hosmac pulse - taking healthcare beyond the metros
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Hosmac Pulse April 2011TRANSCRIPT
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HOSMAC FOUNDATION
Vol. 1 No. 5 April, 2011
PPP: Is it really the solution?
Pg. 29
Cover StoryPg. 11
North East Region
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w w w . h o s m a c f o u n d a t i o n . o r g
HOSMAC FOUNDATION
Taking Healthcare Beyond The Metros
HOSMAC Pulse
HOSMAC Pulse is an initiative of HOSMAC Foundation. High-quality standards have been maintained while preparing and presenting the information in this periodical.
However, no legal responsibility will be accepted by HOSMAC Foundation or HOSMAC India Pvt Ltd for any loss or damage resultant from its contents. The views expressed are
solely that of the authors or writers, and do not necessarily represent the views of HOSMAC Foundation or its consultants in relation to any particular projects. No part of this
periodical may be reproduced in any form without the written permission of HOSMAC Fooundation – the publisher.
HOSMAC Pulse is an initiative of HOSMAC Foundation. High-quality standards have been maintained while preparing and presenting the information in this periodical.
However, no legal responsibility will be accepted by HOSMAC Foundation or HOSMAC India Pvt Ltd for any loss or damage resultant from its contents. The views expressed are
solely that of the authors or writers, and do not necessarily represent the views of HOSMAC Foundation or its consultants in relation to any particular projects. No part of this
periodical may be reproduced in any form without the written permission of HOSMAC Fooundation – the publisher.
Editor-in-Chief
Associate Editors
Advisory Panel
Creative Consultant
Dr. Vivek Desai
Vinay Pagarani
Jonathan Fernandes
Narendra Karkera
Isha Khanolkar
Vishal Dhangar
Amit Pandya
Table Of Content
Down-to-Earth Healthcare 3
A Revolution in Rural Healthcare 6
Telehealth: The Reinvention of Healthcare 9
Taking Healthcare beyond the Metros 13
To be or not to be — Accredited 19
A Bird's-Eye View of Microinsurance in India 21
Effective Cost Treatment 26
PPP: Is it really the solution? 29
Just What the Future Ordered 31
Hands-on Nuclear Medicine 33
Vertically Integrated Healthcare Facility Desig 37
Tapping the Opportunity of MES 41
Healthcare For All 43
Editorial Board
Editor-in-Chief
Associate Editors
Advisory Panel
Creative Consultant
Dr. Vivek Desai
Vinay Pagarani
Jonathan Fernandes
Narendra Karkera
Isha Khanolkar
Vishal Dhangar
Amit Pandya
Table Of Content
A Revolution in Rural Healthcare 6
Telehealth: The Reinvention of Healthcare 9
Taking Healthcare beyond the Metros 13
To be or not to be — Accredited 19
A Bird's-Eye View of Microinsurance in India 21
Effective Cost Treatment 26
PPP: Is it really the solution? 29
Just What the Future Ordered 31
Hands-on Nuclear Medicine 33
Tapping the Opportunity of MES 41
Healthcare For All 43
Editorial Board
Vertically Integrated Healthcare Facility Design 37
Down-to-Earth Healthcare 3
The Government’s fortification strategies such as public-private
partnerships, tax holidays, real estate incentives, concessions etc.
have further worked to lure the private sector in penetrating newer
markets and defining new bottom lines in the healthcare industry.
Accessible, affordable and available healthcare, as repetitive as it may sound, is imperative for the health of our nation, which is currently one
of the fastest growing economies of the world. One of the most important steps in ensuring this is to treat every region of the country equally in
terms of quality and magnitude of healthcare services.
The Indian healthcare system typically shows a divide between the developed metropolitans and the rest of India. The metros display a greater
concentration of healthcare services both in terms of quantity and quality. 80% of healthcare resources are concentrated towards 20% of the
country’s population. This divide only accentuates the social phenomenon of the rich getter richer and poor getting poorer. The central and the
state governments of our country, however, have shown great vision and effort in bridging this gap by schemes such as the National Rural
Health Mission (NRHM), Rajiv Aarogyasri Community Health Insurance Scheme and such others. But like most other development sectors in
our country such as infrastructure and power, which have shown remarkable progress and contribution to the growth of our country by the
support and involvement of the private sector, the healthcare sector too calls for their support. With more than 75% of the investments in
healthcare flowing in from the private sector, it is only natural that without their adequate support, penetration of healthcare services into
every nook and corner of this country will be a Herculean task to achieve.
This change, however, has begun. Visionaries in the private healthcare sector have not only answered the call for quality healthcare facilities in
smaller tier II and III cities of the country, but have also understood the underlying, untapped potential of these regions. With the metros
getting saturated in every aspect, growth is shifting towards the tier II and tier III at a multinational level, with foreign investors, too, eying
these markets. The path for healthcare to reach these cities and towns is paved by the growth of information technology, manufacturing
industries and real estate in these regions. The Government’s fortification strategies such as public-private partnerships, tax holidays, real
estate incentives, concessions etc. have further worked to lure the private sector in penetrating newer markets and defining new bottom lines
in the healthcare industry.
It is therefore an optimal time for the private healthcare sector to plunge into every region in the country with innovative models and
customized strategies to enable every citizen of this country to palpate the magnanimous growth of this great nation.
Dr. Vivek DesaiManaging Director, Hosmac India Pvt. Ltd.
Editor’s Note
1
The Government’s fortification strategies such as public-private
partnerships, tax holidays, real estate incentives, concessions etc.
have further worked to lure the private sector in penetrating newer
markets and defining new bottom lines in the healthcare industry.
Accessible, affordable and available healthcare, as repetitive as it may sound, is imperative for the health of our nation, which is currently one
of the fastest growing economies of the world. One of the most important steps in ensuring this is to treat every region of the country equally in
terms of quality and magnitude of healthcare services.
The Indian healthcare system typically shows a divide between the developed metropolitans and the rest of India. The metros display a greater
concentration of healthcare services both in terms of quantity and quality. 80% of healthcare resources are concentrated towards 20% of the
country’s population. This divide only accentuates the social phenomenon of the rich getter richer and poor getting poorer. The central and the
state governments of our country, however, have shown great vision and effort in bridging this gap by schemes such as the National Rural
Health Mission (NRHM), Rajiv Aarogyasri Community Health Insurance Scheme and such others. But like most other development sectors in
our country such as infrastructure and power, which have shown remarkable progress and contribution to the growth of our country by the
support and involvement of the private sector, the healthcare sector too calls for their support. With more than 75% of the investments in
healthcare flowing in from the private sector, it is only natural that without their adequate support, penetration of healthcare services into
every nook and corner of this country will be a Herculean task to achieve.
This change, however, has begun. Visionaries in the private healthcare sector have not only answered the call for quality healthcare facilities in
smaller tier II and III cities of the country, but have also understood the underlying, untapped potential of these regions. With the metros
getting saturated in every aspect, growth is shifting towards the tier II and tier III at a multinational level, with foreign investors, too, eying
these markets. The path for healthcare to reach these cities and towns is paved by the growth of information technology, manufacturing
industries and real estate in these regions. The Government’s fortification strategies such as public-private partnerships, tax holidays, real
estate incentives, concessions etc. have further worked to lure the private sector in penetrating newer markets and defining new bottom lines
in the healthcare industry.
It is therefore an optimal time for the private healthcare sector to plunge into every region in the country with innovative models and
customized strategies to enable every citizen of this country to palpate the magnanimous growth of this great nation.
Dr. Vivek DesaiManaging Director, Hosmac India Pvt. Ltd.
Editor’s Note
1
The World Health Organization defines health as ‘a state of complete
physical, mental and social well-being’ and not merely the absence of
disease or infirmity. The traditional view point directly links
healthcare or improvements in health to the advancements in
medical science. In fact, the medical model of health focuses on the
eradication of illness through diagnosis and effective treatment.
However, the social model of health emphasises on changes that can
be made in society and in the lifestyles of people to make the
population healthier; it defines health from the point of view of the
individuals functioning within the society rather than by monitoring
for changes in biological or physiological signs. Healthcare is thus a
social institution and, as a social philosophy, it represents the primary
means by which people improve the overall quality of their lives.
Given this perspective, health is more or less about the social
determinants like safe drinking water, sanitation, nutrition, literacy
and primary education, income, social relationships, prevalent
lifestyles, and partly about clinical structure. Thus, speaking more
specifically, the essence of public health can be explained as
protecting and improving the health of communities through
education, the promotion of healthy lifestyles, lowering the disease
burden and research for prevention of disease and injury.
Ergo, public health is a social phenomenon with consequent social
ramifications. It implies to improve the health and well-being of
people in local communities around the globe, preventing health
problems before they occur. It entails all the integrated and readily
available gamut of public health services on all health determinants.
Availability of safe sources of drinking water, toilets with flowing
water; proper sewerage and drainage systems for the proper disposal
of human waste; sufficient drug distribution centres to ensure timely
availability of preventive and curative drugs for diseases like malaria
and diarrhoea; functional primary health infrastructure to access
vaccination services, family planning devices: maternal and child
health; and the availability of primary education facilities are a few
services to name. These, along with their ready accessibility, health
seeking behaviour, lifestyle and availability of livelihood
opportunities define the public health status of the population in the
respective area. This in turn is manifested in terms of public health
indicators like life expectancy, infant mortality rate, maternal
mortality rate, total fertility rate and the disease burden for that
population or area.
The study of these public health indicators across nations, different
regions within a country, the rural and urban divide within the
regions and the different social classes therein shows a distinct
health gradient. For instance, the public health indicators in the
South Asian and African countries are dismal in comparison to those
in the US and Japan. The health indicators of the nine EAG states in
our country, which make about 47% of the population, clearly depict
the regional skewedness in the public health status. On a pan-India
basis, these indicators are comparatively poor for the disadvantaged
classes like SCs and STs. The foundation of adult health is laid during
early childhood, and social milieu plays a very significant role in it.
However, the outstanding health indicators of Sri Lanka show that
things can be corrected even in not-so-favourable conditions by
adopting the right approach and putting in sincere effort.
In India, issues related to public health are dealt with mainly by the
Ministry of Health and Family Welfare, the Ministry of Women and
Child Development and the Ministry of Drinking Water and
Sanitation. The Ministry of Health and Family Welfare is concerned
with public health infrastructure, besides reproductive, child health
and disease control programs. Since 2005, they all have been brought
under a broadband flagship program, namely, the National Rural
Health Mission (NRHM). Issues of nutrition particularly focused on
children up to 6 years of age, adolescent girls, pregnant women and
lactating mothers are addressed by the Ministry of Women and Child
Development. The Ministry of Drinking Water and Sanitation looks
after the creation and maintenance of drinking water infrastructure
and sanitation issues. Public health thus is a multi-control sector that
requires a consistent and sustained convergence amongst all
concerned so that health services may be made available readily to
the people in an integrated way.
