1. UNSTOPPABLE
PHARMALEADERS
INDIA’S MOST
POWERFUL
& INFLUENTIAL
HEALTHCARE
LEADERS
2017
Asia’s Most Analytical News Media in Healthcare Communications
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Pharma LeadersPharma LeadersTM
PHARMA LEADERSPHARMA LEADERS
INDIA’S MOST
TRUSTED BRAND
INDIA’S MOST
INNOVATIVE HEALTHCARE
COMPANIES 2017
THE GAME CHANGER
Pharmaleaders 2017 annual edition attempts to bring
a structural , systemic & transformative change in
healthcare eco-systems & fixing the loopholes of the
country's healthcare systems by continuously
engaging the various stakeholders of the healthcare
fraternity. Aptly titled as “The Healthcare
Roundtable - Fixing The Healthcare Chaos &
Transforming Healthcare Delivery Systems” as
the theme of the historic 10th Annual Pharmaceutical
Leadership Summit & Pharma Leaders Business
Leadership Awards 2017 in Mumbai in December.
Pharma Leaders, the healthcare research media wing
of Network 7 Media Group is widely recognized & rated
by the experts as a platform for cutting-edge,
independent, policy driven relevant research and
analysis on the opportunities and challenges facing
Indian healthcare system. The much awaited &
prestigious healthcare meet will bring together the
most powerful & influential healthcare leaders of india
in one single platform including pharma companies
owners & CEO's, Hospital owners & CEO's,healthcare
technology companies, social healthcare foundations,
senior management from healthcare enterprises,
eminent doctors, development financing institutions,
institutional investors, to fundamentally address and
impact poor healthcare outcomes & find a blueprint for
tomorrow's healthcare. Ironically, India's healthcare
suffers from quality, quantity, footprint, access &
affordability issues coupled with faulty policies of the
successive governments. The World Health
Organization estimates that India spent about $267
per capita on health care in PPP adjusted terms in
2014—China spent three times that amount, Brazil five
times, European nations 10 times and the US 20 times.
In aggregate, India spends only about 1.5% of gross
domestic product (GDP) on public healthcare. Most
countries spend two or more times that number. There
is an obvious shortage of medical practitioners in India
so also the public healthcare systems, healthcare
infrastructure & personnel.
Recognizing that existing health systems in the
country are hampered by weak funding, infrastructure
and skills, our idea is to find synergies that can boost
the quality of care while saving both providers and
consumers precious funds. There are broad consensus
that India suffers from an acute shortage of secondary
and tertiary hospitals, a significant shortfall in
specialists and specialized equipment, and a rigid
regulatory framework combined with corrupt
enforcement. All of this leads to appalling quality for
the medical system in the country. Add to this a
hopelessly inadequate feeder system from preventive
health to primary care to secondary and tertiary
referral and you have the makings of system that is so
completely broken that it may not be fixable without a
zero-base approach.
India will have a total bed density of 1.84 per cent per
1,000 people against the WHO guideline of 3.5 by
2022. Clearly, There is a huge gap between demands
for healthcare in India and supply. The summit heard
that India spends 4.7% of GDP on healthcare,
whereas UK spends 9.1 per cent, and that there is a
huge shortage of hospitals in India, particularly a lack
of tertiary care outside tier 1 cities. Another biggest
challenges that are often not spoken about is the state
of medical research in india. The statistics prove the
sorry state of affairs thus india needs to be a robust
research pipeline.Any modern healthcare system
anywhere in the world would have its own share of
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2. UNSTOPPABLE
PHARMALEADERS
INDIA’S MOST
POWERFUL
& INFLUENTIAL
HEALTHCARE
LEADERS
2017
Asia’s Most Analytical News Media in Healthcare Communications
www.pharmaleaders.tv
Pharma LeadersPharma LeadersTM
PHARMA LEADERSPHARMA LEADERS
INDIA’S MOST
TRUSTED BRAND
INDIA’S MOST
INNOVATIVE HEALTHCARE
COMPANIES 2017
THE GAME CHANGER
challenges. Every healthcare system is unique – in its
composition, adaptability and flexibility. We feel that
the challenges mentioned above are all addressable
and are opportunities in which credible medical
organizations can partner and help provide
implementable solutions.
Ranked by Industry experts, Pharma Leaders is
arguably the India's largest & most trusted healthcare
communication company specializing in executing
high profile research findings, media broadcasting,
healthcare campaigning & producing highly acclaimed
world-class events once in a year .We are one of the
very few global healthcare company with leadership
positions in reaching out to the key sectors &
stakeholders of pharmaceutical and life sciences,
healthcare firms, hospitals, medical services, top
notch opinion makers in the medical profession &
other disciplines associated with healthcare industry.
Pharma Leaders research indings are often cited
at various credible places & the annual awards are
most awaited prestigious, coveted & credible
healthcare leadership awards conferred to the
trendsetters & path-breaking companies. Unlike
other companies, Pharma Leaders refuses to
follow the traditional approach in reaching out to
the inal rankings based on false & ambiguous
reports which deny the high performing
companies, though small but rich in innovative
practices & often ignored by the mainstream media
& lost out to the biggies. The robust selection
process at Pharma Leaders awards are a year long
process where only innovations & out of box ideas
triumph.
Health care is ailing and in need of help. Yes,
medical treatment has made astonishing advances
over the years. But the packaging and delivery of
that treatment are often inef icient, ineffective, and
consumer unfriendly. Three kinds of innovation
can make health care better and cheaper. One
changes the ways consumers buy and use health
care. Another uses technology to develop new
products and treatments or otherwise improve
care. The third generates new business models,
particularly those that involve the horizontal or
vertical integration of separate health care
organizations or activities. Innovations in the
delivery of health care can result in more-
convenient, more-effective, and less-expensive
treatments for today's time-stressed and
increasingly empowered health care consumers.
For example, a health plan can involve consumers
in the service delivery process by offering low-cost,
high-deductible insurance, which can give
members greater control over their personal
health care spending. New drugs, diagnostic
methods, drug delivery systems, and medical
devices offer the hope of better treatment and of
care that is less costly, disruptive, and painful.
India is unable to cater to the rising demands of
immediate medical facilities across states as a
major part of the population continues to reside in
remote and hard-to-reach rural areas, suffering
and ighting the worst kind of ailments. Despite
several efforts, India still struggles with a severe
shortage of doctors, especially in the rural areas. Is
it lack of healthcare infrastructure, poor working
conditions for doctors in rural areas, a medical
education system that lacks focus on public health,
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3. UNSTOPPABLE
PHARMALEADERS
INDIA’S MOST
POWERFUL
& INFLUENTIAL
HEALTHCARE
LEADERS
2017
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www.pharmaleaders.tv
Pharma LeadersPharma LeadersTM
PHARMA LEADERSPHARMA LEADERS
INDIA’S MOST
TRUSTED BRAND
INDIA’S MOST
INNOVATIVE HEALTHCARE
COMPANIES 2017
THE GAME CHANGER
lack of government investment in public health
service or is it lack of a political will to address
India's most pressing public health issue?.
India is way behind in health indicators not
because we have shortage of doctors or hospitals,
but because we do not have the needed political
will, which translates in not having a well-
developed national and state level public health
service and public health cadre.Government will
need to take a bigger responsibility in solving this
issue. Lack of a political will is the biggest
hindrance in translating these solutions into
positive results. Currently, our nation stands at a
crossroad where some efforts have helped us to
better our health indicators, yet there is a long way
to go in order to achieve the dream of a healthy
India, where every citizen will have equitable
access to quality healthcare.India will therefore
need to solve every single problem that serves as
an obstacle towards achieving our healthcare
goals. This means that political leaders and
healthcare decision makers will need to work
towards ending corruption and focus more on
making healthcare a right of every citizen.
The six forces—industry players, funding, public
p o l i c y, t e c h n o l o g y, c u s t o m e r s , a n d
accountability—can help or hinder efforts at
innovation. Individually or in combination, the
forces will affect the three types of innovation in
different ways. The health care sector has many
stakeholders, each with an agenda. Often, these
players have substantial resources and the power
to in luence public policy and opinion by attacking
or helping the innovator. For example, hospitals
and doctors sometimes blame technology-driven
product innovators for the health care system's
high costs. Medical specialists wage turf warfare
for control of patient services, and insurers battle
medical service and technology providers over
which treatments and payments are acceptable.
Inpatient hospitals and outpatient care providers
vie for patients, while chains and independent
organizations spar over market in luence.
Nonpro it, for-pro it, and publicly funded
institutions quarrel over their respective roles and
rights. Patient advocates seek in luence with policy
makers and politicians, who may have a different
agenda altogether—namely, seeking fame and
public adulation through their decisions or votes.
