Healthcare Leaders to Chart Out Blueprint of Healthcare Reforms at India Leadership Conclave 2014

Healthcare Leaders to Chart Out Blueprint of Healthcare Reforms at India Leadership Conclave 2014

Veteran Healthcare Leaders Dr B Somraju, Dr Mukesh Batra, Dr Shashank R Joshi, Dr. Gaurav Sharma, Dr Jothydev Kesavadev, Dr. Sandeep Chatrath, Dr. Ashwini Kumar Kudari among others to debate Unequal India & an unfinished agenda  of the Indian Healthcare Challenges

More than Half the population of India who live in the remotest corners of the country are not equal partners of the rest of india with regard to Healthcare access, insurance, affordability & above all the impending critical diseases where healthcare is denied & marginalized due to the poor economic conditions & the failure of the successive governments at the centre to provide the healthcare access & treatment. Healthcare in India is both a complex challenge and an immense opportunity. Beyond the health benefits of medical innovations and interventions, addressing access to affordable basic health and wellness care is imperative to the financial security of low-income Indians. Indeed, health expenses remain the leading reason for India’s growth trajectory. on-communicable diseases (i.e. Diabetes, Heart Disease, and Cancer), Health Financing, Maternal/Infant Medicine remain the bigger challenges in India reflecting the current epidemiology in India’s poor state of Healthcare reforms. Historically, it was communicable diseases, such as Tuberculosis and Polio, which received the attention of public health experts as these globally afflict the poor. NCDs, such as diabetes and hypertension, were not prioritized as these were considered ‘lifestyle diseases’ that only affect wealthy populations. In fact, there are 63 million diabetic patients in India, and rural and urban poor account for over 60% of cases. Lack of access to affordable care makes NCDs more prevalent among poor Indians.

For those who cant afford in private hospitals, the rosy picture of India’s rising space in healthcare domain is a non issue despite the claim that the healthcare sector in India is expected to grow at a CAGR of 15 per cent to touch US$ 158.2 billion in 2017 from US$ 78.6 billion in 2012, & india being a country with a growing population, its per capita healthcare expenditure has increased at a CAGR of 10.3 per cent from US$ 43.1 in 2008 to US$ 57.9 in 2011, and going forward it is expected to reach US$ 88.7 by 2015. It is true that The e factors behind the growth of the sector are rising incomes, easier access to high-quality healthcare facilities and greater awareness of personal health and hygiene.

Healthcare providers in India are expected to spend US$ 1.08 billion on IT products and services in 2014, a four per cent increase over 2013. But why the Doctors are not willing to go out to the villages while assigned to them & Why the Govt is not so serious of revamping the present situation where we have a big requirement of Doctors, Nurses & Primary Healthcare Centres. It is pity that some of the PHC’s in india are either closed or opened for nothing as there are no infrastructure says Mr.Satya Brahma, Chairman & Editor-In-Chief of Network & Media Group on the eve of the debate on “Unequal India & an unfinished agenda  of the Indian Healthcare Challenges” at the 5^th Annual India Leadership Conclave & Indian Affairs Business Leadership Awards 2014. The Conclave attempts to find out the opinions of the Healthcare Professionals who will assemble on Friday, 18^th July 2014 in Mumbai to debate on this important topic”. Dr. B Somaraju,Cardiologist & CMD, Care Hospitals Group Dr. Mukesh Batra, Founder Chairman, Dr Batra’s Dr Shashank R Joshi ,Endocrinologist & Dibetologist, Joshi Clinic Dr Sandeep Chatrath,CEO,Dharamshila Hospital and Research Centre,Dr Gaurav Sharma,Diabetologist & Life Style Doctor,CMD,DrG Wellness(P)Ltd. Dr. Ashwini Kumar Kudari,Associate Professor, Surgical Gastroenterology MS Ramaiah Medical College, Bangalore Dr.Jothydev Kesavadev,Founder Chairman, Jothydev’s Diabetes Research Centre And Hospitals, Dr Chytra.V.Anand, Cometic Dermatologist of Kosmoderma & Dr Deepak K Jumani, Consultant in Sexual Health and Counsellor. The Conclave is running on a theme “Perform or Perish”

Indian Challenges

India is here to stay as a stable marketplace with vanishing boundaries and as the most enduring democracy in South Asia. It is not that the party is entirely out of place. In more than six decades of national independence, India has emerged as a reassuring example of freedom in a region otherwise known for less evolved civil societies; India has also bucked the post-colonial trend of the hero of liberation turning into a cult of autocracy. Here come the party poopers, armed with arguments mined from the twilight zones of freedom. The timing of the spoilers’ entry is perfect: The cheerleaders of India Ascending, all growth fanatics, are too optimistic to be dispirited by the occasional fall of the rupee or the momentary slowdown of the economy.

