extremely important because doctors exchange images within their hospital network but also with tele-radiologists. Even the patient image data will be periodically compared on the image diagnostic devices and have to appear in same contents even after years. The QC is taking care of geometry issues like flicker, artefacts, pixel failure check etc. For such tests, various test patterns are available and embedded in medical standards. The QC

Software of the medical monitor manufacturer supports all medical standards. There are various medical global standards available for example from IEC (worldwide), the USA QC Guideline of AAPM /ACR or the German industry standard DIN and others. In their contents, they are all very similar and matched. The test patterns for the visual check are DICOM based and most of the cases from AAPM TG18 or SMPTE. In terms of brightness, they are almost the same by recommendation of 350cd/m2 for general diagnostic and 450cd/m2 for mammography. There are currently initiatives worldwide to harmonise several existing standards into one global reference standard. Thanks to the existing and future medical standards, the image diagnostic devices can be better understood in their benefits and limitations for better patient healthcare. Medical standards needs to be updated periodically because the equipment is improving so fast. Such standards will be created by several stake holders like medical physicists, industrial experts, doctors and legal experts. Standards will help to improve the accuracy in diagnostic. Some links: AAPM (AAPM TG18/ACR) http://www.aapm.org DIN (6868-157) https://www.din.de/en/ IEC (62563-1) http://www.iec.ch Contact details EIZO Corporation A-5101 Bergheim, Dorfstrasse 15/2 Mobile: +43 664 8440782, Mobile (UAE): +971523381264 E-Mail: juergen.heckel@eizo.com Web: www.eizoglobal.com

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TRADE AND TRENDS

Midmark India launches motorised bed Electra The new bed aims to revolutionise the traditional hospital bed and transform it into an accelerator in a patient’s recovery process

idmark (India), a leader in the area of patient positioning equipment, has announced the launch of their new motorised bed ‘Electra’, designed and positioned to capture a new market in India’s tertiary care sector. The new bed by Midmark India aims to revolutionise the traditional hospital bed and transform it into an accelerator in a patient’s recovery process. The new bed has been designed and built to enhance patient comfort and caregiver efficiency.

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November 2017

Priced between the range of ` 1,30,000 to ` 1,50,000 and engineered incorporating the most modern technological configurations, the new bed Electra is advanced but simpler to use at the same time. Manufactured and designed entirely in India, the bed not only matches world class standards from a quality, efficiency and safety point of view, but also is priced competitively for the Indian healthcare industry. Speaking on the launch of ‘Electra’, Sumeet Aggarwal,

MD, Midmark(India) said, “Electra compliments the motorised bed portfolio of Midmark India and is positioned at a vital transient point on the portfolio. It is powered by the experienced and largest cus-

tomer support network in India which will result in a lower cost of ownership. The company is looking to increase sales of motorised beds by 20 per cent overall. Through the launch of Electra, we look forward to meet the growing demand of quality motorised beds in India and enter competitive global markets like Africa, Latin America and East Europe over the next two years.” Advance positions like the cardiac chair are achieved swiftly with help of its embed-

ded panels, elevating patient from a down right position to a sedentary position without any complexity. Bravo can also be configured with X-ray Permeable Backrest and X-ray Permeable Cassette holder so that the patient doesn’t have to be repositioned, which makes it more convenient for the staff to handle with precision. Contact details India website: http:// www.midmark.in/ Midmark, USA Website: http://www.midmark.com

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