There exists a pyramid of public health networks in the country, right
from the apex at the national level down to the grassroots
community level. From the total organisational structure, we can
slice the configuration of the healthcare system into the national,
state, district, block, sub-block and village levels. The large public
health network has been established with an objective of providing
accessible, affordable, effective and reliable public health facilities to
every citizen across the country.
But all’s not well with the huge, extensive public health system in
India. It suffers from many problems including insufficient funding,
deficient facilities and a severe shortage of optimally trained human
resources. The complex processes and procedures involved in
seeking sanctions and approvals for spending available funds, for
upgrading the facilities and the procurement of goods and services
also adds to the inertia. Moreover, the system is also plagued with a
lack of accountability. The lack of convergence and coordination
among the different components and controls of public health also
contribute to the non-deliverance of integrated public health
facilities to the people.
However, there are many flagship programs that directly or indirectly
address the issues of public health in the country. The National Rural
Health Mission (NRHM) is a major player in bringing architectural
corrections to rural health infrastructure and services. It aims at
progressively improving the indicators of Infant Mortality Rate (IMR),
Maternal Mortality Rate (MMR) and Total Fertility Rate (TFR), thereby
enhancing the life expectancy and achieving population stabilization.
The Integrated Child Development Services (ICDS) program provides
six major services including supplementary nutrition to children of up
to six years, pregnant women and lactating mothers, routine
vaccination, health education and preschool education through
‘Aanganwadi Centres’ (AWCs). The recent impetus on the
universalization of ICDS has helped in opening of AWCs in hitherto
uncovered areas also. AWCs also serve as point of convergence for
health and nutrition programs at the village or habitation level.
National Rural Drinking Water Program (NRDWP) is to ensure
availability of quality drinking water to every rural household. The
programme provides for a drinking water security plan to be
developed at the local level only with the help of locally trained
personnel. It also provides to cover all the elementary schools and
aanganwadi centers with safe drinking water facilities. Total
Sanitation Campaign (TSC) is a programme that provides latrines for
individual households, schools, aanganwadi centers as well as builds
community latrines. Right of Children for Free and Compulsory
Education Act was enacted on April 1, 2010. It puts this responsibility
on the respective governments and local authorities to ensure that
all the children of 6 to 14 years compulsorily go to schools and
complete their elementary education. It also provides a framework
for bringing the aspect of quality to elementary education. School
Health Program as a component of NRHM is an intervention to
conduct regular health checkups of children in schools. Aside from
that is the Rashtriya Madhyamik Siksha Abhiyan (RMSA), which
intends to improve the secondary education scenario. Though
individually all these programs have their own objectives,
collectively they aim to improve the socioeconomic conditions of the
people and hence also contribute in one way or another to improving
the health status of the communities.
NRHM, in its bid to escalate the effectiveness of the service delivery
at all levels of healthcare, framed a number of strategic interventions
that would enable and enhance the reliability and accessibility of
these facilities. Despite this, the scenario remains grim at the lower
level due to reasons which are deep-rooted, and looks for a critical
paradigm shift. The pertinent reasons for the crisis may be
enumerated as follows:
Critical non-availability of doctors and paramedical staff at
all levels, particularly at the PHC level
Apathy towards the perception of quality care
Irrational deployment of the available manpower
Inadequate physical infrastructure and basic facilities for a
decent work environment in terms of water, toilets,
electricity, communication, transport facilities etc.
Lack of accountability in the public health delivery system
Non-existence of community participation
Down-to-Earth Healthcare'Why treat people without changing what makes them sick?' Ms. Sonali Sinha puts it right.
3 4
The World Health Organization defines health as ‘a state of complete
physical, mental and social well-being’ and not merely the absence of
disease or infirmity. The traditional view point directly links
healthcare or improvements in health to the advancements in
medical science. In fact, the medical model of health focuses on the
eradication of illness through diagnosis and effective treatment.
However, the social model of health emphasises on changes that can
be made in society and in the lifestyles of people to make the
population healthier; it defines health from the point of view of the
individuals functioning within the society rather than by monitoring
for changes in biological or physiological signs. Healthcare is thus a
social institution and, as a social philosophy, it represents the primary
means by which people improve the overall quality of their lives.
Given this perspective, health is more or less about the social
determinants like safe drinking water, sanitation, nutrition, literacy
and primary education, income, social relationships, prevalent
lifestyles, and partly about clinical structure. Thus, speaking more
specifically, the essence of public health can be explained as
protecting and improving the health of communities through
education, the promotion of healthy lifestyles, lowering the disease
burden and research for prevention of disease and injury.
Ergo, public health is a social phenomenon with consequent social
ramifications. It implies to improve the health and well-being of
people in local communities around the globe, preventing health
problems before they occur. It entails all the integrated and readily
available gamut of public health services on all health determinants.
Availability of safe sources of drinking water, toilets with flowing
water; proper sewerage and drainage systems for the proper disposal
of human waste; sufficient drug distribution centres to ensure timely
availability of preventive and curative drugs for diseases like malaria
and diarrhoea; functional primary health infrastructure to access
vaccination services, family planning devices: maternal and child
health; and the availability of primary education facilities are a few
services to name. These, along with their ready accessibility, health
seeking behaviour, lifestyle and availability of livelihood
opportunities define the public health status of the population in the
respective area. This in turn is manifested in terms of public health
indicators like life expectancy, infant mortality rate, maternal
mortality rate, total fertility rate and the disease burden for that
population or area.
The study of these public health indicators across nations, different
regions within a country, the rural and urban divide within the
regions and the different social classes therein shows a distinct
health gradient. For instance, the public health indicators in the
South Asian and African countries are dismal in comparison to those
in the US and Japan. The health indicators of the nine EAG states in
our country, which make about 47% of the population, clearly depict
the regional skewedness in the public health status. On a pan-India
basis, these indicators are comparatively poor for the disadvantaged
classes like SCs and STs. The foundation of adult health is laid during
early childhood, and social milieu plays a very significant role in it.
However, the outstanding health indicators of Sri Lanka show that
things can be corrected even in not-so-favourable conditions by
adopting the right approach and putting in sincere effort.
In India, issues related to public health are dealt with mainly by the
Ministry of Health and Family Welfare, the Ministry of Women and
Child Development and the Ministry of Drinking Water and
Sanitation. The Ministry of Health and Family Welfare is concerned
with public health infrastructure, besides reproductive, child health
and disease control programs. Since 2005, they all have been brought
under a broadband flagship program, namely, the National Rural
Health Mission (NRHM). Issues of nutrition particularly focused on
children up to 6 years of age, adolescent girls, pregnant women and
lactating mothers are addressed by the Ministry of Women and Child
Development. The Ministry of Drinking Water and Sanitation looks
after the creation and maintenance of drinking water infrastructure
and sanitation issues. Public health thus is a multi-control sector that
requires a consistent and sustained convergence amongst all
concerned so that health services may be made available readily to
the people in an integrated way.
There exists a pyramid of public health networks in the country, right
from the apex at the national level down to the grassroots
community level. From the total organisational structure, we can
slice the configuration of the healthcare system into the national,
state, district, block, sub-block and village levels. The large public
health network has been established with an objective of providing
accessible, affordable, effective and reliable public health facilities to
every citizen across the country.
But all’s not well with the huge, extensive public health system in
India. It suffers from many problems including insufficient funding,
deficient facilities and a severe shortage of optimally trained human
resources. The complex processes and procedures involved in
seeking sanctions and approvals for spending available funds, for
upgrading the facilities and the procurement of goods and services
also adds to the inertia. Moreover, the system is also plagued with a
lack of accountability. The lack of convergence and coordination
among the different components and controls of public health also
contribute to the non-deliverance of integrated public health
facilities to the people.
However, there are many flagship programs that directly or indirectly
address the issues of public health in the country. The National Rural
Health Mission (NRHM) is a major player in bringing architectural
corrections to rural health infrastructure and services. It aims at
progressively improving the indicators of Infant Mortality Rate (IMR),
Maternal Mortality Rate (MMR) and Total Fertility Rate (TFR), thereby
enhancing the life expectancy and achieving population stabilization.
The Integrated Child Development Services (ICDS) program provides
six major services including supplementary nutrition to children of up
to six years, pregnant women and lactating mothers, routine
vaccination, health education and preschool education through
‘Aanganwadi Centres’ (AWCs). The recent impetus on the
universalization of ICDS has helped in opening of AWCs in hitherto
uncovered areas also. AWCs also serve as point of convergence for
health and nutrition programs at the village or habitation level.
National Rural Drinking Water Program (NRDWP) is to ensure
availability of quality drinking water to every rural household. The
programme provides for a drinking water security plan to be
developed at the local level only with the help of locally trained
personnel. It also provides to cover all the elementary schools and
aanganwadi centers with safe drinking water facilities. Total
Sanitation Campaign (TSC) is a programme that provides latrines for
individual households, schools, aanganwadi centers as well as builds
community latrines. Right of Children for Free and Compulsory
Education Act was enacted on April 1, 2010. It puts this responsibility
on the respective governments and local authorities to ensure that
all the children of 6 to 14 years compulsorily go to schools and
complete their elementary education. It also provides a framework
for bringing the aspect of quality to elementary education. School
Health Program as a component of NRHM is an intervention to
conduct regular health checkups of children in schools. Aside from
that is the Rashtriya Madhyamik Siksha Abhiyan (RMSA), which
intends to improve the secondary education scenario. Though
individually all these programs have their own objectives,
collectively they aim to improve the socioeconomic conditions of the
people and hence also contribute in one way or another to improving
the health status of the communities.
NRHM, in its bid to escalate the effectiveness of the service delivery
at all levels of healthcare, framed a number of strategic interventions
that would enable and enhance the reliability and accessibility of
these facilities. Despite this, the scenario remains grim at the lower
level due to reasons which are deep-rooted, and looks for a critical
paradigm shift. The pertinent reasons for the crisis may be
enumerated as follows:
Critical non-availability of doctors and paramedical staff at
all levels, particularly at the PHC level
Apathy towards the perception of quality care
Irrational deployment of the available manpower
Inadequate physical infrastructure and basic facilities for a
decent work environment in terms of water, toilets,
electricity, communication, transport facilities etc.
Lack of accountability in the public health delivery system
Non-existence of community participation
Down-to-Earth Healthcare'Why treat people without changing what makes them sick?' Ms. Sonali Sinha puts it right.