Advances in digital technologies will create
enormous new possibilities and opportunities.
The wise will recognize and ride this trend. Those
who ignore it will do so at their peril.
Over the past several decades, thanks to improved
diagnostic and therapeutic options, healthcare has
experienced an explosion of innovations designed
to improve life expectancy and quality of life. As
healthcare organizations face unprecedented
challenges to improve quality, reduce harm,
improve access, increase ef iciency, eliminate
waste, and lower costs, innovation is becoming a
major focus once again. Under our present system,
just doing our best or working harder will not be
enough. The healthcare industry is on the brink of
massive change.
The exorbitant cost of healthcare is an economic,
social, political and medical challenge at the top of
every nation's agenda. Growing, ageing
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4. UNSTOPPABLE
PHARMALEADERS
INDIA’S MOST
POWERFUL
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HEALTHCARE
LEADERS
2017
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www.pharmaleaders.tv
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PHARMA LEADERSPHARMA LEADERS
INDIA’S MOST
TRUSTED BRAND
INDIA’S MOST
INNOVATIVE HEALTHCARE
COMPANIES 2017
THE GAME CHANGER
populations and increased prevalence of chronic
illness drive healthcare costs up. Indian healthcare
is experiencing a new wave of opportunity.
Providers are reinventing existing delivery models
to bring healthcare closer to the patient.
The Indian healthcare sector is diversifying and
opportunities are emerging in every segment, be it
providers, payers or medical technology. With
growing competition, organisations are cognisant
of new challenges and are looking to explore the
latest business dynamics and trends impacting
their segment. New players are building their entry
strategy and domestic players are exploring new
care models to stay ahead.
India is a huge country in the continent of Asia with
a population of over 1.32 billion as of 2016. The
country has added over 450 million people in last
25 years during which the fraction of people below
poverty has fallen by 50%. This period of
increasing prosperity has been marked by the Dual
Disease burden – combining communicable and
non-communicable diseases (also called lifestyle
diseases) – that became the cause of half of the
deaths in the year 2015 (42% higher than that in
2001-2003).Keeping an eye on the lowest
government and public spends in terms of the
proportion of GDP (Gross Domestic Product), it is
observed that more than 62% of Indians spend
their savings on healthcare expenses, which is
called the “Out-of-pocket” expenses.
The existing infrastructure of India is not good
enough to cater to the increasing demand across
the country. There are certain roadblocks for the
healthcare industry of India.The Population of
India–India houses the second largest population
in the world, which increased to 1.3 billion in 2015
from 760 million in 1985. Senior citizens
constitute 8.6 percent of the population in
India.Sky-rocketing health care costs and medical
in lation makes healthcare treatment out of reach
for middle-class. Senior citizens are prone to
frequent hospitalization due to old-age factor.
Therefore, it is very important for them to have
senior citizen health insurance so that their health
care needs are covered up to an extent.
Rural Urban Gap– The rural healthcare
infrastructure in India is three-tiered. It includes a
sub-center, a primary health center, and a CHC.
Particularly in PHC, the system lacks over 3000
doctors.This shortage has been up by around
200% in the last 10 years, reaching 27,421.
Infrastructure–The current healthcare
infrastructure of India is not good enough for the
population with respect to their needs. Although
various hospitals under the central and state
governments provide universal healthcare service
along with free of cost treatment as well as drugs,
these hospitals are less equipped, under- inanced,
and lack staff. This medical scenario forces
patients to prefer private medical practitioners
over government hospitals.
Insurance – Apparently, India is amongst the
countries with the lowest per capita health care
expenses across the world. As opposed to 83.5% in
the United Kingdom, the government contributes
to insurance stands at approx. 32% only. As
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5. UNSTOPPABLE
PHARMALEADERS
INDIA’S MOST
POWERFUL
& INFLUENTIAL
HEALTHCARE
LEADERS
2017
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www.pharmaleaders.tv
Pharma LeadersPharma LeadersTM
PHARMA LEADERSPHARMA LEADERS
INDIA’S MOST
TRUSTED BRAND
INDIA’S MOST
INNOVATIVE HEALTHCARE
COMPANIES 2017
THE GAME CHANGER
mentioned above, 76% of Indians spend their
savings on their health care expenses, which
further implies that this much of the country's
population has no health insurance coverage.
However, there are potential catalysts to improve
India's healthcare system. Indian Union Budget for
the iscal year 2017-18 contains suf icient
measures to boost macroeconomic stability and
infrastructure, and rural development. This union
budget includes health care as high as 27% while
the respective allocations could have been better
matched with the government's vision,
considering the announcement of new healthcare
programs and adjustment against in lation.
Information Technology is all set to play a major
part with different IT applications that are being
used for social-division schemes on a substantial
level. Various hospitals in India, empaneled under
the scheme of government insurance are IT-
empowered and directly linked to the servers in
various regions. Bene iciariesare allowed to use a
smartcard to get to various healthservices in any of
these empaneled hospitals spread nationwide.On
the World's Health Day in 2016, several new
cellphone and PC-basedm-health and e-health
activities were propelled on World Health Day in
2016. These initiatives include the Swastha Bharat
application for mobiles that was aimed at
providing disease-speci ic information like
common symptoms, treatment, health tips and
alerts. Also, e-RaktKosh (a blood donation center
administration data framework) and India Fights
Dengue were launched.
At present, individual states nationwide are
embracing technology applications to help health
insurance plans. For example, Remedinet
Technology (India's irst electronic cashless
medical coverage claims processing system) has
been marked as the technology partner for the
K a r n a t a ka G ove r n m e n t ' s m o s t re c e n t
announcement regarding cashless medical
insurance plans.The health care delivery in the
country is now subject to undergo amendments at
all the stages, i.e. prevention of diseases, diagnosis,
and preliminary treatment. Going forward, there
will be no single entity across the healthcare sector
in India, which can operate in isolation.The rapid
evolution of the healthcare section of India calls for
the participation of all its stakeholders in order to
implement the technology applications to bridge
the gaps that have been encountered so far. India
now has the opportunity to leapfrog most of the
problems faced by the healthcare system is facing,
which includes the medical records are not
centralized and overspending.
What Government can do
The government is expected to make amendments
in the ways of healthcare delivery in India. People
today prefer to visit a private multi-specialty
hospital rather than going to a government
hospital for the health care treatment. The
importance of health insurance awareness also
needs to be addressed in order to change people's
mind to make the most of the health coverage
without spending their hard-earned money on the
treatment of an ailment.
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6. UNSTOPPABLE
PHARMALEADERS
INDIA’S MOST
POWERFUL
& INFLUENTIAL
HEALTHCARE
LEADERS
2017
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PHARMA LEADERSPHARMA LEADERS
INDIA’S MOST
TRUSTED BRAND
INDIA’S MOST
INNOVATIVE HEALTHCARE
COMPANIES 2017
THE GAME CHANGER
When it comes to healthcare awareness, over 70%
of Indian population lacks it, especially those living
in the rural areas. Government needs to launch
healthcare awareness programs in these areas to
encourage more and more people to buy health
insurance for both health and inancial stabilities.
At the same time, individuals need to cooperate
with these programs to make them a success.
With a huge talent pool and growing demand for
innovation in drugs and medical devices to address
the rising disease burden, it is time we created a
favourable environment for clinical trials in the
country. Epidemiological transition, in recent
decades, compounded with the burgeoning
population as well as widespread malnutrition and
poverty, have resulted in the steep rise in both
communicable and non-communicable diseases in
the country, across all age groups. To counter this
rising burden of disease, there is a compelling need
for local clinical trials.
Clear advantages
Despite the pressing demand for clinical trials,
after a peak in 2009-2010, the clinical research
sector in India is continually contracting.
According to the Journal of Clinical Research and
Bioethics, India represents 17.5% of the world's
population but conducts only 1.4% of global
clinical research. This is unfortunate, considering
we have all the requisite factors, such as English-
speaking health-care professionals, a large
number of experts, steady economic growth,
access to world-class technologies, strong IT- and
data-management infrastructure, access to
ethnically diverse patient populations and
competitive operational costs. All these factors
present clear advantages for clinical research.
We have been lagging in this area primarily
because the regulatory system in India for clinical
research has become increasingly a deterrent for
biopharmaceutical- and device-companies which
sponsor clinical trials. The existing legal
framework lacks credibility, in terms of
predictability and transparency, in the criteria and
protocols governing clinical research. Data suggest
that improvements in the overall policy
environment can have a signi icant impact on
attracting and securing greater investment and the
associated economic gains. A study, “Medical
research in India and the rise of non-
communicable disease”, published in the British
Medical Journal in 2016, brings out the
multifaceted and far-reaching bene its of clinical
trials to the health-care delivery system. It states:
“health research is not only crucial to the
development of new diagnostic tools and
treatments, it goes on to guiding the planning of
health-care services in the appropriate direction,
facilitating continuous evaluation and
improvement of medical care, and allowing a
thorough investigation of risk factors and disease
associations”.