AN UNFINISHED AGENDA

The record of India’s achievements is not easy to dismiss, but is that the whole story? An agreeable picture of a country in a rapid march forward towards development with justice would definitely not be a comprehensive, or even a balanced, account of what has been actually happening: indeed far from it. There are many major shortcomings and breakdowns-some of them gigantic-even though privileged groups, and especially the celebratory media, are often inclined to overlook them. We also have to recognize with clarity that the neglect-or minimizing-of these problems in public reasoning is tremendously costly, since democratic rectification depends crucially on public understanding and widespread discussion of the serious problems that have to be addressed.

So what is the way out of the health crisis which is perhaps the biggest adversity facing India today? The problems are large, but rather than being overwhelmed by their enormity, we should identify the ways and means of overcoming this adversity, drawing both on the analyses of the factors that have contributed to this crisis, and also-closely related to that investigation-on the lessons that have emerged from the experiences of other developing countries which have dealt with these problems much better than India has. There is also much to learn from the better performance of those Indian states (Kerala and Tamil Nadu in particular) which have taken care of the health of the people a lot better than the rest of India. As far as the rest of the world is concerned, the countries that offer immediate lessons for India include-most importantly-China, but also Brazil, Mexico and Thailand, among others.

A boy receiving polio drops

There has to be renewed focus on primary health centres and village-level health worker.Perhaps the first-and the most crucial-thing to appreciate is the importance of the commitment to universal coverage for all in a comprehensive vision of health care for the country as a whole. Thailand, Brazil and Mexico have got there in recent years, and transformed the reach of health care for their people. China’s experience is particularly interesting, since it attempted, first, to deny the necessity of this commitment when the economic reforms first occurred, in 1979, and by reversing the earlier universalism, China paid a heavy price for this denial in terms of the progress of longevity and general health. China eventually realized the error in this denial and, from 2004, started moving rapidly back to universal commitment (China is already 95 per cent there), reaping as it is sowing. And contrary to what we often hear from alleged admirers of China who want India to follow China without being quite sure of what it is that the Chinese do, China does not leave the coverage of health in the hands of private health insurance-the state is the major player to ensure this. These experiences are, as we have already discussed, entirely in line with what we would expect on grounds of economic reasoning, particularly because of (1) the ‘public goods’ character of the health of people, (2) the role of asymmetric information, and (3) the impact of inequality on the achievement of general health in a community and a nation.

The commitment to universal health coverage would require a major transformation in Indian health care in at least two respects. The first is to stop believing, against all empirical evidence, that India’s transition from poor health to good health could be easily achieved through private health care and insurance. This recognition does not, of course, imply that there is no role at all for the private sector in health care. Most health care systems in the world do leave room for private provision in one way or another, and there is no compelling reason for India to dispense with it. Nor can health planning in India ignore the accountability issues and other challenges that affect the operation of the public sector-including the public provision of health care. Nevertheless, the overarching objective of ensuring access to health services and other requirements of good health ‘to all members of the community irrespective of their ability to pay’ (as the Bhore Committee aptly stated the core principle of universal health coverage many years ago) is intrinsically a public responsibility. Further, given the limitations of market arrangements and of private insurance in the field of health care, public provision of health services has an important foundational role to play in the realization of universal health coverage.

Following on this, the second respect in which the proposed approach demands a change in India lies in the need to go ‘back to basics’ as far as public provision of health care services-both of a preventive and curative kind-is concerned, with a renewed focus on primary health centres, village level health workers, preventive health measures, and other means of ensuring timely health care on a regular basis. While RSBY (the newly established scheme of subsidized health insurance for poor households) is a humane programme and much better than leaving the poor to die or suffer from neglected health care and unaffordable intervention, better results can be achieved at far less cost through early and regular health care for all (supplemented by providing expensive intervention if and when it is needed despite early and more systematic medical care for all).