3 4
2008.
The CSDH’s aim was to stimulate action to reduce the health
inequalities that exist between countries and within countries.
According to the CSDH, in situations where health inequalities are
preventable and avoidable, but are not avoided, they are
inequitable, and taking action to reduce them is a matter of social
justice.
CSDH’s recommendations are based on three principles for
action:
To revive the condit ions of dai ly l i fe – the
circumstances in which people are born, grow, live,
work and age.
Tackle the inequitable distribution of power, money, and
resources – the structural drivers of those conditions of
daily life – globally, nationally and locally.
Gauge the problem, evaluate action, expand the
knowledge base, develop a workforce that is trained in the
social determinants of health, and raise public
awareness about the social determinants of health.
Crucial to the social determinants of health approach is that where
differential health outcomes are linked to social inequalities; the
action to improve health outcomes must include the action to reduce
social inequalities. Seen in this light, every sector is in effect a health
sector, because every sector, including finance, business, agriculture,
trade, energy, education, employment and welfare, impacts on
health and health equity.
Action needs to ensue at global, national and local levels. The
national level policy environment needs to empower grassroots
community participation in identifying what needs to be done, in
developing interventions and programmes and in evaluating their
effects. The CSDH report is optimistic. The global movement for
health equity is growing. Progress may be patchy but it certainly is
evident. The report contains examples of successful action including
work in Sri Lanka and India. But there needs to be more innovation
and more evaluation so that promising approaches can be developed
and extended to reach more people. Public health workers at the
heart of communities have a pivotal role to play in raising awareness
and calling for action on social determinants, and in the process of
developing and evaluating action at a local and national level. Only
then would we be able to create a healthy society and a happy
nation.
The author has varied experience in implementing public health
programs at the grassroot levels and has served both at the
Government & non-government sectors. She has worked with
Hosmac Public Health Department as a Principal Consultant.
Lack of established standards for monitoring quality of care
Inadequacy/unavailability of proper accommodation
facilities at the facility level (especially in rural areas)
Unavailability of quality laboratory services at the block
and sub-block level
Although these have been perennial problems, there can be few real-
time alternatives to mitigate them through:
Incentivisation/professional motivation to the health
professionals who stay and serve at the block level or who
provide compulsory rural service for a minimum of two years
Rationalising utilization of paramedical staff or
‘paramedicalising’ the block facilities so that doctors can be used at
higher facilities
Ensure multi-skilling of the staff through capacity building to
address the impact of manpower shortage
Increase awareness in the community and other stakeholders
to bring in more accountability amongst the staff
Enhance public-private partnerships with an effective
monitoring system for efficient service delivery
Accreditation/Certification of the facilities to e s t a b l i s h
processes and systems to raise the quality quotient at all
levels of service delivery
Community Risk Pooling and Health Insurance
Harness the support of the big industrial houses as
their Corporate Social Responsibility
Advocacy and awareness amongst key stake holders
India needs to make its public health system operative and effective.
Programs are already in operation. The need is to create convergence
amongst them, synergize them so that they are able to deliver their
services in a more desirable way.
A Commission on Social Determinants of Health (CSDH) was set up by
the World Health Organization in 2005 to support action on the social
determinants of health to improve the overall population’s health,
refine the distribution of health, and to reduce disadvantage due to
poor health. It published its final report and recommendations in
Healthcare is one of India’s largest sectors, in terms of revenue and
employment, and the sector is expanding rapidly. During the 1990s,
Indian healthcare grew at a compound annual rate of 16%. Today the
total value of the sector is more than $34 billion. This translates to
$34 per capita, or roughly 6% of GDP. By 2012, India’s healthcare
sector is projected to grow to nearly $40 billion.
The private sector accounts for more than 80% of total healthcare
spending in India. Unless there is a decline in the combined federal
and state government deficit, which currently stands at roughly 9%,
the opportunity for significantly higher public health spending will be
limited.
When it comes to healthcare, there are two Indias: the country that
provides high-quality medical care to middle-class Indians and
medical tourists, and the India in which a vast population lives —
whose residents have limited or no access to quality care. Today, only
25% of the Indian population has access to Western (allopathic)
medicine, which is practiced mainly in urban areas, where two-thirds
of India’s hospitals and health centers are located. Many of the rural
poor must rely on alternative forms of treatment, such as ayurvedic
medicine, unani and acupuncture.
The next time you walk into a clinic for a cough and cold, spare a
thought for your rural brethren. Latest government data reveals that
rural India is short of over 16,000 doctors, including 12,000
specialists.
While the situation is often attributed to the unwillingness of doctors
to work in difficult areas, others say not enough is being done to
incentivise the postings.
“In India, the patient-doctor ratio is around 1/30,000. Of course, it
will be higher in Uttar Pradesh and Madhya Pradesh due to non-
availability of doctors as well as lack of health facilities and proper
infrastructure,” public health expert S. Sunder Raman told IANS over
phone from Chennai.
According to a Planning Commission report of 2008, India is short of
600,000 doctors, one million nurses and 200,000 dental surgeons. An
official in the health ministry said, “Many doctors are unwilling to
work in difficult and hard-to-reach areas. This could be because they
face accommodation problems in these far-off places. Besides,
general infrastructure in remote areas pose problems (as they come
from cities and towns),” the official told IANS.
While 70% of India is living in semi-urban and rural areas, 80% of
India’s healthcare facilities are located in urban/metro regions.
Vaatsalya is bridging this gap by building and managing
hospitals/clinics in semi-urban and rural areas, bringing healthcare
services where it is needed the most. Vaatsalya is India’s first hospital
network focused on tier II and tier III cities.
Dr. Ashwin Naik, 37, and Dr. Veerendra Hiremath, 35, who grew up in
Hubli, Karanataka, went around the world and returned to set up
Vaatsalya, a unique model of an affordable hospital network in the
under-served areas. “Doctors from rural districts rarely go back to
their roots,” says Naik. They decided to address this demand-supply
gap.
All healthcare stalwarts underscore the importance of making
healthcare more affordable and accessible, but how many of them
dare to address the lack of healthcare services in semi-urban and
Inauguration of Vaatsalya Hospital, Hubli by A.PJ. Kalam
Madhuri Umeshchandra, Project Coordinator, divulges the story behind Vaatsalaya, with words from its founding healers.
A Revolution in Rural Healthcare
5 6
2008.
The CSDH’s aim was to stimulate action to reduce the health
inequalities that exist between countries and within countries.
According to the CSDH, in situations where health inequalities are
preventable and avoidable, but are not avoided, they are
inequitable, and taking action to reduce them is a matter of social
justice.
CSDH’s recommendations are based on three principles for
action:
To revive the condit ions of dai ly l i fe – the
circumstances in which people are born, grow, live,
work and age.
Tackle the inequitable distribution of power, money, and
resources – the structural drivers of those conditions of
daily life – globally, nationally and locally.
Gauge the problem, evaluate action, expand the
knowledge base, develop a workforce that is trained in the
social determinants of health, and raise public
awareness about the social determinants of health.
Crucial to the social determinants of health approach is that where
differential health outcomes are linked to social inequalities; the
action to improve health outcomes must include the action to reduce
social inequalities. Seen in this light, every sector is in effect a health
sector, because every sector, including finance, business, agriculture,
trade, energy, education, employment and welfare, impacts on
health and health equity.
Action needs to ensue at global, national and local levels. The
national level policy environment needs to empower grassroots
community participation in identifying what needs to be done, in
developing interventions and programmes and in evaluating their
effects. The CSDH report is optimistic. The global movement for
health equity is growing. Progress may be patchy but it certainly is
evident. The report contains examples of successful action including
work in Sri Lanka and India. But there needs to be more innovation
and more evaluation so that promising approaches can be developed
and extended to reach more people. Public health workers at the
heart of communities have a pivotal role to play in raising awareness
and calling for action on social determinants, and in the process of
developing and evaluating action at a local and national level. Only
then would we be able to create a healthy society and a happy
nation.
The author has varied experience in implementing public health
programs at the grassroot levels and has served both at the
Government & non-government sectors. She has worked with
Hosmac Public Health Department as a Principal Consultant.
Lack of established standards for monitoring quality of care
Inadequacy/unavailability of proper accommodation
facilities at the facility level (especially in rural areas)
Unavailability of quality laboratory services at the block
and sub-block level
Although these have been perennial problems, there can be few real-
time alternatives to mitigate them through:
Incentivisation/professional motivation to the health
professionals who stay and serve at the block level or who
provide compulsory rural service for a minimum of two years
Rationalising utilization of paramedical staff or
‘paramedicalising’ the block facilities so that doctors can be used at
higher facilities
Ensure multi-skilling of the staff through capacity building to
address the impact of manpower shortage
Increase awareness in the community and other stakeholders
to bring in more accountability amongst the staff
Enhance public-private partnerships with an effective
monitoring system for efficient service delivery
Accreditation/Certification of the facilities to e s t a b l i s h
processes and systems to raise the quality quotient at all
levels of service delivery
Community Risk Pooling and Health Insurance
Harness the support of the big industrial houses as
their Corporate Social Responsibility
Advocacy and awareness amongst key stake holders
India needs to make its public health system operative and effective.
Programs are already in operation. The need is to create convergence
amongst them, synergize them so that they are able to deliver their
services in a more desirable way.
A Commission on Social Determinants of Health (CSDH) was set up by
the World Health Organization in 2005 to support action on the social
determinants of health to improve the overall population’s health,
refine the distribution of health, and to reduce disadvantage due to
poor health. It published its final report and recommendations in
Healthcare is one of India’s largest sectors, in terms of revenue and
employment, and the sector is expanding rapidly. During the 1990s,
Indian healthcare grew at a compound annual rate of 16%. Today the
total value of the sector is more than $34 billion. This translates to
$34 per capita, or roughly 6% of GDP. By 2012, India’s healthcare
sector is projected to grow to nearly $40 billion.
The private sector accounts for more than 80% of total healthcare
spending in India. Unless there is a decline in the combined federal
and state government deficit, which currently stands at roughly 9%,
the opportunity for significantly higher public health spending will be
limited.
When it comes to healthcare, there are two Indias: the country that
provides high-quality medical care to middle-class Indians and
medical tourists, and the India in which a vast population lives —
whose residents have limited or no access to quality care. Today, only
25% of the Indian population has access to Western (allopathic)
medicine, which is practiced mainly in urban areas, where two-thirds
of India’s hospitals and health centers are located. Many of the rural
poor must rely on alternative forms of treatment, such as ayurvedic
medicine, unani and acupuncture.