Clinical trials also seem to be misunderstood in the
media and have sometimes been portrayed as
experimental procedures, where new products are
being unsafely tested on people. Admittedly, there
have also been instances of lapses in
con identiality or non-adherence to protocols or
shortcomings in getting informed consent from
participants and these are to be totally condemned.
However, this cannot be a cause for throwing the
baby out with the bathwater, and everyone
conducting clinical trials must not be looked at
with suspicion. There are numerous honest
doctors and scientists, who do world-class
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PHARMALEADERS
INDIA’S MOST
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HEALTHCARE
LEADERS
2017
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PHARMA LEADERSPHARMA LEADERS
INDIA’S MOST
TRUSTED BRAND
INDIA’S MOST
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COMPANIES 2017
THE GAME CHANGER
research in India, and these individuals and their
institutions should be encouraged to conduct
clinical research.
Fixing the edges
Fortunately, things have started to change recently.
Recognising the importance of local clinical trials
in developing better and safer drugs, the
Government of India is now working on new
policies that could ensure swift approvals to begin
clinical trials without making compromises on
patient safety. The Government has taken steps
such as recognising ethics committees,
centralising a system whereby adverse side-effects
can be appropriately investigated by the Drugs
Controller General of India and formally
recognising centres which are capable of
conducting clinical trials in accord with
regulations. To reap the bene its of clinical trials,
our objective should be to bring about more
clinical research in the country while maintaining
high standards to ensure patient safety and
accuracy of data. The new policy, which also
promises to be more transparent, includes some
major amendments such as single-window
clearance for clinical trials. To further speed up the
availability of new and effective drugs, the
Government has proposed waiving off clinical
trials for those drugs that have already proved
their ef icacy in developed markets.
Hopefully, with increasing political will to create a
favourable environment for research by foreign
investors and to give domestic research and
development the essential push, we will be able to
build a stronger research ecosystem that promotes
ongoing innovation.
Dr. Vishwanath Mohan is Chairman and Chief
Diabetologist, Dr. Mohan's Diabetes Specialities
Centre
GST Impact On The Indian Pharmaceutical
Industry
India's healthcare market may see threefold rise as
its size in value terms is likely to reach $372 billion
(bn) by 2022 from the level of $110 bn as of 2016
thereby clocking a compounded annual growth
rate (CAGR) of 22 per cent. Growing incidence of
lifestyle diseases, rising demand for affordable
healthcare delivery systems due to increasing
healthcare costs, technological advancements,
emergence of telemedicine, rapid health insurance
penetration, mergers and acquisitions helping to
reach untapped markets and government
initiatives like e-health together with tax bene its,
incentives and a host of upcoming regulatory
policies are driving healthcare market in India.
Factors like growing geriatric population, uptick in
medical tourism and gradual decline in cost of
medical services will drive medical devices market
in India which was valued at $4 bn as of 2016 and is
likely to cross $11 bn mark by 2022 thereby
registering a CAGR of 15 per cent. It however will
make imports make up about 75 per cent of Indian
medical devices market. Goods and Services Tax
(GST) will have a positive impact on Indian
h e a l t h c a r e m a r k e t , p a r t i c u l a r l y t h e
pharmaceutical sector.
GST would not only streamline taxation structure
but lead to ease of doing business by minimising
cascading effect of many taxes applied to a product,
rationalise supply chain, enable low of seamless
tax credit, lower manufacturing cost, reduce cost of
technology and make healthcare affordable.
Generic drugs account for about 70 per cent of
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2017
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India's $20 bn worth pharmaceutical market. Of
these, anti-infectives occupy the largest share of 16
per cent followed by cardiovascular (13 per cent),
gastro-intestinal (11 per cent), respiratory (nine
per cent), vitamins/minerals (eight per cent)
analgesic (seven per cent), anti diabetic (seven per
cent) and others (29 per cent).
Increasing expenditure on research and
development (R&D), rising collaborations
between Indian and foreign companies, reduction
in product approval time and other such factors are
driving the growth of Indian pharmaceutical
market.Indian pharmaceutical market is third
largest globally in terms of volume and 13th largest
in terms of value.
From being a desired destination for medical
tourism (1,34,344 foreigners visited India in 2015
on medical visas), India is sadly heading towards a
situation where there is a sudden exodus of Indian
patients seeking healthcare services abroad. While
the Centre has been rolling out initiatives to attract
medical tourism, ironically, a number of Indians
have been lying out of the country for medical
services.
Patients from India are lying to neighboring
countries... for the implantation of cardiac stents,
where the differentiation in the quality of these
medical devices still exists. India's extremely high
incidence of non-communicable diseases is widely
known, accounting for 60% of all deaths. In a
country grappling with cases of diabetes,
hypertension, and cardiovascular diseases on the
rise, the immediate focus must be on making good
quality healthcare accessible. India is catapulting
towards being a technology hub, and is not far from
becoming a global power. The country has to tread
a long path, however, in terms of healthcare where
its budget continues to be a negligible 1.3% of the
GDP; 70% of healthcare spending in India is out-of-
pocket.
The government's recent decision to put a price
cap on coronary stents, implemented with well-
meaning intentions has not necessarily been in the
best interest of the healthcare sector. In the
absence of robust quality control regulations in the
country, there is a strong possibility that the
ineness of stents may be undermined. Since all
stents are not the same, their prices should be
categorised on the basis of their quality. Because of
the government move, one cannot use a high-end
stent even if one so wishes in India.
By extending the narrow capping mechanism to
include manufacturers, the health industry runs a
massive risk of losing out on numerous counts. The
multinational manufacturers that invest heavily in
R&D may well be discouraged to do so hereon,
imposing an impediment to any potential
advancements in technology. In addition, the local
manufacturing sector for medical devices has not
quite developed yet to sustain the market on its
own. Importing raw materials and latest
technology may no longer be feasible, leading to
poor quality stents inding their way into the
market. Accessibility and affordability, while
central to policy making in the health sector,
cannot overpower concerns over quality. It is not
just people from abroad today, but even patients
from India who are lying to neighboring countries
including Nepal and Thailand for the implantation
of cardiac stents, where the differentiation in the
quality of these medical devices still exists.
Any move to impose price caps on medical devices
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2017
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without a fair mechanism in place will... have the
detrimental effect of stunting innovation, research
and development. On the heels of this price cap is
the newfound and justi ied anxiety over possible
price caps of other essential medical devices such
as hip and knee implants. The government recently
extended tax sops to Apple, even as the industry in
the healthcare sector struggles to provide high
quality medical devices in the absence of
manufacturing or import incentives. This helps
drive home an integral point – that we may need to
work on our priorities as a developing nation with
a 1.3 billion population, more than half of which
does not have access to quality healthcare services.
Any move to impose price caps on medical devices
without a fair mechanism in place will be short-
sighted, and will have the detrimental effect of
stunting innovation, research and development
The Union ministry of health and family welfare
has suggested an ambitious policy framework that
envisages making health a fundamental right,
besides offering universal access to free
diagnostics and medicines in government
hospitals.
While every Indian deserves a guaranteed health
cover, the timing of the noble pronouncement is
somewhat peculiar given that the Centre only
recently decided to cut back on healthcare by 20
per cent. Public spending on health in India is
already one of the lowest in the world; now the
budget faces trimming by about Rs 6,000 crore to
keep expenditure down to about Rs 30,000 crore
this iscal.
The cost of offering universal healthcare to a
population of 125 crore and counting may require
a budgetary jump to an ideal ive per cent of GDP
from less than two per cent at present.
Furthermore, there is a manpower crisis in doctors
as there are only seven allopathic doctors per
10,000 people currently, and a fair proportion of
them is always trying to gravitate towards private
hospitals.
Providing suf icient doctors to primary health
centres in rural India and administering a
corruption-free system is a mega challenge that it
appears this is another policy which will be
impossible to implement. Given the pace of the
justice delivery system, to make the denial of
healthcare an actionable offence would be to
increase the workload of the legal system. This
means the common man will simply continue to
suffer. It may be simpler to put down achievable
targets.
Thanks to lax rules and lazy regulators, unquali ied
'doctors' are taking vulnerable, ignorant patients
for a ride.
Unquali ied medical practice is big business in
India. I had a unique opportunity to research the
phenomenon through a ield study. The major
bene iciaries, apart from those that rely on the
services of unquali ied health providers (UMPs),
were, quite unexpectedly, quali ied doctors.