The need for public involvement is particularly strong in a range of activities aimed at preventing rather than curing disease, such as immunization, sanitation, public hygiene, waste disposal, disease surveillance, vector control, health education, food safety regulation, and so on (what is technically known as ‘public health’).

The inaugural years of nation-building, though, were an exercise in Sovietisation with a dash of tentative capitalism; Nehru’s New Man of Scientific Temperament was sustained by a socialist regime that spent all its resources on creating a mammoth public sector. It took more than four decades and the courage of a few men in power for India to break out of the comfort zone of socialism and stop looking at the world through the prism of Cold War. The late awakening and an accelerated growth rate, an aspirational middle class and an ambitious entrepreneurial class-the familiar India Stagnant has been replaced by India Rising, as if the world was waiting for the dawn of this democratic counterpoint to the Chinese superpower. It is this velvet narrative of inevitable glory that Nobel Laureate Amartya Sen and his disciple Jean Dreze, two finest minds in development economics, debunk in An Uncertain Glory: India and Its Contradictions, a mandatory reading for every Indian politician in power.

Healthcare Challenges in India

India is among the five countries that spends the least on public health. Overall, we spend a meager four percent of our GDP on health. Out of pocket (uninsured) expenses, meanwhile, account for 70 percent of healthcare expenditure. As a result, families are often choked with medical debt and sink into poverty. And this is affecting India’s growth.

The Innovation of Healthcare in India

Healthcare in India is at a crossroads. On the one hand, it’s never been rosier. According to the World Health Organization, India has made significant strides over the past 50 years by improving life expectancy from 42 years to 65 years, reducing infant mortality by two-thirds, and eradicating small pox and polio. Yet on the other hand, the rising incidence of chronic illnesses such as diabetes, hypertension, and cardiac disease will eventually overwhelm a system that is already hampered with limitations in accessibility, affordability, and awareness.

The elephant in the room is the wealth disparity that is clearly evident in the Indian healthcare system. Those in the lower socioeconomic strata are confined to underfunded public facilities and insufficient medical providers, whereas those with the ability to pay have the chance to enter world-class centers of care that offer cutting-edge technology and super-specialists at their beck and call. Interestingly, the summation of all of these factors makes the current climate in healthcare a fertile area for both entrepreneurs and investors.

The answer to India’s crisis in healthcare cannot be addressed by simply throwing more money at the problem. The process will need decentralized care, physician extenders, and greater involvement of consumers in their own self-care. Technology will need to be leveraged in each area to create solutions that will improve quality and service without driving up cost. We are already seeing the early promise of telemedicine extending the specialist’s reach, vision-screening vans facilitating efficient rural outreach, and the early nibbling of electronic medical records. Future innovations will come from tapping into the one object that straddles individuals of all socioeconomic backgrounds – a cell phone. Understanding the potential of using SMS and mobile health apps can help us find actionable information to manage individual and population health.

Advice for Entrepreneurs

The best opportunities for entrepreneurs in healthcare should:

1) Revolve around solving a problem worth solving – meaning fix something that is a big deal which affects everyone and is a “must have” to all providers and not just a tiny irritant for a few.

2) Incorporate what has worked successfully in other similar countries and learn from what has failed there as well.

3) Gather the best and brightest as you lay the foundations of your team.

One of our biggest healthcare initiatives is to empower consumers to be active participants in their own healthcare. It is time for them to challenge the status quo around diagnostic testing, treatment decisions, and the need for certain procedures. Our belief is that technology can create platforms that will add a layer of objectivity to a very subjective practice. By enabling consumers to become more aware and informed, we allow them to be partners in the process. Over time, this will lead to a paradigm shift that will prioritize wellness and prevention. India will need to move forward in this uphill march against the entrenched cultural roots of the medical system in order to catch up with the momentum in the developed world.

Here are five major healthcare challenges for the next government, including the grim statistics that nearly every election manifesto has conveniently ignored:

1. 1.    Anaemia

Facts: Over half the women in India are anaemic. They have unusually low levels of haemoglobin, which makes it difficult for the blood to clot and increases the risk of postpartum hemorrhage (excessive bleeding) during childbirth. Studies show that anaemia is responsible for 40 percent of maternal deaths in India. And that’s only the women; the World Bank estimates that nearly 70 percent of the children in the country are also anaemic.