The next time you walk into a clinic for a cough and cold, spare a
thought for your rural brethren. Latest government data reveals that
rural India is short of over 16,000 doctors, including 12,000
specialists.
While the situation is often attributed to the unwillingness of doctors
to work in difficult areas, others say not enough is being done to
incentivise the postings.
“In India, the patient-doctor ratio is around 1/30,000. Of course, it
will be higher in Uttar Pradesh and Madhya Pradesh due to non-
availability of doctors as well as lack of health facilities and proper
infrastructure,” public health expert S. Sunder Raman told IANS over
phone from Chennai.
According to a Planning Commission report of 2008, India is short of
600,000 doctors, one million nurses and 200,000 dental surgeons. An
official in the health ministry said, “Many doctors are unwilling to
work in difficult and hard-to-reach areas. This could be because they
face accommodation problems in these far-off places. Besides,
general infrastructure in remote areas pose problems (as they come
from cities and towns),” the official told IANS.
While 70% of India is living in semi-urban and rural areas, 80% of
India’s healthcare facilities are located in urban/metro regions.
Vaatsalya is bridging this gap by building and managing
hospitals/clinics in semi-urban and rural areas, bringing healthcare
services where it is needed the most. Vaatsalya is India’s first hospital
network focused on tier II and tier III cities.
Dr. Ashwin Naik, 37, and Dr. Veerendra Hiremath, 35, who grew up in
Hubli, Karanataka, went around the world and returned to set up
Vaatsalya, a unique model of an affordable hospital network in the
under-served areas. “Doctors from rural districts rarely go back to
their roots,” says Naik. They decided to address this demand-supply
gap.
All healthcare stalwarts underscore the importance of making
healthcare more affordable and accessible, but how many of them
dare to address the lack of healthcare services in semi-urban and
Inauguration of Vaatsalya Hospital, Hubli by A.PJ. Kalam
Madhuri Umeshchandra, Project Coordinator, divulges the story behind Vaatsalaya, with words from its founding healers.
A Revolution in Rural Healthcare
5 6
rural areas? Not many! And that’s why the two doctor friends from
Karnataka Medical College (KMC), Hubli have come in the limelight
for pioneering Vaatsalya Healthcare Solutions.
Explains Dr. Ashwin Naik, Founder and CEO of Vaatsalya, “While 70%
of India stays in villages, healthcare services are concentrated only in
urban areas. To bridge this gap and make quality healthcare services
affordable and accessible in semi-urban and rural areas, we set up
Vaatsalya.”
The idea of catering healthcare to tier II and tier III cities did not
engender immediately after graduating from KMC. Dr. Naik went to
the US for his Master’s degree from the University of Houston, Texas,
followed by working in a leading genomics company in the US, while
Dr. Hiremath graduated with a degree in Hospital Administration
from P.D. Hinduja Hospital and was working in Malaysia.
“In early 2004, when we both met after coming back to India, I
proposed the plan to Hiremath. He believed in it and we got started
with Vaatsalya,” says Dr. Naik. By the end of 2004, Vaatsalya was
registered.
Rolling out the First Centre
Setting up low-cost hospitals in semi-urban and rural areas entailed
multiple hurdles. Initially, the challenges were financing, seeking
good clinical staff and establishing the proof of concept. For
financing, the duo was not sure of getting access to traditional means
— venture capital or bank debt. “We tapped into our network of NRI
contacts, who were from small towns and believed in the potential of
Vaatsalya. They provided the initial capital to set up our first unit,”
informs Dr. Naik. Getting local doctors to join a start-up and the first
privately organized entity in that region was also an uphill task. The
duo had to initially tap into their personal networks to slowly build
the team. Based on this initial funding from NRIs, the first centre was
rolled out in the outskirts of Hubli in 2005.
What was the reason for choosing Hubli, a regional town and one of
the fastest developing industrial hubs in Karnataka? The group felt
that Hubli, which was devoid of good healthcare facilities, could be an
ideal testing ground for the innovative business model.
“The first centre started with gynaecology, paediatrics, surgery and
general medicine along with diabetes care and physiotherapy,”
informs Dr. Naik. Once the first unit was commissioned, the group
charted out an ambitious plan to spread its tentacles.
So, was the expansion plan finalized before the first centre rolled out?
“We had put together a rough plan of establishing a network of
hospitals and we did plan for growth, both within the state and
outside, from the very beginning,” says Dr. Naik. However, zeroing in
on the business model for expansion was crucial. It explored a slew of
models in the beginning, ranging from a daycare, OPD centre to a 25-
bed hospital. Eventually, it settled on the 25-40 bed hospital, which it
scaled up and now focuses on 70 beds in each hospital.
To expand its network, it soon received funding from social venture
capital fund ‘Aavishkaar’. Thus, it established two more units in quick
succession. Subsequently, it raised money from Seedfund and Oasis
Capital.
“The initial round was to expand the concept from one location to
two, two to three locations, and later rounds were to expand outside
the state of Karnataka,” says Dr. Naik.
As of now, it has built 10 hospitals spread across Hubli, Gadag,
Bijapur, Mandya, Hassan, Mysore, Gulbarga and Shimoga in
Karnataka; Vizianagaram and Narasannapetta in Andhra Pradesh.
The centres are similar, mid-sized hospitals with an average bed
strength of about 70. The Vizianagarama centre is the largest centre
with 122 beds, 95 of which are operational.
Model la Revolution
One significant aspect of Vaatsalya is its low-cost business model,
which aims at providing high quality medical services at an affordable
price. It attains its low-cost model by controlling cost to the
maximum and by optimum utilization of resources. It uses a ‘no frills’
approach and invests only in high quality medical equipment
relevant to its specialties — obstretics, paediatrics, surgery and
medicine. Moreover, it does not invest in land and building, since
they are provided on lease for a long-term basis or partnership with
existing nursing homes.
“On the operational front, we have very high utilization of our
services which further helps reduce the cost of providing care,”
explains Dr. Naik.
The cost of setting up a new centre comes to INR two crore. Vaatsalya
uses two strategies for expansion: green field and brown field. The
ratio of green field to brown field is the same.
In a green field strategy, Vaatsalya rents a space suitable for a
hospital, remodels it for hospital purpose, recruits doctors, and starts
operating. In the brown field project, it partners with an existing
hospital, usually has one or more star medicos having a good practice
and the building is owned by the doctor(s). As part of partnering, the
hospital is rebranded as a Vaatsalya Hospital.
“It took Vaatsalya three years to attain breakeven for its first centre in
Hubli, primarily because it was still in the learning phase. Today, a
new centre could breakeven in about eighteen months,” asserts Dr.
Renganathan.
While all Vaatsalya hospitals focus on the core specialities of
gynaecology, paediatrics, general surgery and general medicine,
sometimes, depending on the unmet needs of the local community,
specialized services like dialysis, intensive care units, paediatric
surgery, diabetology and neuro-surgery are added to the service
portfolio. The doctors range from full-timers to visiting consultants.
All of them are local. Currently, all 10 centres put together witness
three lakh foot falls in their OPDs, annually.
Marketing Strategies
Since it is frugal with its budget for marketing, it does not engage in
print or TV media. “In fact, we don’t have a separate marketing
department. The business development team assumes the role of
marketing when needed. We rely on word-of-mouth and spend our
money wisely on health camps in and outside the hospital. We think
of innovative ways to serve the community, even if it does not have
any direct gains for us. Basically all our marketing activities are about
gaining or reinforcing the trust customers have in us,” says Dr.
Renganathan.
Vaatsalya has partnered with the Deshpande Foundation in their
quest to improve healthcare in and around the Dharwad district of
Karnataka. It is also coalesced with nursing homes, wherein their
doctors join Vaatsalya’s team and help expand the services offered.
“This helps the doctors to focus on their clinical practice, while we
take care of the administration part,” says Dr. Naik.
The Impact
The hospitals have made a tremendous impact. Vaatsalya opened its
first NICU unit in Gadag with just two beds some four years back.
Today, the hospital in Gadag has 10 NICU beds, while there are about
70 NICU beds in the entire network, which are nearly full all the time.
Prior to Vaatsalya, only a mission hospital in Gadag that had a few
NICU beds served the entire district of one million population. People
had to take their ailing newborns to Hubli for treatment. In addition
to the cost of transportation, the NICU charges in Hubli were high,
and more importantly, the time lost in transport is critical. The first 24
hours of a neonate are critical, particularly when they are pre-
mature. Vaatsalya’s NICU in Gadag has saved many newborns.
Similarly in Bijapur, the group started its first multi-specialty hospital
of the district with a dialysis centre. Prior to it, people had to travel to
Solapur, which is 120 km from Bijapur.
“Our charges are 25% less than Solapur and, in addition, patients save
on other incidental expenses than when seeking care in Solapur,” says
Dr. Renganathan.
The Edge
Vaatsalya’s largest hospital (with 122 beds) is located at
Vizianagarama in Andhra Pradesh. Vaatsalya's efforts to take
healthcare to the rural hinterland has received acclaim and it has
been bestowed with a slew of awards ranging from the Frost &
Sullivan, India’s Excellence In Healthcare Award, 2010; Rashtriya
Samman Puraskar in 2010 for Outstanding Contribution in the
Healthcare Sector; Sankalp Award for Social Entrepreneurship in
2009 for healthcare inclusion; LRAMP award for grassroots
innovation in 2008; and Business In Development Challenge India,
2007.
According to the founders, the reason Vaatsalya has been a
resounding success is not because of the range of services that it
offers. In fact, in many centres it offers similar core services that other
hospitals in that area provide.
“The differentiator is that we are assuredly customer centric
compared to other hospitals. We overlay these services with a few
specialized services such as Neonatal ICU (NICU), ICU, and dialysis
centres. We don’t overcharge just because we have captive
customers who have nowhere else to go,” adds Dr. Madhuri, Project
Cordinator.
Exploring Newer Business Models
With an endeavour to reduce maternal mortality and, at the same
time, decrease the overall cost of pregnancy care in villages, the
group is foraying into birthing centres. As of now, two centres are in
the pipeline, costing INR 10 lakh - 12 lakh per centre. The first birthing
centre is coming up at Kotumachigein Gadag district and is located
around 20 km from the Gadag town. The birthing centre is spread
over about 1,500 sq. ft. and will have a labour room for two
deliveries. The delivery will be attended by a midwife. There is also an
antenatal programme consisting of consultations, diagnostics, and
medicines. The first centre is slated to be operational in the next two
months.
Vaatsalya has also devised a micro-insurance scheme, for which it
was seeking grant from the Microinsurance Innovation Facility, ILO,
Switzerland. This insurance scheme leverages the Government’s
affordable scheme (INR 450 for an APL family of five members and
INR 150 in the case of BPL family), but adding discounted out-patient
services such as doctor consultations, diagnostics and drugs.