The revolving door opens when a quali ied doctor
employs a medically unquali ied worker as an
apprentice. Over 18 months to ive years the
assistant learns the tricks of the trade —
prescribing drugs for practically all outpatient
conditions — vomiting, diarrhoea, fever, crashes,
joint pains, respiratory distress, abdominal pain,
lu, typhoid, dengue besides children's illnesses.
The door closes when the UMP sets up his own
practice but re-opens when the UMP starts
referring his patients to the doctor for earning
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commissions.
Jhola chaaps
Across every district in the country and in every
village, slum and the unorganised areas in all cities
these quacks known as RMP's, doctors, jhola chaap
Bangali doctors or just quacks, thrive. WHO (2016)
reports that as many as 57 per cent allopathic
doctors in India do not have a medical
quali ication. Even when free facilities are
available in the vicinity as is the case with urban
slums and nearby public sector dispensaries, the
poor go to quacks as the irst port of call.
For the daily wage earner the incapacity to report
for work means a loss of wages which must be
circumvented at any cost. He has no capacity or
willingness to ponder on obscure things like side
effects or drug resistance. For him the nearby
UMP's treatment is a one stop transaction, cheap
and available 24x7. There is security and comfort
in knowing that the neighbouring community also
relies on the UMP whose treatment generally
works.
Besides, attempting to go to a Primary Health
Centre (PHC) where the nearest Government
doctor is located is beset with problems. According
to Census data most PHCs are located ive, 10 or
more kilometres away from the surrounding
villages.
Getting there would necessitate taking the patient
on a cycle, a two wheeler or by bus only to ind that
the doctor is absent or medicine unavailable. The
second alternative is to go to a private practitioner
and pay a minimum of ₹200 over and above
outgoings on transport and incidentals.
Considering the generally “effective” and
inexpensive treatment that a village or slum based
UMP provides going to him in the irst instance is a
no-brainer. And given the time, cost and
convenience factors this trend is unlikely to
change.
A marriage of convenience
How did the UMPs acquire skills to treat medical
conditions? They learnt what they know from
quali ied doctors who engaged them as helpers.
Once they leave the relationship grows into a
marriage of convenience when the UMP provides a
regular supply of patients and receives
commissions (up to 30 per cent of the fees
charged) for this service.
Women UMPs too are in high demand. Trained
under quali ied doctors who hired them as cheap
help during deliveries, these skilled birthing
attendants eventually move on and open their own
maternity businesses. The ones I met were smartly
turned out and articulate.
They describe every detail of how labour is
induced; including the use of oxytocin injections
after the dilation is suf iciently advanced. They
could recognise pregnancy complications and
were astute enough to refer cases to quali ied
doctors in time. The cost of delivering a baby here
remains less than one quarter of going to a doctor's
clinic.
Pseudo pharmacists form another large and
ubiquitous category. They readily sell antibiotics
and steroids over the counter based on stated
symptoms and by recalling AIIMS and other senior
doctors' prescriptions for given conditions. In
addition the medical representatives of
pharmaceutical companies were their trusted
allies as they gifted them a bagful of free samples
on every visit along with a tutorial on medical
conditions and drug dosage.
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Often such (medicine) shops were owned by dawai
doctors but the front face was a quali ied
pharmacist who was but a proxy.
A fourth category of UMPs were found dabbling in a
mixture of allopathy, Ayurveda, homoeopathy —
even electro-homoeopathy. From signboards and
the display of a wide variety of medicine it was
apparent that they were in demand for treating
gupt rog (secret diseases) aka sexually transmitted
diseases, reproductive tract infections, sexual
problems and piles.
Taken together the number of such practitioners is
enormous. Few have anything more than a school
education and even those who are graduates have
not studied medicine. Their framed certi icates
and diplomas generally hark back to medical
sounding titles which are all unrecognised.
In a 2015 working paper by Shailender Kumar
Hooda an economist working with the Indian
School of Industrial Development he has decoded
NSSO data to show that there are 10.7 lakh medical
establishments in the country.
Of these only 8 per cent are hospitals and the
overwhelming majority are single practitioner
enterprises run by unquali ied practitioners.
Missing in action
One might well ask what different regulatory
agencies are doing, knowing full well that this
phenomena is entrenched in the lives of the poor.
Apart from the side effects of using steroids and
antibiotics irrationally, the greater risk is the
probability of spreading multi-drug resistance in
the wider population.
Under law the Medical Council of India and its state
chapters are responsible for taking action against
those who practice medicine without a medical
quali ication. Responses given by the Health
Ministry to Parliament have invariably stated that
it is for the State Medical Councils to take action.
The Indian Medical Association castigates
quackery but does not deregister its members
from training and then paying commissions to
UMPs to garner patients.
Other law enforcers too have safe alibis. Police
of icers and district magistrates even when they
see what is tantamount to cheating and
impersonation do nothing because the offences
are not “cognizable”.
In other words arrests cannot be made without a
complaint — something no member of the public is
willing to give. The State Drug Controllers have a
responsibility to ensure that prescription drugs (of
which there are nearly six hundred listed in the
Regulations,) are only sold under a doctor's
written advice. In fact there is virtually no
checking.
While most State health departments prefer to
look away, West Bengal began training the RMPs
some seven years ago with the stated aim of
preventing harm. Regular training classes have
been organised using funds provided under the
National Rural Health Mission.
It is another matter that unsupervised use of
antibiotics, steroids and fourth generation drugs
has serious costs for society and ought to give
nightmares to all authorities. To ignore an
inconvenient truth any longer would be iniquitous,
unprincipled and dangerous.
The writer is former secretary, Department of
AYUSH
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Indian healthcare's inconvenient truth
Shailaja Chandra*
Doctors are clear now that several factors or
vectors are responsible for microbes turning into
pathogens that can cripple our bodies. It is not
being cold that gives us lu. It is the combination of
exposure to viruses and low levels of immunity
that usually does it. It is the same with governance,
a fact our leaders should not ignore as they select
their Cabinet for the next ive-year term. This week,
Oxfam released new and startling statistics on
inequalities in Kenya. About 8,300 individuals own
more wealth than 44 million Kenyans. A total of 19
million people are absolutely poor and six million
are completely destitute. Yet, the number of
millionaires is set to grow by 80 per cent. Extreme
inequality is now out of control. ALSO READ: Few
skilled workers big threat to health plan
Inequalities slice across gender, class and
geography. It directly affects our access to health
and other essential services. One in four Kenyans
do not have regular access to healthcare. Sixty six
percent of our population risks bankruptcy by
surgery or hospitalisation bills. Middle and upper-
class women have three times more access to
maternal health-care than the poor.
Tragically, being dead on arrival or being detained
at child-birth is a familiar danger for too many now.
How we manage public health matters. Health is
also big business. By 2014, it grew to Sh234 billion
across private, public and not for pro it services.
The competing interests pit international, national
and county interests against each other. Return on
investment rather than development assistance is
increasingly the lens by which North American,
European and Asian governments and companies
view Kenya's health sector. DFID recently shifted
its policy from “aid not for commercial interest” to
“aid with spin off commercial results”. The new
Dutch “A world to gain: A New Agenda for Aid,
Trade and Investment” policy emphasizes market
access by Dutch companies. Similar aid and trade
policies exist in the US and China. Bolstered by this,
Philips, GE Healthcare and Toshiba lead new public
private partnerships like Managed Equipment
Services that fund a range of public private projects
across the counties. Companies like Abraaj Health
Group have recently acquired 50 per cent
ownership in the Avenue Group of hospitals among
other investments including Brookside Dairy
Group and the Java chain of restaurants. Universal
primary healthcare is a priority for national and
county governments. To succeed, they will have to
improve their capacity for direct policy control and
regulation.
We know from the 1980s that unregulated
privatisation led to health workers being laid off,
increased health-care disparities and the collapse
of the public health systems across Africa. We must
do more to seal the factors or vectors that weaken
our public health system. The revolving door
between policy-making and private business is
simply too luid. Corporate business advisory
board positions, research funding and technical
assistance crowd out the voice and interest of
patients and the public. Over-invoicing, dubious
investments, bene iciary inequities and arbitrary
bene its challenge the impact of NHIF. Why did it
take so long to bring the doctors' strike to an end?
We know now that the primary bene iciaries of the
strikes were private facilities. As patient access
dropped 33 per cent in public hospitals, twice as
many accessed private facilities this year than in
2016. Tenderpreneurs still stalk the corridors of
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our public hospitals and chase after ambulances
with too much con idence. 2015 and 2016 saw
massive diversion of public funds and last minute
budgetary supplements. Not even ixed generators
are safe as we learned in the case of Tharaka Nithi.
These risks conspire to produce low levels of
immunity within our public health system. Left
unchecked, they will overwhelm it. Private
healthcare does not undermine our right to health.