Why:  Although some kinds of anaemia can result from infection, most cases of the disease in the developing world are the result of poor nutrition, especially deficiency in iron. Tablets and injections that supplement iron are cheap and accessible, but diagnosis remains a challenge because most poor women and children never get tested for anaemia.

2.Maternal Mortality

Facts:  Each year, 56,000 women in India die due to complications arising from pregnancy or childbirth. According to data released by the Registrar General last year, India’s Maternal Mortality Ratio (MMR) — the number of women who die during pregnancy and childbirth per 100,000 live births — has dropped from 212 to 178 between 2007 and 2012. However, the regional disparities are huge. States such as Tamil Nadu and Kerala, with an MMR of 105, have fared better than poorer states such as Bihar, Uttar Pradesh, Madhya Pradesh, and Chhattisgarh, whose MMR is still over 250. The country as a whole is far behind the Millenium Development Goal of 103. The number of women dying in childbirth is fewer than before, but it still kills more than 150 women everyday.

Why: Too many women in India, who are poor and often anaemic, give birth at home. Many of them are stunted or too thin, which puts them at a higher risk for complications. With no access to sufficient nutrition, antenatal care or even decent hospitals, they succumb to the complications.

1. 3.    Under-Five Mortality

Facts:  According to a 2012 report by the UNICEF, 1.7 million children under the age of 5 die in India every year. Diarrhea — yes, loose bowel movements — alone kills 98,000 children under the age of 5 years. In 2011, India, along with four other countries (Democratic Republic of Congo, China, Pakistan and Nigeria) accounted for half the global deaths of children under five. Alone, it accounted for nearly a quarter of the deaths. The causes include pneumonia, malaria, HIV and measles, but a majority of them died within a month of being born because of complications arising from their birth.

Why:  The biggest reason, according to the UNICEF study, is poor nutrition. Poor education, lack of breastfeeding and maternal mortality drive up child deaths, especially in the immediate weeks following the birth – when they are most vulnerable to weakness and infection.

4.Visual Impairment

Facts: Research organizations such as The Brien Holden Institute in Australia estimate that 456 million people in India need vision correction to help them see clearly. Of those, 133 million, including 11 million children, are blind or visually impaired only because they don’t have access to an eye examination and a pair of glasses.

Why:  For the latter group, the biggest reason is lack of access to an eye test — a room where a trained optometrist can measure their refractive error and write them a prescription for glasses.

5.Cervical Cancer

Facts: A report in 2013 by the US-based Cervical Cancer Free Coalition said that 72,000 women in India die from cervical cancer every year. That’s more than a quarter of the global toll. It’s also the most common cancer among women in India.

Why: The disease, which is sexually contracted, carries a fierce taboo. In addition to that, access to a pap smear test (a reliable cervical cancer screening), and subsequent treatment, is hard to come by in rural India where access to gynaecologists is limited.

A 2009 study says that most of India’s 27 regional cancer centers don’t have gynecological oncologists on staff, and that they don’t reach enough women anyway. Another study from 2013 depicts the sorry state of community health centers, with 70 percent of spots for specialists such as surgeons, paediatricians, gynaecologists lying vacant.

lack of health insurance and its low penetration causes further challenge towards access to healthcare. With 75 percent of the Indian population paying for healthcare services from their own pockets, it puts tremendous financial burden. The Indian healthcare system is a dilapidated state. The costs seem to raise everyday which makes it unaffordable for a large chuck of the population

According to Aman Gupta, “India is the second most populous country in the world and with an healthcare infrastructure that is over-burdened with this ever increasing population, a set of challenges that are unique to India arise.” He explains below:

• “India faces the twin epidemic of continuing/emerging infectious diseases as well as chronic degenerative diseases.
• The former is related to poor implementation of the public health programs, and the latter to demographic transition with increase in life expectancy.
• Economic deprivation in a large segment of population results in poor access to health care.
• Poor educational status leads to non-utilisation of scanty health services and increase in avoidable risk factors.
• India faces high burden of disease because of lack of environmental sanitation and safe drinking water, under-nutrition, poor living conditions, and limited access to preventive and curative health services.
• Lack of education, gender inequality and explosive growth of population contribute to increasing burden of disease.
• Expenditure on health by the Government continues to be low. It is not viewed as an investment but rather as a dead loss.
• States under financial constraints cut expenditure on health.
• Growth in national income by itself is not enough, if the benefits do not manifest themselves in the form of more food, better access to health and education.”