This proposal was one of 10 finalists (only one of two from India) out
of 100 proposals submitted internationally to the Microinsurance
Innovation Facility, ILO. With Vaatsalya failing to get the grant from
ILO, it plans to find other resources to launch this product.
The courage to reform coupled with ambitious plans and innovative
ideas could surely change the healthcare landscape of rural India.
The author is an expert in Quality Management and Clinical Trial
Audits. She can be reached at [email protected]
Diabetes Day at Vaatsalya, Hubli
Vaatsalya - Hubli Hospital
7 8
rural areas? Not many! And that’s why the two doctor friends from
Karnataka Medical College (KMC), Hubli have come in the limelight
for pioneering Vaatsalya Healthcare Solutions.
Explains Dr. Ashwin Naik, Founder and CEO of Vaatsalya, “While 70%
of India stays in villages, healthcare services are concentrated only in
urban areas. To bridge this gap and make quality healthcare services
affordable and accessible in semi-urban and rural areas, we set up
Vaatsalya.”
The idea of catering healthcare to tier II and tier III cities did not
engender immediately after graduating from KMC. Dr. Naik went to
the US for his Master’s degree from the University of Houston, Texas,
followed by working in a leading genomics company in the US, while
Dr. Hiremath graduated with a degree in Hospital Administration
from P.D. Hinduja Hospital and was working in Malaysia.
“In early 2004, when we both met after coming back to India, I
proposed the plan to Hiremath. He believed in it and we got started
with Vaatsalya,” says Dr. Naik. By the end of 2004, Vaatsalya was
registered.
Rolling out the First Centre
Setting up low-cost hospitals in semi-urban and rural areas entailed
multiple hurdles. Initially, the challenges were financing, seeking
good clinical staff and establishing the proof of concept. For
financing, the duo was not sure of getting access to traditional means
— venture capital or bank debt. “We tapped into our network of NRI
contacts, who were from small towns and believed in the potential of
Vaatsalya. They provided the initial capital to set up our first unit,”
informs Dr. Naik. Getting local doctors to join a start-up and the first
privately organized entity in that region was also an uphill task. The
duo had to initially tap into their personal networks to slowly build
the team. Based on this initial funding from NRIs, the first centre was
rolled out in the outskirts of Hubli in 2005.
What was the reason for choosing Hubli, a regional town and one of
the fastest developing industrial hubs in Karnataka? The group felt
that Hubli, which was devoid of good healthcare facilities, could be an
ideal testing ground for the innovative business model.
“The first centre started with gynaecology, paediatrics, surgery and
general medicine along with diabetes care and physiotherapy,”
informs Dr. Naik. Once the first unit was commissioned, the group
charted out an ambitious plan to spread its tentacles.
So, was the expansion plan finalized before the first centre rolled out?
“We had put together a rough plan of establishing a network of
hospitals and we did plan for growth, both within the state and
outside, from the very beginning,” says Dr. Naik. However, zeroing in
on the business model for expansion was crucial. It explored a slew of
models in the beginning, ranging from a daycare, OPD centre to a 25-
bed hospital. Eventually, it settled on the 25-40 bed hospital, which it
scaled up and now focuses on 70 beds in each hospital.
To expand its network, it soon received funding from social venture
capital fund ‘Aavishkaar’. Thus, it established two more units in quick
succession. Subsequently, it raised money from Seedfund and Oasis
Capital.
“The initial round was to expand the concept from one location to
two, two to three locations, and later rounds were to expand outside
the state of Karnataka,” says Dr. Naik.
As of now, it has built 10 hospitals spread across Hubli, Gadag,
Bijapur, Mandya, Hassan, Mysore, Gulbarga and Shimoga in
Karnataka; Vizianagaram and Narasannapetta in Andhra Pradesh.
The centres are similar, mid-sized hospitals with an average bed
strength of about 70. The Vizianagarama centre is the largest centre
with 122 beds, 95 of which are operational.
Model la Revolution
One significant aspect of Vaatsalya is its low-cost business model,
which aims at providing high quality medical services at an affordable
price. It attains its low-cost model by controlling cost to the
maximum and by optimum utilization of resources. It uses a ‘no frills’
approach and invests only in high quality medical equipment
relevant to its specialties — obstretics, paediatrics, surgery and
medicine. Moreover, it does not invest in land and building, since
they are provided on lease for a long-term basis or partnership with
existing nursing homes.
“On the operational front, we have very high utilization of our
services which further helps reduce the cost of providing care,”
explains Dr. Naik.
The cost of setting up a new centre comes to INR two crore. Vaatsalya
uses two strategies for expansion: green field and brown field. The
ratio of green field to brown field is the same.
In a green field strategy, Vaatsalya rents a space suitable for a
hospital, remodels it for hospital purpose, recruits doctors, and starts
operating. In the brown field project, it partners with an existing
hospital, usually has one or more star medicos having a good practice
and the building is owned by the doctor(s). As part of partnering, the
hospital is rebranded as a Vaatsalya Hospital.
“It took Vaatsalya three years to attain breakeven for its first centre in
Hubli, primarily because it was still in the learning phase. Today, a
new centre could breakeven in about eighteen months,” asserts Dr.
Renganathan.
While all Vaatsalya hospitals focus on the core specialities of
gynaecology, paediatrics, general surgery and general medicine,
sometimes, depending on the unmet needs of the local community,
specialized services like dialysis, intensive care units, paediatric
surgery, diabetology and neuro-surgery are added to the service
portfolio. The doctors range from full-timers to visiting consultants.
All of them are local. Currently, all 10 centres put together witness
three lakh foot falls in their OPDs, annually.
Marketing Strategies
Since it is frugal with its budget for marketing, it does not engage in
print or TV media. “In fact, we don’t have a separate marketing
department. The business development team assumes the role of
marketing when needed. We rely on word-of-mouth and spend our
money wisely on health camps in and outside the hospital. We think
of innovative ways to serve the community, even if it does not have
any direct gains for us. Basically all our marketing activities are about
gaining or reinforcing the trust customers have in us,” says Dr.
Renganathan.
Vaatsalya has partnered with the Deshpande Foundation in their
quest to improve healthcare in and around the Dharwad district of
Karnataka. It is also coalesced with nursing homes, wherein their
doctors join Vaatsalya’s team and help expand the services offered.
“This helps the doctors to focus on their clinical practice, while we
take care of the administration part,” says Dr. Naik.
The Impact
The hospitals have made a tremendous impact. Vaatsalya opened its
first NICU unit in Gadag with just two beds some four years back.
Today, the hospital in Gadag has 10 NICU beds, while there are about
70 NICU beds in the entire network, which are nearly full all the time.
Prior to Vaatsalya, only a mission hospital in Gadag that had a few
NICU beds served the entire district of one million population. People
had to take their ailing newborns to Hubli for treatment. In addition
to the cost of transportation, the NICU charges in Hubli were high,
and more importantly, the time lost in transport is critical. The first 24
hours of a neonate are critical, particularly when they are pre-
mature. Vaatsalya’s NICU in Gadag has saved many newborns.
Similarly in Bijapur, the group started its first multi-specialty hospital
of the district with a dialysis centre. Prior to it, people had to travel to
Solapur, which is 120 km from Bijapur.
“Our charges are 25% less than Solapur and, in addition, patients save
on other incidental expenses than when seeking care in Solapur,” says
Dr. Renganathan.
The Edge
Vaatsalya’s largest hospital (with 122 beds) is located at
Vizianagarama in Andhra Pradesh. Vaatsalya's efforts to take
healthcare to the rural hinterland has received acclaim and it has
been bestowed with a slew of awards ranging from the Frost &
Sullivan, India’s Excellence In Healthcare Award, 2010; Rashtriya
Samman Puraskar in 2010 for Outstanding Contribution in the
Healthcare Sector; Sankalp Award for Social Entrepreneurship in
2009 for healthcare inclusion; LRAMP award for grassroots
innovation in 2008; and Business In Development Challenge India,
2007.
According to the founders, the reason Vaatsalya has been a
resounding success is not because of the range of services that it
offers. In fact, in many centres it offers similar core services that other
hospitals in that area provide.
“The differentiator is that we are assuredly customer centric
compared to other hospitals. We overlay these services with a few
specialized services such as Neonatal ICU (NICU), ICU, and dialysis
centres. We don’t overcharge just because we have captive
customers who have nowhere else to go,” adds Dr. Madhuri, Project
Cordinator.
Exploring Newer Business Models
With an endeavour to reduce maternal mortality and, at the same
time, decrease the overall cost of pregnancy care in villages, the
group is foraying into birthing centres. As of now, two centres are in
the pipeline, costing INR 10 lakh - 12 lakh per centre. The first birthing
centre is coming up at Kotumachigein Gadag district and is located
around 20 km from the Gadag town. The birthing centre is spread
over about 1,500 sq. ft. and will have a labour room for two
deliveries. The delivery will be attended by a midwife. There is also an
antenatal programme consisting of consultations, diagnostics, and
medicines. The first centre is slated to be operational in the next two
months.
Vaatsalya has also devised a micro-insurance scheme, for which it
was seeking grant from the Microinsurance Innovation Facility, ILO,
Switzerland. This insurance scheme leverages the Government’s
affordable scheme (INR 450 for an APL family of five members and
INR 150 in the case of BPL family), but adding discounted out-patient
services such as doctor consultations, diagnostics and drugs.
This proposal was one of 10 finalists (only one of two from India) out
of 100 proposals submitted internationally to the Microinsurance
Innovation Facility, ILO. With Vaatsalya failing to get the grant from
ILO, it plans to find other resources to launch this product.
The courage to reform coupled with ambitious plans and innovative
ideas could surely change the healthcare landscape of rural India.
The author is an expert in Quality Management and Clinical Trial
Audits. She can be reached at [email protected]
Diabetes Day at Vaatsalya, Hubli
Vaatsalya - Hubli Hospital
7 8
“Mr. Watson, come here – I want to see you.” said Alexander Graham
Bell on March 20, 1876, when he inadvertently spilled battery acid on
himself, while making the world’s first telephone call. Little did Bell
realize that this was also the world’s first telemedical consultation.
We have come a long way since then.