If regulated well, it compliments it. ALSO READ:
Why diabetes is still on the rise Citizens must press
for robust con lict of interest policies and greater
regulatory oversight in line with national
standards. Our 47+1 Governments must regulate
the excessive in luence of business and increase
the in luential role of citizens in decision-making.
Health business associations must hold corporates
liable for any illegal activity and actively challenge
all forms of corruption. By doing this, pro its will
not threaten patients and microbes can be stopped
from becoming pathogens and overwhelming our
nation's health and prosperity.
India needs to lower overall healthcare costs
without compromising on the quality of care
delivered
The Indian healthcare system can reasonably be
characterised as low-cost by global standards, still
is unaffordable to a majority of the Indian
population. For-pro it private set-ups provide a
majority of healthcare services in urban India, in
the backdrop of a virtually non-existent non-pro it
or government establishment. With an estimated
per capita income of less than $3 a day, private
healthcare service is beyond the reach for almost
80% of the population. Even the top quintile earner
averages around $5 a day and will have to shelve
years of saving for a procedure such as knee
replacement.
Cities that can boast of excellent government
healthcare set-ups (New Delhi, Chandigarh, and
Lucknow, to name a few) are facing a different set
of problems — high volumes, lack of adequate
manpower and poor infrastructure. Years have
passed since I left the All India Institute of Medical
Sciences, and I still get phone calls from friends and
family asking if I can 'get them in' for a doctor's visit
or a procedure (at the AIIMS, in the national
capital) since the waiting time is in weeks to
months, with added bureaucratic processes.
Working past capacity, it's only natural that
'excellence' becomes a far-fetched goal of these
over-burdened 'centres of excellence'. Virtues like
physician-patient rapport and professionalism are
left to be discussed only in lecture halls and
textbooks. Private set-ups try to ill in for the
de iciencies of the government healthcare system,
but at a inancial cost. This brings me back to where
I started. Private hospitals, just like any other
private business enterprise, are here to make a
pro it and one cannot criticise them for doing so.
Medical tourism
Patients from Dubai, Afghanistan, Qatar, Kuwait,
even the United States can often be seen in
corporate hospitals of Indian cities like New Delhi.
Cheap and ef icient healthcare delivery offered at
such set-ups has turned India into a major medical
tourism destination. Private hospitals in India have
managed to keep the cost low enough, providing
the required economic incentive. To give an
example: for a patient in the United States who
requires a hip replacement and doesn't have a high
premium/low co-pay health insurance, getting the
surgery done in India is cheaper (compared to out-
of-pocket expenses outside of insurance coverage)
even after factoring in the cost of round-trip airline
tickets and accommodation for the patient and
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family. The same cost that may be economical for
international patients is often too high for an
average Indian family. The race to make healthcare
affordable for an average Indian household
continues.
One must understand the basic difference between
out-of-pocket expenditure for healthcare in India
as compared to other countries (let's take the U.S.
as an example). Out-of-pocket cost in the U.S. is
simply what the patient pays (co-payment or
deductible) while third party payment systems
such as insurance, government schemes,
employee/school bene it and so on (a typical two-
payee system) pay the rest of the amount. Making
healthcare affordable in a two-payee system may
include reducing total out-of-pocket expense for
an individual by allocating a higher proportion of
the total bill to the third party. In the Indian fee-for-
service model where the entire transaction occurs
between the patient and the service provider, in
order to decrease healthcare cost one has to either
reduce the actual cost of the procedure or reduce
the pro it margin. In a country where an informed
patient shops around various hospitals before
deciding where to get treatment, reducing cost also
offers a competitive advantage to private hospitals.
A logical Indian must ask how India is able to
provide such low-cost healthcare, which many
developed countries are struggling with, and still
continue to drop the cost further.
Re-using medical equipment (after the
sterilisation process) that are labelled single-use-
only is a common practice in India (and many other
developing countries). The rationale is simple: it
brings the cost down. Take coronary angioplasty
and stenting, for example. While a simple
procedure can be done using a ixed set of
equipment, often multiple catheters, balloons,
wires and so on are required, particularly if
anatomical challenges are encountered. If a new
piece of equipment is used every time (and the
patient is charged for the same), those procedures
will have an astronomically high cost, something
that won't be inancially viable under the Indian
self-pay healthcare model.
While bringing about undesirable heterogeneity in
procedure costs across patients, the practice also
has huge corruption potential. Instead, equipment
are re-used and the patient is billed for only one set
of equipment regardless of how many sets are
used. One can see it as a form of shared-risk model
as sometimes it is dif icult to predict which cases
will require additional equipment. Realising that
re-using single-use equipment may impose
additional risks to patients, the Health Ministry
issued a memorandum in early 2017 against re-
using disposable items. If executed this will be an
excellent move towards providing healthcare
services the way it was designed to. On the other
hand, the inancial implications of such action will
be huge, rendering many procedures outside the
reach of an average Indian household.
Capping pro it margins
Capping pro it margins for such procedures is
another way to curb the cost, but that can have
disastrous consequences. For a private business
enterprise, less pro itable procedures will soon be
replaced by more pro itable ones, regardless of the
clinical need. Unless a shared-risk model such as
health insurance or government assistance picks
up the tab, or robust government healthcare set-
ups that are readily available across the country
providing high-quality services, the re-use of
medical equipment are here to stay.
Heart attack is the quintessential medical
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emergency. It presents itself in many forms, with
ST elevation myocardial infarction (STEMI) being
the worst kind. In developed countries over the
past two decades, STEMI-related mortality has
come down dramatically, owing in part to
emergent angiography and opening of the blocked
blood vessel by placing a metallic stent (in a
procedure called primary angioplasty). Medical
systems in most of the developed countries
emphasise opening the occluded vessel within 90
minutes of diagnosis (door-to-balloon-time). An
inferior alternative is the administration of clot-
dissolving medicine, given as an injection. Primary
angioplasty not only saves more lives when
compared to medicine alone, it also improves the
quality of life. Since primary angioplasty costs
more to the patient (compared to medicine alone),
Indian healthcare set-ups often resort to medicine
alone to keep the cost low.
Early intervention also entails having a robust
transport system available for sick patients to be
transferred to an equipped facility should a patient
arrive at a smaller centre irst. Such a system
requires additional infrastructure, adding to
overheads and hence the cost. The lack of such a
system certainly keeps healthcare costs low, but at
the cost of human lives. Obviously there are private
institutes with high regard for improved clinical
outcomes and they do primary angioplasty for a
majority of STEMI cases that come in, but such
institutes are too few and far between. More so,
such institutes do run the risk of not getting
reimbursed for their services when patients are
presented with the bill later on. With no inancial
guarantee from the government in such cases, it's a
dif icult business practice to promote for any
enterprise.
Diagnosis-Related Group (DRG) is a system of
labelling hospital services into individual products
and tie reimbursement according to each DRG. For
example, routine cholecystectomy (removal of the
gall bladder) can be put under a DRG and
reimbursed a ixed amount regardless of the actual
cost to the hospital. While the DRG-based payment
model provides a platform to develop fair and
transparent reimbursement policies, it does run
the risk of pro it-maximising tactics such as
overstating the illness, providing the lowest
service quality, compromising on investigations
and treatment, and so on. The Center for Medicare
and Medicaid Services (CMS) in the United States
utilises a DRG-based bundled payment system and
has laid out vigilance to ensure that unethical
pro it-maximising practices are discouraged and
penalised.
Treatment packages
The Indian private healthcare system has a similar
DRG-based cost structure called 'package'. While
the 'package' model promotes low-cost healthcare
since hospitals can gain competitive advantage by
offering a lower-rate package for the same DRG,
negative externalities sometimes overrun its
positive aspects. In an attempt to keep the cost of
the 'package' low and homogenous, 'package'
charges are typically not adjusted for age or pre-
existing co-morbidities that may drive up the cost
of the procedure, or there may not be enough
inancial buffer to accommodate the additional
cost of any unforeseen complication. Inherent
biases are quite obvious and lead to con licts
where, just like any other contract work, business
enterprise tries to minimise the incurred cost
while consumer (the patient, in this case) attempts
to maximise their care and stay.
As a cost-cutting measure, two key components of
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this model are often missed. First, oversight to
ensure that no unethical cost-cutting strategies are
being employed. This also includes liability for any
events that may occur after discharge as well (for a
inite period of time). Second, 'package' price
adjusted for any risk factors that predict higher
cost than usual as well as buffer for any
complications.
Cost-combating strategies are not restricted to
these scenarios. From a patient's irst encounter to
the inal delivery of any service in any ield of
medicine, the system struggles to lower the cost as
much as possible. While most of the strategies are
valid, many are undesirable or may impose risks on
the patient. Even procedures or tests which seem
to be costly are watered-down versions of what
they should be, thanks to the cost-sensitive market.