The points that were highlighted in the discussion between IHP and PhRMa were crucial to make healthcare affordable. These are the main points that were discussed, says Aman.

“Innovation in healthcare can, partnership amongst pharmaceutical companies (Generic and Research driven), Government of India, NGOs and other stakeholders will be key to this critical role towards ‘Access to Healthcare’.

Innovative business models need to be explored to tackle issues which are very specific to India. These could be PPP, social entrepreneurship or patient assistance programs, etc.

Rapidly ageing population requires affordable, accessible and quality public health services and innovation will key role in meeting these needs.”

But like all plans there are hurdles that slow down the process; these are the speed bumps for India suggests Aman Gupta. “Lack of awareness is a problem which is faced in building access to healthcare. Mass awareness is important since even if the treatment is free, unless the masses are educated and informed about the symptoms of the diseases, its repercussions and complications and finally the treatment available; there is no guarantee that people will avail these.”

“Besides this, lack of health insurance and its low penetration causes further challenge towards access to healthcare. With 75 percent of the Indian population paying for healthcare services from their own pockets, it puts tremendous financial burden.”

Positive India

India being a country with growing population, country’s per capita healthcare expenditure has increased at a CAGR of 10.3% from $43.1 in 2008 to $57.9 in 2011 and going forward this figure is expected to rise to $88.7 by 2015.The factors behind the growth is rising incomes, easier access to high-quality healthcare facilities and greater awareness of personal health and hygiene, the report said.The country’s healthcare system is developing rapidly and it continues to expand its coverage, services and spending in both the public as well as private sectors, it said.

The private sector has emerged as a vibrant force in India’s healthcare industry, lending it both national and international repute. Private sector’s share in healthcare delivery is expected to increase from 66% in 2005 to 81% by 2015. Private sector’s share in hospitals and hospital beds is estimated at 74% and 40%, respectively.There is substantial demand for high-quality and speciality healthcare services in tier-II and tier-III cities. To encourage the private sector to establish hospitals in these cities, government has relaxed the taxes on these hospitals for the first 5 years.

Many healthcare players such as Fortis and Manipal Group are entering management contracts to provide an additional revenue stream to hospitals.Over the years, health insurance is gaining momentum in India; gross healthcare insurance premium is expanding at a CAGR of 39% over FY06-10. This trend is likely to continue, benefitting the country’s healthcare industry

Strong mobile technology infrastructure and launch of 4G is expected to drive mobile health initiatives in the country. Mobile health industry in India is expected to reach $0.6 billion by 2017, the report said.To standardise the quality of service delivery, control cost and enhance patient engagement, healthcare providers are focussing on the technological aspect of healthcare delivery.Digital health knowledge resources, electronic medical record, mobile healthcare, hospital information system are some of the technologies gaining acceptance in the sector. Going forward, the healthcare sector’s spending on IT products and services is expected to rise from $53 billion in 2012 to $57 billion in 2013.

Telemedicine is also a fastemerging sector in India. In 2012, the telemedicine market in India was valued at $7.5 million, and is expected to rise at a CAGR of 20% to $18.7 million by 2017. With increased private participation, the healthcare sector has also witnessed rise in FDI inflows. As per law, 100% FDI is permitted for all health-related services under the automatic route.Demand growth, cost advantages and policy support were instrumental in attracting FDI inflows into the healthcare sector. During April 2000-March 2013, FDI inflows for drugs and pharmaceuticals stood at $10.3 billion, while inflows into hospitals and diagnostic centres, and medical appliances stood at $1.6 billion and $0.6 billion, respectively.India’s primary competitive advantage over its peers lies in its large pool of well-trained medical professionals in the country. Also India’s cost advantage compared to peers in Asia and Western countries is significant — cost of surgery in India is one-tenth of that in the US or Western Europe.India’s competitive advantage also lies in increased success rate of Indian companies in getting Abbreviated New Drug Application ( ANDA) approvals. India also offers vast opportunities in R&D as well as medical tourism, the report said.