Telemedicine is a method, by which patients can be examined,
investigated, monitored and treated with the patient and the doctor
physically located in different places. ‘Tele’ is a Greek word meaning
‘distance’ and ‘mederi’ is a Latin word meaning ‘to heal’. In
Telemedicine one transfers the expertise, not the patient. A major
goal of telemedicine is to eliminate unnecessary travelling of patients
and their escorts. Image acquisition, storage, display and processing,
and image transfer form the basis of telemedicine. While
telemedicine has been developing for the last two decades, in the last
ten years this growth has been exponential. High quality medical
services can be brought to the patient, rather than transporting the
patient to distant and expensive tertiary care centres. Images are
acquired, stored and forwarded to the specialist centre in a
compressed format and digital manipulation can be done by the
teleconsultant at the remote end. Immediate electronic access to
specialists saves time, costs and reduces the enormous physical effort
normally required of a patient in travelling long distances. Text,
reports, voice data, images and video can be transferred. Through
cost effective video tele-conferencing, expertise available in the cities
can be transferred to rural areas. Ultimately standards of healthcare
in rural areas will be increased, and costs reduced. Preliminary trials
with telemedicine have revealed high levels of satisfaction among
patients, general practitioners, specialists and technologists.
What is the relevance of telehealth in India? Well, the Indian
healthcare industry is one of the biggest industries in the world, with
every sixth individual on the planet being a consumer. To expect a
fledgling, different method of healthcare delivery (i.e. telemedicine)
to have a significant effective impact on the healthcare scenario very
soon is to turn a Nelson’s eye to the stark realities. In the last eleven
years, thanks to the relentless work done by several groups of
committed champions of telemedicine spearheaded by Apollo
Hospitals, a beginning has been made.
The Indian Space Research Organization (ISRO), SGPGI in Lucknow,
SRMC in Chennai, AIMS in Kochi, and Narayana Hrudayalaya, among
others, have all contributed to this.
The effective delivery of telehealth services will require
establishment of standards in clinical practice, privacy,
confidentiality, telecommunications, record keeping and ethical
behaviour. Telehealth technical standards should be assessed on
requirements covering access to patient data, availability,
encryption, guaranteed reliability, interpretability, legal obligations,
limiting access to authorised users, multimedia applications,
performance levels and security, and must be an ongoing process.
Interoperability of systems, compatibility and scalability are an
absolute must. All equipment should meet international DICOM
standards. Privacy, authentication, authorization, certification,
digital signature standardization, equipment liability, digital
compression and constant benchmarking is required.
Today’s video conferencing systems are so sophisticated that even
four different groups of people can be viewed simultaneously on a
giant screen. Minute facial expressions can be discerned with
TeleHealth: The Reinvention of Healthcare
unbelievable clarity. Participants remain in view at all times making it
literally a face-to-face meeting. The spontaneity, naturalness, and
interactivity of a conventional person-to-person meeting are all there
– excepting that the patient and doctor are hundreds (or even
thousands) of miles away. Issues can be addressed and multiple
opinions can be obtained from all around the globe quickly. High-
speed networks and multimedia servers allow medical professionals
to exchange many types of healthcare information
The necessity of home telecare systems is growing due to an increase
in chronic diseases, aged population (living alone) and medical
expenses; a video visit to the patient’s home will be more cost
effective. Tabletop sensors can monitor blood pressure, cardiac
rhythms, blood sugar, and other parameters – signs that can provide
an immediate objective assessment. A homebound patient could use
a digital camera to take a picture of his post operative wound or bed
sore and upload the photo directly to his medical record via e-mail for
his surgeon to see. Intelligent telephones will monitor vital functions
from thousands of miles away. A video surveillance unit can watch an
old man take his pills, look at his bed sore, and even ensure that the
refrigerator and pantry are adequately stocked. Implanted devices
will directly relay vital parameters through satellite telephones,
enabling monitoring from a distance. The author has personally
directed 17 electronic house visits where non-medical personnel
have taken a webcam enabled laptop with a high speed wireless data
card and connected a patient from their house to a specialist via video
conferencing.
Technology differentiates the victors from the vanquished, and the
haves from the have-nots. A good image doesn’t do much good if it
exists in only one place. If a picture is worth a thousand words, then a
picture accompanied with hypertext links and a sound file (e.g. a
good web page) must be worth several thousand. Telemedicine gives
equal education opportunities to doctors in big cities or small towns.
Web-based medical education will become one of the most
successful and visible forms of telemedicine. It will affect every
dimension of the relationship between doctors, patients, hospitals,
health plans, employers, the government and other entities involved
in healthcare.
India, though considered a developing country, is a paradox. We
produce and launch our own satellites; there has been an
unprecedented growth and development in Information Technology
in India; we no longer has to follow the advanced countries, nor do we
even have to piggy back, we can leap frog! Today there are about 575
telemedicine units located in suburban and rural India and about
seventy five telemedicine units functioning in tertiary care hospitals.
However, about 20 units have contributed to 80% of the 700,000
teleconsults that have now taken place. With 70% of the population
residing in rural areas and having access to less than 20% of the
available doctors, which itself is only 1:2000, telehealth appears to
be the only way to bridge the urban-rural health divide. The India of
tomorrow will be different economically, socially and culturally.
Tomorrow’s slogan may even be ‘Roti, kapada, makan aur
bandwidth!’ Today the teledensity of India is almost 62% (103% in
metros and 20% even in rural India). Obviously it is easier to set up an
excellent telecommunication infrastructure, than to place thousands
of medical specialists in suburban and rural India.
Telemedicine can bridge the gap only when telediagnosis is followed
up by appropriate referrals for investigations and subsequent
management. To achieve this, universal insurance is an absolute
necessity. Telemedicine patients can ensure that the care they get is
the care they want. Empowered patients will embrace location-
independent care, thus imposing global standards
One also has to accept the fact that if it was a choice between having
one’s illness cured through a remote teleconsultation versus having
your hand held by an extremely sympathetic but ignorant doctor,
most would prefer the former. The ideal scenario is where the urban
elitist super specialist virtually wipes a tear of his rural patient. Many
countries have started addressing these issues by starting courses on
ethics and humanism in conjunction with the use of hi-tech gizmos.
Indian doctors all over the world excel because of their innate ability
to combine professionalism with compassion. Pastoral as well as
technical skills, and art as well as science is required. This has to be
taught in medical school now so that when telemedicine is
commonplace, it will not be forgotten.
Issues in implementing telemedicine include acceptance of the
modality by society, patients, family physicians, specialists,
administrators and the government; designing cost effective
appropriate technology, connectivity, hardware and software,
standardising, certifying, authenticating and registering
telemedicine units so that minimum safe standards are uniformly
adopted; running short term courses to train the trainers and the
users, passing a telehealth act for India, payment to teleconsultants
to make the scheme attractive and viable; getting grants, subsidies
and waivers to introduce telemedicine in suburban and rural areas,
getting Indian telemedicine units recognized by other countries so
that we can provide overseas teleconsults for revenue generation,
which can be used to subsidize rural telemedicine; and introducing
telemedicine in the medical/IT curriculum.
Questions are often raised – and rightly so – whether telemedicine is
the result of a technology push rather than clinical pull. Information
Technology has changed, is changing, and will continue to change the
delivery of healthcare, worldwide. Humankind is witnessing a
growth in technology unprecedented in the annals of history.
Hospitals of the future will draw patients from all over the world,
without geographical limitations.
Telemedicine’s champions will have to work hard to make sure that
Telehealth: The Reinvention of HealthcareDr. K. Ganapathy, President Elect — Indian Society of Stereotactic and Functional Neurosurgery, envisions a future where new age technology and traditional medical practices join hands to meet India's unique healthcare needs.
9 10
“Mr. Watson, come here – I want to see you.” said Alexander Graham
Bell on March 20, 1876, when he inadvertently spilled battery acid on
himself, while making the world’s first telephone call. Little did Bell
realize that this was also the world’s first telemedical consultation.
We have come a long way since then.
Telemedicine is a method, by which patients can be examined,
investigated, monitored and treated with the patient and the doctor
physically located in different places. ‘Tele’ is a Greek word meaning
‘distance’ and ‘mederi’ is a Latin word meaning ‘to heal’. In
Telemedicine one transfers the expertise, not the patient. A major
goal of telemedicine is to eliminate unnecessary travelling of patients
and their escorts. Image acquisition, storage, display and processing,
and image transfer form the basis of telemedicine. While
telemedicine has been developing for the last two decades, in the last
ten years this growth has been exponential. High quality medical
services can be brought to the patient, rather than transporting the
patient to distant and expensive tertiary care centres. Images are
acquired, stored and forwarded to the specialist centre in a
compressed format and digital manipulation can be done by the
teleconsultant at the remote end. Immediate electronic access to
specialists saves time, costs and reduces the enormous physical effort
normally required of a patient in travelling long distances. Text,
reports, voice data, images and video can be transferred. Through
cost effective video tele-conferencing, expertise available in the cities
can be transferred to rural areas. Ultimately standards of healthcare
in rural areas will be increased, and costs reduced. Preliminary trials
with telemedicine have revealed high levels of satisfaction among
patients, general practitioners, specialists and technologists.
What is the relevance of telehealth in India? Well, the Indian
healthcare industry is one of the biggest industries in the world, with
every sixth individual on the planet being a consumer. To expect a
fledgling, different method of healthcare delivery (i.e. telemedicine)
to have a significant effective impact on the healthcare scenario very
soon is to turn a Nelson’s eye to the stark realities. In the last eleven
years, thanks to the relentless work done by several groups of
committed champions of telemedicine spearheaded by Apollo
Hospitals, a beginning has been made.
The Indian Space Research Organization (ISRO), SGPGI in Lucknow,
SRMC in Chennai, AIMS in Kochi, and Narayana Hrudayalaya, among
others, have all contributed to this.
The effective delivery of telehealth services will require
establishment of standards in clinical practice, privacy,
confidentiality, telecommunications, record keeping and ethical
behaviour. Telehealth technical standards should be assessed on
requirements covering access to patient data, availability,
encryption, guaranteed reliability, interpretability, legal obligations,
limiting access to authorised users, multimedia applications,
performance levels and security, and must be an ongoing process.
Interoperability of systems, compatibility and scalability are an
absolute must. All equipment should meet international DICOM
standards. Privacy, authentication, authorization, certification,
digital signature standardization, equipment liability, digital
compression and constant benchmarking is required.