I do not believe higher cost leads to better care, or
vice versa. I do however believe that our approach
towards healthcare costs in India needs
introspection. The healthcare provider's medical
decisions should be clinically, not economically,
driven. Similarly, hospital business enterprises
should provide services that are medically relevant
even if such services are economically unviable. To
achieve these, we as a society will need to provide
economic security to healthcare providers to
enable them to make unbiased decisions free of
inancial repercussions. Hospitals will need to
have their own safety net so that inancial losses
from one kind of service can be adjusted with a
more pro itable product. Compensating for lack of
vigilance of industry practices by price-throttling a
pro itable product is bound to have a negative
impact on how both healthcare providers and
enterprises work.
Bracing for medical expenses
Mostly seen as a sudden, unexpected burden
affecting a few unfortunate ones, healthcare
expense is anything but selective and as a society
we don't seem to be prepared for it. Our society
favours reserving funds for our sons' or daughters'
wedding over our own future health (both are
inevitable expenses). Financial assistance in the
form of gifts are social norms across acquaintances
during social events such as weddings, but there is
no such social obligation to help our friends and
family when it comes to healthcare expenses.
Humans in general don't fare too well preparing for
future disasters and it is not uncommon for a
person to have no discrete inancial reserve for
healthcare needs even after 20 years or more of
earnings.
In a country where only a minority of the
population is covered by health insurance or any
other form of shared risk pool, where the entirety
of the healthcare bill is paid out-of-pocket without
any measurable social assistance, low-cost
healthcare is unlikely to ever be low enough to be
constituted 'affordable'. People easily mal-adapt
seeking the lowest-cost healthcare (or worse, don't
seek healthcare at all) disregarding the quality of
care delivered, and all the while private healthcare
systems continue to work their way to drop the
cost further. Quality here is not restricted to the
physical products themselves, but encompasses
professionalism, compassion, empathy, humanity,
facetime with the healthcare provider, medical
knowledge and its implementation… the list goes
on. Each of these traits imposes indirect economic
costs on the system. If not accounted and
compensated for, these traits are dropped early on
to minimise healthcare costs. If quality is not
valued, be it in clinical care, medication, equipment
or procedures, it will stop featuring in regular
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transactions as seen commonly. Humanity costs
time and money to earn, but unfortunately doesn't
have any intrinsic monetary value in the
commercial market. Humanity doesn't pay the
bills.
As the developed world is innovating on low-cost
healthcare, it is worthwhile to introduce ourselves
to some of their practices. These include
preventing diseases in the irst place, reducing
disease-related morbidity (physical and
psychological independence, reduced hospital
stay, hospital re-admission rates and so on),
minimising complications by public reporting and
education, evidence-based medicine (minimise
unnecessary or unproven treatment/procedures),
de-fragmentation of care, incorporating greater
number of lower-risk population into shared risk
and so on. The role of healthcare insurance that
plays into all this makes for an interesting
discussion. Clinical, administrative and regulatory
bodies ensure such measures are taken with an
intent to improve outcomes while the price is
dictated by market forces. Although not foolproof,
such an approach is far likely to lower overall
healthcare cost without compromising on the
quality of care delivered.
We are riding a wagon of low-cost healthcare that
doesn't seem to have a destination. Ethical or not,
(the healthcare) market will keep delivering low-
cost products till demand exists. In such an
environment, quality is not revered, human values
are not compensated, and research and
development is non-existent. Our low-cost
healthcare comes with a long, boring ine print
written in an incomprehensible language. It costs
us our health, quality of life, and longevity. While
the problem is quite obvious, the solutions may not
be. Third-payer systems like health insurance is a
valid shared risk model that combats many of the
issues listed here, but it introduces another set of
problems (still, a far better trade-off). National
health insurance is a great idea but to implement it
in a country like India which spends less than 2% of
its GDP on healthcare almost seems impossible.
Social safety nets are often unreliable and lack
accountability.
Introducing new non-pro it or government set-ups
to deliver excellence in clinical care will certainly
bring healthy competition to the private sector.
Public-private collaboration in the form of
government-assisted private set-ups or public
hospitals with regional participation can be put in
place. Most important of all, though, we have to
centre stage healthcare. It's time we addressed the
elephant in the room.
India added 450 million people over the 25 years to
2016, a period during which the proportion of
people living in poverty fell by half.This period of
rising prosperity has been marked by a “dual-
disea se b u rden”, a c on t in u in g rise in
communicable diseases and a spurt in non-
communicable or “lifestyle” diseases, which
accounted for half of all deaths in 2015, from 42%
in 2001-03.The result of this disease burden on a
growing and ageing population, economic
development and increasing health awareness is a
healthcare industry that has grown to $81.3 billion
(Rs 54,086 lakh crore) in 2013 and is now
projected to grow by 17% (compounded annual
growth rate, or CAGR) by 2020, up from 11% in
1990.As that happens, in rural areas, mobile
technology and improved data services are
expected to play a critical role in improving
healthcare delivery. Although limited, some
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companies are also investing in innovative services
and creating lucrative yet low-cost digital and
device solutions, an example of which would be GE
Healthcare's Lullaby Baby Warmer.
Launched in 2009, the Lullaby baby warmer
provides direct heat in an open cradle to help
newborn babies adjust to room temperature. At
$3,000 (Rs 193,245) per unit in India, the Lullaby
warmer is cheap compared to the baby warmer GE
sells in the US; that warmer costs four times as
much, starting at $12,000 (772,980), although, in
addition to its basic warming function, the
monitors sold in the US also check a baby's pulse
and weight.
About 1,500 of the Lullaby baby warmer sold in the
irst year after launch—half of those in its original
intended target market: Smaller, rural towns in
India. It has since been sold in 62 countries,
including Belgium, Brazil, Dubai, Egypt, Italy and
Switzerland.
However, despite some advances, India's
healthcare sector must deal with a plethora of
challenges, as our analysis of national health
spending indicates:
Despite the lowest government spend and public
spend, as a proportion of gross domestic product
(GDP) and the lowest per capita health spend –
China spends 5.6 times more, the US 125 times
more – Indians met more than 62% of their health
expenses from their personal savings, called “out-
of-pocket expenses”, compared with 13.4% in the
US, 10% in the UK and 54% in China.
Public healthcare under- inanced, short-
staffed; rural areas particularly affected.
India's existing infrastructure is just not enough
to cater to the growing demand.
While the private sector dominates healthcare
delivery across the country, a majority of the
population living below the poverty line (BPL)–the
ability to spend Rs 47 per day in urban areas, Rs 32
per day in rural areas–continues to rely on the
under- inanced and short-staffed public sector for
its healthcare needs, as a result of which their
healthcare needs remain unmet.
Moreover, the majority of healthcare professionals
happen to be concentrated around urban areas
where consumers have higher paying power,
leaving rural areas underserved, as the table below
reveals.India meets the global average in number
of physicians, but 74% of India's doctors cater to a
third of the urban population, or no more than 442
million people, according to KPMG report.
44,22,67,192 as per population count of
1,326,801,576 in 2016
India compares unfavourably with China and the
US in number of hospital beds and nurses. The
country is 81% short of specialists at rural
community health centres (CHCs), and the private
sector accounts for 63% of hospital beds,
according to Indian government health and family
welfare statistics.
Rising population, inadequate resources and
insurance
Some of the key roadblocks, then, for India's
healthcare industry:
1. Population: India has the world's second-
largest population, rising from 760 million in 1985
to an estimated 1.3 billion in 2015. Migrants from
rural areas continue to lock to urban settlements;
roughly 32% of them inhabiting cities–although
estimates of this migration vary–that are already
bursting at the seams.
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2. Infrastructure: India's existing healthcare
infrastructure is just not enough to meet the needs
of the population. The central and state
governments do offer universal healthcare
services and free treatment and essential drugs at
government hospitals. However, the hospitals are,
as we said, understaffed and under- inanced,
forcing patients to visit private medical
practitioners and hospitals.
3. Insurance: India has one of the lowest per
capita healthcare expenditures in the world.
Government contribution to insurance stands at
roughly 32%, as opposed to 83.5% in the UK. The
high out-of-pocket expenses in India, as we
detailed earlier, stem from the fact that 76% of
Indians do not have health insurance, according to
data from the Insurance Regulatory and
Development Authority.
4. Rural-urban disparity: The rural healthcare
infrastructure is three-tiered and includes a sub-
center, primary health center (PHC) and CHC.
Indian PHCs are short of more than 3,000 doctors,
with the shortage up by 200% over the last 10
years to 27,421, as IndiaSpend reported in 2016.
