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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
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
32
Asia’s Most Analytical News Media in Healthcare Communications
www.pharmaleaders.tv
Pharma LeadersPharma LeadersTM
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,	
33
Asia’s Most Analytical News Media in Healthcare Communications
www.pharmaleaders.tv
Pharma LeadersPharma LeadersTM
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
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	
34
Asia’s Most Analytical News Media in Healthcare Communications
www.pharmaleaders.tv
Pharma LeadersPharma LeadersTM
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
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	
35
Asia’s Most Analytical News Media in Healthcare Communications
www.pharmaleaders.tv
Pharma LeadersPharma LeadersTM
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
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.
36
Asia’s Most Analytical News Media in Healthcare Communications
www.pharmaleaders.tv
Pharma LeadersPharma LeadersTM
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
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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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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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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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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THE GAME CHANGER
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	
53
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THE GAME CHANGER
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	
54
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THE GAME CHANGER
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	
55
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PHARMA LEADERSPHARMA LEADERS
INDIA’S MOST
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INDIA’S MOST
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COMPANIES 2017
THE GAME CHANGER
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	
56
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Pharma leaders 2017 white paper

  • 1. 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 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 32 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 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, 33 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 3. 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 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 34 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 4. 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 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 35 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 5. 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 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. 36 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 6. 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 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 37 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 7. 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 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 38 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 8. 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 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 39 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 9. 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 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 40 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 10. 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 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. 41 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 11. 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 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 42 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 12. 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 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 43 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 13. 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 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 44 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 14. 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 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 45 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 15. 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 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 46 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 16. 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 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 47 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 17. 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 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 48 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 18. 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 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. 49 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 19. 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 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 50 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 20. 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 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 51 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 21. 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 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 52 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 22. 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 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 53 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 23. 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 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 54 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 24. 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 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 55 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM
  • 25. 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 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 56 Asia’s Most Analytical News Media in Healthcare Communications www.pharmaleaders.tv Pharma LeadersPharma LeadersTM