Today’s video conferencing systems are so sophisticated that even
four different groups of people can be viewed simultaneously on a
giant screen. Minute facial expressions can be discerned with
TeleHealth: The Reinvention of Healthcare
unbelievable clarity. Participants remain in view at all times making it
literally a face-to-face meeting. The spontaneity, naturalness, and
interactivity of a conventional person-to-person meeting are all there
– excepting that the patient and doctor are hundreds (or even
thousands) of miles away. Issues can be addressed and multiple
opinions can be obtained from all around the globe quickly. High-
speed networks and multimedia servers allow medical professionals
to exchange many types of healthcare information
The necessity of home telecare systems is growing due to an increase
in chronic diseases, aged population (living alone) and medical
expenses; a video visit to the patient’s home will be more cost
effective. Tabletop sensors can monitor blood pressure, cardiac
rhythms, blood sugar, and other parameters – signs that can provide
an immediate objective assessment. A homebound patient could use
a digital camera to take a picture of his post operative wound or bed
sore and upload the photo directly to his medical record via e-mail for
his surgeon to see. Intelligent telephones will monitor vital functions
from thousands of miles away. A video surveillance unit can watch an
old man take his pills, look at his bed sore, and even ensure that the
refrigerator and pantry are adequately stocked. Implanted devices
will directly relay vital parameters through satellite telephones,
enabling monitoring from a distance. The author has personally
directed 17 electronic house visits where non-medical personnel
have taken a webcam enabled laptop with a high speed wireless data
card and connected a patient from their house to a specialist via video
conferencing.
Technology differentiates the victors from the vanquished, and the
haves from the have-nots. A good image doesn’t do much good if it
exists in only one place. If a picture is worth a thousand words, then a
picture accompanied with hypertext links and a sound file (e.g. a
good web page) must be worth several thousand. Telemedicine gives
equal education opportunities to doctors in big cities or small towns.
Web-based medical education will become one of the most
successful and visible forms of telemedicine. It will affect every
dimension of the relationship between doctors, patients, hospitals,
health plans, employers, the government and other entities involved
in healthcare.
India, though considered a developing country, is a paradox. We
produce and launch our own satellites; there has been an
unprecedented growth and development in Information Technology
in India; we no longer has to follow the advanced countries, nor do we
even have to piggy back, we can leap frog! Today there are about 575
telemedicine units located in suburban and rural India and about
seventy five telemedicine units functioning in tertiary care hospitals.
However, about 20 units have contributed to 80% of the 700,000
teleconsults that have now taken place. With 70% of the population
residing in rural areas and having access to less than 20% of the
available doctors, which itself is only 1:2000, telehealth appears to
be the only way to bridge the urban-rural health divide. The India of
tomorrow will be different economically, socially and culturally.
Tomorrow’s slogan may even be ‘Roti, kapada, makan aur
bandwidth!’ Today the teledensity of India is almost 62% (103% in
metros and 20% even in rural India). Obviously it is easier to set up an
excellent telecommunication infrastructure, than to place thousands
of medical specialists in suburban and rural India.
Telemedicine can bridge the gap only when telediagnosis is followed
up by appropriate referrals for investigations and subsequent
management. To achieve this, universal insurance is an absolute
necessity. Telemedicine patients can ensure that the care they get is
the care they want. Empowered patients will embrace location-
independent care, thus imposing global standards
One also has to accept the fact that if it was a choice between having
one’s illness cured through a remote teleconsultation versus having
your hand held by an extremely sympathetic but ignorant doctor,
most would prefer the former. The ideal scenario is where the urban
elitist super specialist virtually wipes a tear of his rural patient. Many
countries have started addressing these issues by starting courses on
ethics and humanism in conjunction with the use of hi-tech gizmos.
Indian doctors all over the world excel because of their innate ability
to combine professionalism with compassion. Pastoral as well as
technical skills, and art as well as science is required. This has to be
taught in medical school now so that when telemedicine is
commonplace, it will not be forgotten.
Issues in implementing telemedicine include acceptance of the
modality by society, patients, family physicians, specialists,
administrators and the government; designing cost effective
appropriate technology, connectivity, hardware and software,
standardising, certifying, authenticating and registering
telemedicine units so that minimum safe standards are uniformly
adopted; running short term courses to train the trainers and the
users, passing a telehealth act for India, payment to teleconsultants
to make the scheme attractive and viable; getting grants, subsidies
and waivers to introduce telemedicine in suburban and rural areas,
getting Indian telemedicine units recognized by other countries so
that we can provide overseas teleconsults for revenue generation,
which can be used to subsidize rural telemedicine; and introducing
telemedicine in the medical/IT curriculum.
Questions are often raised – and rightly so – whether telemedicine is
the result of a technology push rather than clinical pull. Information
Technology has changed, is changing, and will continue to change the
delivery of healthcare, worldwide. Humankind is witnessing a
growth in technology unprecedented in the annals of history.
Hospitals of the future will draw patients from all over the world,
without geographical limitations.
Telemedicine’s champions will have to work hard to make sure that
Telehealth: The Reinvention of HealthcareDr. K. Ganapathy, President Elect — Indian Society of Stereotactic and Functional Neurosurgery, envisions a future where new age technology and traditional medical practices join hands to meet India's unique healthcare needs.
9 10
world order a drastic change toward a better world of health. Major
paradigm shifts will emerge from ‘hospital-centred healthcare’ to
‘citizen-centred health’ and from ‘treatment’ to ‘prevention’.
However, it must be stressed that the ultimate success or failure of
implementation of telemedicine will not be due to technological
glitches, or lack of funding, or even red tapism. It will be due to
human inertia, lack of involvement, commitment and the passionate
burning desire so necessary to break traditional barriers. To
paraphrase Don Quixote in ‘The Man of La Mancha’: “To reach the
unreachable star. This is my quest – To follow that star, no matter how
hopeless, no matter how far.” History has shown time and again that
what is unreachable today is reachable tomorrow.
Though I do not wish to conclude on a cynical note, eleven years of
involvement with telehealth has taught me that we will never ever
achieve that critical mass essential for a successful takeoff unless we
have an answer to the question ‘WiiiFM’? It is not Wi Max or Wi-Fi
but ‘WiiiFM’ that will ultimately determine whether telemedicine
will be incorporated. ‘What is in it For Me?’ – when every stakeholder
understands the WiiiFM quotient, only then will there be an
involvement, a dedication and a passion which alone will further the
growth of telemedicine. It is not technology, nor regulations (or the
lack of it), nor even paucity of funds, but purely human inertia which
is now standing in the way.
The author is the former Secretary and President of the Neurological
Society of India, and former Secretary General of the Asian
Australasian Society of Neurological Surgery. He may be contacted at
investment decisions are made with respect to the future, not the
past. ‘Easy to use’ should be a prerequisite in the selection of
equipment and systems for telemedicine. User-friendly, it must
enhance, not hinder the process of healthcare. Like any revolutionary
force, telemedicine will encounter considerable resistance as it
moves from the fringe to the mainstream of healthcare over the next
decade. Deciding how to pay for it, who is qualified to do it and how
to assess its quality are already major issues. Teleconsultation is not a
new medical service but a new way of delivering a consultation.
Previous generations of physicians will find the new concepts of
telemedicine unfathomable – to many it may sound blasphemous.
What will happen to the individual doctor-patient relationship
considered sacrosanct for centuries? Is it not sacrilegious and
bordering on heresy to treat a patient in another continent without
knowing his family and cultural background? Yes, say the diehards.
No, say the technology enthusiasts. The first generation of
telemedicine enthusiasts should not forget that technology should
be used as a support to treat patients, not viewed as the goal itself.
The challenge today is not confined to overcoming technological
barriers, insurmountable though they may appear; it is true that
available technology still has scope for improvement. Rather, the
challenge is why, where and how to implement which technology and
at what cost. A needs assessment is critical. However, technology can
only treat diseases. To treat sick people, empathy and understanding
is needed.
The takeoff problems facing telemedicine are legion. It is our dream
and hope that within the next few years there will be telemedicine
units in most parts of suburban and rural India. Eventually, no Indian
will be deprived of a specialist consultation wherever he or she is –
consultation will soon be only a mouse click away! For this to happen,
a critical mass must be reached. What is required is not implementing
better technology and getting funds, but changing the mindset of the
people involved. Awareness should permeate throughout society.
Real growth will take place only when society realizes that distance is
meaningless today, and that telemedicine can bridge the gap
between the haves and the have nots, at least insofar as access to
healthcare is concerned.
There are critics who believe telemedicine is a waste of precious
resources that are needed urgently for higher health priorities.
Telemedicine, however, is a part of the wider phenomenon of
information, and information is arguably the strongest change agent.
Telemedicine is a part of this great change. Information brings to the
11
world order a drastic change toward a better world of health. Major
paradigm shifts will emerge from ‘hospital-centred healthcare’ to
‘citizen-centred health’ and from ‘treatment’ to ‘prevention’.
However, it must be stressed that the ultimate success or failure of
implementation of telemedicine will not be due to technological
glitches, or lack of funding, or even red tapism. It will be due to
human inertia, lack of involvement, commitment and the passionate
burning desire so necessary to break traditional barriers. To
paraphrase Don Quixote in ‘The Man of La Mancha’: “To reach the
unreachable star. This is my quest – To follow that star, no matter how
hopeless, no matter how far.” History has shown time and again that
what is unreachable today is reachable tomorrow.
Though I do not wish to conclude on a cynical note, eleven years of
involvement with telehealth has taught me that we will never ever
achieve that critical mass essential for a successful takeoff unless we
have an answer to the question ‘WiiiFM’? It is not Wi Max or Wi-Fi
but ‘WiiiFM’ that will ultimately determine whether telemedicine
will be incorporated. ‘What is in it For Me?’ – when every stakeholder
understands the WiiiFM quotient, only then will there be an
involvement, a dedication and a passion which alone will further the
growth of telemedicine. It is not technology, nor regulations (or the
lack of it), nor even paucity of funds, but purely human inertia which
is now standing in the way.
The author is the former Secretary and President of the Neurological
Society of India, and former Secretary General of the Asian
Australasian Society of Neurological Surgery. He may be contacted at
investment decisions are made with respect to the future, not the
past. ‘Easy to use’ should be a prerequisite in the selection of
equipment and systems for telemedicine. User-friendly, it must
enhance, not hinder the process of healthcare. Like any revolutionary
force, telemedicine will encounter considerable resistance as it
moves from the fringe to the mainstream of healthcare over the next
decade. Deciding how to pay for it, who is qualified to do it and how
to assess its quality are already major issues. Teleconsultation is not a
new medical service but a new way of delivering a consultation.
Previous generations of physicians will find the new concepts of
telemedicine unfathomable – to many it may sound blasphemous.
What will happen to the individual doctor-patient relationship
considered sacrosanct for centuries? Is it not sacrilegious and
bordering on heresy to treat a patient in another continent without
knowing his family and cultural background? Yes, say the diehards.
No, say the technology enthusiasts. The first generation of
telemedicine enthusiasts should not forget that technology should
be used as a support to treat patients, not viewed as the goal itself.