There are, however, potential catalysts to improve
the quality of healthcare in India.the government,
information technology and innovation.
The Union Budget 2017–18 includes measures to
boost rural development, infrastructure and
macroeconomic stability, and although the health
budget has been increased 27%, allocations could
have been matched more holistically with the
government's ambitions, particularly when
considering adjustment against in lation and new
health-program announcements.
Analysts argue that the national insurance scheme
(the Rashtriya Swasthya Suraksha Yojana) is a
minor improvement on the existing one, with the
annual limit per family increased from Rs 30,000 to
Rs 100,000, with an additional “top-up” of Rs
30,000 for senior citizens. Our estimates suggest
that enrolling all BPL families in the country in
health-insurance programmes would cost
anywhere from Rs 2,460 to Rs 3,350 crore, or less
than the cost of two French Rafale ighters.
Information Technology (IT) is set to play a big role
with IT applications being used for social- sector
schemes on a large scale. Bene iciaries are issued a
biometric-enabled smart card containing their
ingerprints and photographs. Hospitals
empaneled under the government insurance
scheme are IT enabled and connected to servers in
districts. Bene iciaries can use a smart card that
allows them to access health services in any
empaneled hospital across India.
Additionally, the ministry of health and family
welfare launched several new computer and
mobile-phone based e-health and m-health
initiatives on World Health Day in 2016. These
include the Swastha Bharat mobile application for
information on diseases, symptoms, treatment,
health alerts and tips; ANMOL-ANM online tablet
application for health workers, e-RaktKosh (a
blood-bank management information system) and
India Fights Dengue.
Individual states are adopting technology to
support health-insurance schemes. For instance,
Remedinet Technology (India's irst completely
electronic cashless health insurance claims
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processing network) has been signed on as the
technology partner for the Karnataka
Government's recently announced cashless health
insurance schemes.
Driven by investment, starts, healthcare is
poised to change
As technology increasingly plays an important role
in healthcare, the data indicate growing attention
from private investment and startups.
The government's National Innovation Council,
which is mandated to provide a platform for
collaboration amongst healthcare domain experts,
stakeholders and key participants, should
encourage a culture of innovation in India and help
develop policy on innovations that will focus on an
Indian model for inclusive growth.Additionally,
there has also been an emergence of “frugal
innovation” in the private sector — products and
business models that offer quality diagnostics and
care at a much more affordable price.Healthcare
delivery in India is now uniquely poised to undergo
a change at all its stages – prevention, diagnosis,
and treatment. No single entity in the healthcare
sector can work in isolation.
The evolution of the sector calls for involvement
from all stakeholders and the use of innovation to
bridge intent and execution. India has the
opportunity to leap-frog a lot of the healthcare
problems that developed nations are grappling
with, such as unlinked electronic medical records
and overspending. The question is, can she seize
the opportunity?
Public healthcare is government's prime
responsibility and they are responsible to protect
the rights of doctors as well as patients. But
unfortunately we are not so lucky to have such
governments since independence. As citizens pay
the tax, they expect good services from the
government in return but we all know what kind of
service we citizens are getting in government
hospitals. Government is completely at failure for
providing quality health services.
Fortunately to ill this gap private hospitals took
lead and started doing wonders in health sector,
obviously at certain cost. Patients have to pay hefty
bills in order to enjoy good healthcare services.
The bills which are un-affordable by most of the
people and even if a person recovers from physical
illness, he is indebted to inancials illness which
leads to severe inancial crisis for a family.
At this crucial juncture of our country, I think,
Indian citizens really deserve the cutting edge
technology, highly skilled doctors at affordable
cost. There are certain questions which still
remained unanswered like why still India does not
have structured insurance system for every Indian.
Why whole family has to suffer when someone
suddenly falls ill due to serious disease like heart
attack or cancer. Where is the inancial shock
absorber?
We still lack grass root level education among
countrymen and hence we are not matured enough
to understand the disease and its consequences.
The medical inancial burden on a family leads to
loss of trust in minds of attenders.
As a doctor myself and our fraternity knows the
dif iculties running a hospital in present situation.
It's becoming a costly affair to build, furnish,
provision medical equipment and employing staff.
Its long list which just doesn't end here, you have to
give competitive service, pay doctor referral
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amount, govt. taxes and political pressure and so
on. We can easily conclude that running a hospital
is no longer a white collar job!
Who will ix all these issues?
Instead of making government hospitals ef icient
and well equipped, govt. is projecting doctors as
central villain. Doctors who are working in
corporate hospitals are just employees and they
get only 5% to 10% of the bill amount as their
professional fees. The major component of bill
consists of service and medicines cost in corporate
hospitals.
Why we should take the blame as a doctor. Is it
because we are the face of a hospital? This is the sin
which we did not commit. You can observe this
situation in metro cities.
Now let's talk about small place like a village or
taluka place, there are small clinics/hospitals run
by a doctor or group of doctors who are providing
excellent medical services with limited resources
and skills that too in a very cost effective manner.
But here too doctors are demonized; many doctors
running a clinic earn less than the medical store
established beside their clinic.
We all know that generic medicines have huge
margin which directly goes to pharmacist pocket.
They buy the medicines on wholesale price and sell
it at maximum retail price. Sometimes medicines
are sold at 5 times more than the wholesale price.
But no pharmacist is blamed or demonized by
society and eventually blame goes to the doctor!
My point is why be portrayed as We as a Doctor
demons and why we should be blamed for the
higher medical cost charged by the pharmaceutical
companies and implant companies?
Let's come forward and dissociate ourselves from
Materialistic demons and practice as light bearers
of the Hippocratic Oath.
The author is Consultant Physician & Clinical
Cardiologist MBBS (MRCP UK Internal Medicine)
DIP CARDIOLOGY in Hyderabad
The changing nature of healthcare practice in
India has spawned a plethora of issues that
need attention
In recent times there has been much change in all
walks of life. Medicine is no exception. Over the
past four decades in this ield we have seen vast
changes in the attitude of doctors, hospitals,
patients and the media. First and foremost, patient
expectations have changed.
The earlier generations depended on family
doctors and there was a bond between doctor and
patient. Money was only incidental. Today, with the
media and the Internet proliferating and
generating new expectations, patients want quick-
ix solutions. The same attitude is found in the
younger generation of doctors. The sea change in
medical treatment regimes came in the mid-1980s
with the founding of corporate hospitals and
nursing homes.
Today there is a trust de icit between doctor and
patient. The communication between them is at a
low. We may be in a digital world, but in patient-
care there should be a personal touch and
communication to solve most problems. That's
often not there today.
Once, all the top specialists were in major
government general hospitals. Corporate hospitals
changed that. The investors built the best hospitals
with state-of-the-art technology and paid well to
hire the best medical talent from across the globe.
Virtually overnight, in Chennai for example, we had
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the best treatment available in the country, with
specialists on a par with those anywhere in the
world. For such care, there is a price to be paid.
Investors and managements expect returns. We
should not think government hospitals are doing
free service — salaries and running costs come
from the taxpayer; it is only returns that are not
expected. Today there is no denying that private
hospitals and private medical colleges have a
signi icant role in healthcare delivery. If private
medical colleges don't have the standards
stipulated by various accreditation bodies, they
will disappear, as many engineering colleges have.
But unlike engineering colleges, the cost of running
private medical colleges and hospitals is
considerably more. They also need an adequate
patient load to make possible teaching, training,
and research publishing. And looking after
hospitalised patients has a cost too.Today every
patient wants American standard medical care at
local cost. We are not doing too badly on that.
India at present is a destination for patients from a
large number of neighbouring countries. In the
next decade it will be a major medical destination
for patients from other countries as well, a
development similar to it having become a
destination for information technology services
since the 1980s. This is because we have the best of
doctors, nurses and technicians. And we still offer
caring treatment at comparatively reasonable
costs.One of my patients, in spite of having medical
insurance in the United States, came to me to have
his treatment done instead of getting it done in the
U.S. When I asked him why, he told me that in the
ICU there the nurses and doctors don't
communicate with parents and are more bothered
with their charts and records.
American medical care is driven by lawyers,
insurance and medical administrators. In such a
situation, charts and records become more
important than personal involvement with
patients.
Let's look at another issue. When a doctor operates
in an emergency case or has to deal with a very
serious case, he or she is doing his best, based on
the knowledge and experience. They have to take
spot decisions in critical situations. They don't
have the luxury of adjournment or a higher court.
For a doctor to act in an emergency situation, he or
she should have freedom from fear of litigation and
physical assault.
If there is gross medical negligence, let the law take
its course. If hostile relatives and rowdy elements
take centre stage, the poor doctor is a sitting duck.
No other profession comes in contact with the
public as a doctor's profession does.
Defensive mode
If doctors are to fear litigation, then they will get
into a defensive mode. They will think twice before
doing complex procedures, not because of any
medical problem but the fear of the courts and,
possibly, being asked to pay huge compensation.
Today most doctors take medical indemnity bonds,
only adding to the cost for the patient. This was
something unheard of in the past in India.
A doctor will be close to 40 years of age when he
becomes a specialist or super-specialist. From
there it takes a decade more of hard work day and
night, Sundays and holidays, to get recognised. No
other profession has such a long incubation period.
Surely he or she is entitled to respect — and
understanding if there is medical error. He is, after
all, human. Every doctor is doing his or her best for
the patient. Don't shoot the doctor; he or she is
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helpless. It cannot happen to lawyers, bureaucrats,
industrialists or politicians because there will be
repercussions.
The times have changed. With greater scienti ic
progress, people's expectations have increased.
Who will bear the cost? Healthcare cost cannot be
the complete responsibility of the government
alone with just 2.5% being the share of the GDP for
health care. It is the responsibility of individuals,
institutions and philanthropic bodies to ill the gap
to attain the goal of a healthy nation. Private
participation is needed in numerous ways. Please
don't shoot the doctor.
That cancer is a genetic disease and not one
speci ic to localised tissues and organs is
percolating to therapy
Cancer is a disease that af licts particular organs.
That is why there are lung cancers and blood
cancers and, under the in luence of genetics, an
organ serves as an epicentre from where it could
radiate and consume a person. This constitutes the
classical view and in luences treatment strategy
today.
In 2014, a study published in the International
Journal of Cancer found an intriguing link among
cancers. The researchers sourced genetic data
—from 14 major cancer entities and 4,796 cases
available through The Cancer Genome Atlas
(TCGA) — based on all available genes as well as
different cancer-related gene sets.
The researchers found that in about 43% of the
cases, on average, tumours of a particular anatomic
site are genetically more similar to tumours from
different organs and tissues (trans-similarity) than
to tumours of the same origin (self-similarity).
These similarities existed not only for carcinomas
from different sites but are also present among
neoplasms (an abnormal mass of cells that may or
may not be cancerous) from a different tissue
origin such as melanoma, acute myeloid
leukaemia, and glioblastoma.
“The current World Health Organisation cancer
classi ication is therefore re lected on the genetic
level by only about 57% of the tumours,” they
report in their study.
New approach to tests
In the last three years, the approach that cancer is a
genetic disease and not one speci ic to localised
tissues and organs is percolating to therapy. For
instance, pembrolizumab was a drug speci ically
approved only for metastatic melanoma.
This May, the United States Food and Drug
Administration (FDA) cleared the drug, marketed
by Merck as Keytruda, for use in any kind of solid
tumour that resulted due to mutations that affect
the DNA's ability to perform a function called
mismatch repair. This is a system whereby DNA can
check for errors during the cell-division process.
This approval marked the irst instance in which
the FDA approved marketing of a drug based only
on the presence of speci ic genetic mutations in a
person, irrespective of whether it was a skin or a
colorectal cancer. Several more have followed suit.
Consequently, several major drug companies are
now working on being able to design tests that link
a person's cancer to their genetic make-up in the
hope that they could avoid drugs that wouldn't
work or be able to sign for clinical trials that were
testing new therapies.
Betting on genetic pro iling
For instance, Foundation Medicine (FM), a
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company in Cambridge, Massachusetts, has just
launched a diagnostic test for “personalised cancer
care”.
This means that physicians can order in a test that
looks for genetic alterations in 324 genes known to
drive cancer growth, and identify patients with
advanced cancer who are likely to bene it from
targeted therapies. FM, in which Swiss health-care
major Roche has a majority stake, is betting that
genetic pro iling will become a critical part of
cancer care. “Going ahead, cancer will be seen as a
treatable, chronic disease that can be managed
with speci ic therapies,” says Steve Ka ka, Chief
Operating Of icer, FM.
“Even in the United States, only 1% of those who
need genomic pro iling are getting it.”
FM's tests build on a knowledge base of over
160,000 clinical cases. Though they aren't yet
available in India, representatives say that those,
especially in advanced stages of the disease, could
still avail of them. “We are in the process of talking
to physicians and doctors in India about the
potential of these tests,” says Josh Lauer, Lifecycle
Leader, FM. However, a key drawback in India is the
lack of access to clinical trials, all of which are
located internationally, to addressing particular
cancers.
Other experts say that the approach to cancer is
signi icantly determined by where patients are
located — a developing country in India or the
United States — or more mundanely, the type of
cancer in question.
“The genetic approach exists but the location of the
cancer tells a surgeon whether it can be cut away or
not. Most doctors anywhere would, as far as
possible, like to reduce the size of the tumour,” says
Anurag Agrawal, Director, Institute of Genomics
and Integrative Biology, “At the other end, there are
cutting edge treatments like CAR T cells that
engineer people's immune cells to ight. Cost: Half
a million dollars.
(The writer was a guest of Roche at a press
conference in Boston on genomic pro iling in cancer
care.)
UHC provides the framework in which the
issues of access, quality and cost can be
integrated
Three recent incidents involving the health-care
sector in Delhi have sparked widespread outrage
over the alleged mercenary motives and callous
conduct of high-pro ile corporate hospitals. Two
cases involved children with dengue who died
soon after leaving these hospitals in a serious
condition after their families were presented huge
hospitalisation and treatment bills. The third case
involved a live premature baby being “declared
dead” and handed over to the parents wrapped in
plastic.
Distrust and despair
Questions have been raised, and rightly so, about
the lack of professional standards in terms of
competence and compassion. The medical bills,
running into huge igures, also stoked anger at
perceived corporate addiction to pro it
maximisation. The government, the hospital
managements and the Indian Medical Association
have begun inquiries. Even as these go on, there is
deep public distrust and despair over health care in
private and public sector hospitals.
Three major issues are involved when we assess
health care: access, quality and cost. Each of these
needs to be addressed with clarity, and not in
isolation. Solutions have to be those that it into a
common system architecture, or a system best
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designed and delivered as Universal Health
Coverage (UHC), now enshrined in the Sustainable
Development Goals.
Access to readily reachable, trustworthy and
affordable health care is a major challenge before
poorly served rural areas and overcrowded urban
areas. Also, the inadequacy of organised primary
health services here is compounded by a weakness
at the intermediate level of care in many district
hospitals and nursing homes. While corporate
hospitals boast of high quality advanced care and
compete with each other for a signi icant share of
medical tourism, they are mostly inaccessible to
the rural population and the urban poor.
Government institutions of advanced care suffer
from low budgets and a lack of managerial talent.
Steps to improving access
The pathway to improving access lies in expanding
the network of public sector facilities at all levels.
This calls for higher levels of public inancing,
investment in training and incentivised
placements of more health personnel and
improved management through the creation of a
public health management cadre. These measures
have been envisaged in the National Health Policy,
2 0 1 7 a n d n e e d u r g e n t a n d e a r n e s t
implementation. Health-care providers in the
private and voluntary sectors should be
empanelled to ill the gaps through carefully
crafted contracting mechanisms that best serve
public interest.
Quality of care is determined by the extent to which
appropriate care is provided in each clinical
context. Here there must be an emphasis on the
bene it and safety of tests and treatment, and
ensuring that satisfaction levels of patients,
families, care providers in the nature of
institutional processes as well as human
interactions are met. This requires ensuring
conformity to accepted scienti ic and ethical
standards. Here, the Clinical Establishments Act is
a good beginning, in moving health-care facilities
towards registration, ensuring compliance with
essential standards of equipment and
performance, adopting standard management
guidelines, grievance redress mechanisms, and
respecting encoded patient rights.
Managing cost
Cost of care is a major challenge in a system where
patients and families have to bear the burden. High
out-of-pocket spending on health care leads to
unacceptable levels of impoverishment. With high
levels of poverty and a very large segment of the
working population in the informal sector, both
private insurance and employer provided
insurance can cover only small population
segments. With a small risk pool, these schemes
can only provide limited cost coverage to
subscribers. Government-funded social insurance
schemes do increase access to advanced care. But
they have not been shown to provide inancial
protection as they cover only part of the
hospitalisation cost and none of the expenses of
prolonged outpatient care which forms a higher
percentage of out-of-pocket spending.
The solution lies in doubling the level of public
inancing to at least 2.5% of GDP by 2019, rather
than 2025, as proposed in the National Health
Policy, and by pooling tax funding, all Central and
State insurance schemes and employer-provided
health insurance into a “single payer system”. That
can be managed by an empowered autonomous
authority which purchases services from a
strengthened public sector and, as necessary, from
empanelled private health-care providers. Quality
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