The challenge today is not confined to overcoming technological
barriers, insurmountable though they may appear; it is true that
available technology still has scope for improvement. Rather, the
challenge is why, where and how to implement which technology and
at what cost. A needs assessment is critical. However, technology can
only treat diseases. To treat sick people, empathy and understanding
is needed.
The takeoff problems facing telemedicine are legion. It is our dream
and hope that within the next few years there will be telemedicine
units in most parts of suburban and rural India. Eventually, no Indian
will be deprived of a specialist consultation wherever he or she is –
consultation will soon be only a mouse click away! For this to happen,
a critical mass must be reached. What is required is not implementing
better technology and getting funds, but changing the mindset of the
people involved. Awareness should permeate throughout society.
Real growth will take place only when society realizes that distance is
meaningless today, and that telemedicine can bridge the gap
between the haves and the have nots, at least insofar as access to
healthcare is concerned.
There are critics who believe telemedicine is a waste of precious
resources that are needed urgently for higher health priorities.
Telemedicine, however, is a part of the wider phenomenon of
information, and information is arguably the strongest change agent.
Telemedicine is a part of this great change. Information brings to the
11
The Indian President recently announced that, “A strong and
prosperous nation needs healthy and educated citizens.” With 71% of
India’s citizens residing in rural areas, the most obvious approach is to
redistribute the concentrated resources from the remaining 29% and
to create region-specific opportunities for new means of
development. Good health and education go hand in hand, where
one cannot increase its expanse without the help of the other. The
term ‘functional literacy’ is fast gaining popularity because of its
practical and effective approach in making an individual self reliant,
progressive and aware.
The metropolitan cities in India are Mumbai, Chennai, Kolkata, Delhi,
Bangalore and Hyderabad. Another city that is fast catching up to
make it to this list is Pune. According to the classification by Knight
Frank, India; which is based primarily on information technology (IT)
progress and real estate market growth , these are the tier I cities as
they are most favoured by investors in all industry sectors, especially
IT and Real Estate (occupying 60% of the total real estate space). The
tier II cities are those which have seen a significant and steep growth
in IT and real estate space in the past few years, while tier III are those
that are trying to emerge as IT hubs. Similar trends of growth have
been observed in the healthcare industry too. The liberalisation of
policies to make investments in healthcare more lucrative for private
investors has seen a saturation of the market (in terms of services and
space) with respect to the metros. Once this was achieved and the
government further incentivised the penetration of healthcare
projects (allocation of Socio-Economic Zones for healthcare projects,
tax holidays for hospitals with more than 100 beds) in the tier II and
tier III cities, a steep rise of such projects was observed, specifically in
the tier II cities. This has currently become the target market for big
(Apollo Group, Fortis Healthcare, Manipal Group, CARE Hospitals
etc.) and medium sized (targeting particular states e.g. Kamineni
Hospital in Andhra Pradesh) healthcare players. The market also saw
the inception and rapid growth of a novel healthcare model
consisting of a chain of hospitals; called ‘Vaatsalya Healthcare’,
catering only to the Tier II and III cities with an aim to bridge the
disparity between the services provided in these cities and the
metros. Their mission is to bring ‘Affordable, Accessible and
Appropriate’ healthcare services to under-served areas of the
country.
This market penetration distal to the metropolitans has been
manoeuvred by the development in other sectors such as electricity,
water, sanitation, education, connectivity, infrastructure and
technology. The parallel growth in these sectors not only form the
support pillars to bring healthcare services as close to people's
doorsteps as possible, but also helps in attaining basic quality
standards of healthcare delivery. For example, preventive healthcare
initiatives will be successful and effective only when people are
provided with clean drinking water, adequate nutritious food and
sanitation facilities.
In the past decade or so, the tier II and III cities have
become more lucrative than tier I. The reasons for the
same have been attributed to the following:
· Availability of space in terms of land or ready commercial
premises
· Affordability of space
· Cheaper Resources – manpower, materials,
Taking Healthcarebeyond the Metros
Our villages lie both ignored and untapped.
Dr. Divya Pottath maps where we've gone wrong,
and gives us solutions to make amends.
consumables etc.
· Government incentives
· Lower cost of living
These basic criteria served as the first impetus for IT companies and
manufacturing industries to set up their units in tier II and III cities.
High paying IT jobs and the volume of jobs available in manufacturing
industries led to migration of people from the bigger cities to these
smaller, lesser developed areas. But to retain this population and to
incentivise highly skilled personnel, it was important to create a self
sustaining society with good education, healthcare and recreational
facilities. Thus healthcare in these cities saw a new dimension beyond
secondary care with the entry of tertiary care healthcare facilities and
corporate hospital groups providing quality healthcare services
comparable to those provided in the metropolitan cities. A city thus
fortified with industries and these support amenities will progress
towards overall development and growth and become attractive
grounds for investment (national and foreign investors); thus making
it a self sustaining growth cycle which was incentivised by the
visionaries from the public and private sectors of all industries,
including healthcare.
The Gap between Metros and Tier II & III
Although the wheel of fortune for tier II and III cities has begun to
turn, the challenge still remains to bridge the gap between the
metropolitans and these cities with respect to the portfolio and
quality of services being provided.
The table below shows the difference between healthcare resources
available in the metros as compared to the rest of India:
The global standard for number of hospital beds per 1000 population
is 4 (As per the WHO) and India falls far behind this standard at 0.9.
Some of the metropolitan cities, however, come considerably close to
this number with Hyderabad being the closest at 3.17; followed
closely by Bangalore at 3, which is comparable to China's average of 3.
The other metros are also above the Indian average of 0.9 beds/1000
population, with the total average of the metropolitan cities being 2.3
beds/1000 population as against the rest of India at 0.8 beds/1000
population (lower than the Indian average).
This disparity between the distribution of hospital beds shows that
15% of the beds are available among 6% of the population. This also
implies that investments in the healthcare industry as a whole
(including diagnostics, day care, medical insurance, medical
technology etc.) are concentrated or directed more towards the
same 6% metropolitan population.
Also, the total beds in the tier II and III cities mainly comprise of those
from secondary care hospitals whereas those in the metros are
mainly from tertiary care hospitals.
Apart from this, there are other growth impetuses available in the
metros that make them a more favoured investment ground for
healthcare; some of which are listed below:
· Denser population
· Greater paying capacity
· Easily and economically available advanced technology
· Easily available manpower (both skilled and unskilled)
· Better organized healthcare delivery system
· Better insurance penetration
A metro’s advantages also serve as challenges to improve
penetration of healthcare delivery in the tier II and III cities.
The Need – Tier II & III
Saturation of healthcare services in the metros is only relative
because of the polarity between them and the rest of India. In
essence however, these cities too need to strengthen their
healthcare system to match global standards. But the point of
contention here is the distribution of sub-optimal resources and
basic healthcare; where the latter is considered to be the right of the
citizens of a country and should be distributed as equally as possible.
The need for channelizing healthcare services towards the tier II and
III cities is further detailed below:
· Self reliance
Healthcare services, both basic and specialized, should be
made available and accessible for the population living in
cities capable of providing quality services in order to render
them self reliant.
· Double burden of disease
Non-communicable – mostly the population working in the
corporate sector
Communicable – mainly the lower socioeconomic strata
who may be migrants or original inhabitants
Therefore it will be challenging for the existing secondary
care institutions to serve the requirements of the entire
Taking Healthcare beyond the MetrosOur villages lie both ignored and untapped. Dr. Divya Pottath maps where we've gone wrong,and gives us solutions to make amends.
13 14
Region Total Hospital Beds Beds per 1000 pop
Indian 1,063,271 0.9
NCR 37,602 2.13
Mumbai 35,595 1.75
Hyderabad 23,993 3.17
Bangalore
20,938
3
Kolkata
20,508
1.29
Chnnai
162,055
2.52
Total Metropolitan
901,216
2.3
Rest of India 0.8
23.,419
The Indian President recently announced that, “A strong and
prosperous nation needs healthy and educated citizens.” With 71% of
India’s citizens residing in rural areas, the most obvious approach is to
redistribute the concentrated resources from the remaining 29% and
to create region-specific opportunities for new means of
development. Good health and education go hand in hand, where
one cannot increase its expanse without the help of the other. The
term ‘functional literacy’ is fast gaining popularity because of its
practical and effective approach in making an individual self reliant,
progressive and aware.
The metropolitan cities in India are Mumbai, Chennai, Kolkata, Delhi,
Bangalore and Hyderabad. Another city that is fast catching up to
make it to this list is Pune. According to the classification by Knight
Frank, India; which is based primarily on information technology (IT)
progress and real estate market growth , these are the tier I cities as
they are most favoured by investors in all industry sectors, especially
IT and Real Estate (occupying 60% of the total real estate space). The
tier II cities are those which have seen a significant and steep growth
in IT and real estate space in the past few years, while tier III are those
that are trying to emerge as IT hubs. Similar trends of growth have
been observed in the healthcare industry too. The liberalisation of
policies to make investments in healthcare more lucrative for private
investors has seen a saturation of the market (in terms of services and
space) with respect to the metros. Once this was achieved and the
government further incentivised the penetration of healthcare
projects (allocation of Socio-Economic Zones for healthcare projects,
tax holidays for hospitals with more than 100 beds) in the tier II and
tier III cities, a steep rise of such projects was observed, specifically in
the tier II cities. This has currently become the target market for big
(Apollo Group, Fortis Healthcare, Manipal Group, CARE Hospitals
etc.) and medium sized (targeting particular states e.g. Kamineni
Hospital in Andhra Pradesh) healthcare players. The market also saw
the inception and rapid growth of a novel healthcare model
consisting of a chain of hospitals; called ‘Vaatsalya Healthcare’,
catering only to the Tier II and III cities with an aim to bridge the
disparity between the services provided in these cities and the
metros. Their mission is to bring ‘Affordable, Accessible and
Appropriate’ healthcare services to under-served areas of the
country.
This market penetration distal to the metropolitans has been
manoeuvred by the development in other sectors such as electricity,
water, sanitation, education, connectivity, infrastructure and
technology. The parallel growth in these sectors not only form the
support pillars to bring healthcare services as close to people's
doorsteps as possible, but also helps in attaining basic quality
standards of healthcare delivery. For example, preventive healthcare
initiatives will be successful and effective only when people are
provided with clean drinking water, adequate nutritious food and
sanitation facilities.
In the past decade or so, the tier II and III cities have
become more lucrative than tier I. The reasons for the
same have been attributed to the following:
· Availability of space in terms of land or ready commercial
premises
· Affordability of space
· Cheaper Resources – manpower, materials,
Taking Healthcarebeyond the Metros
Our villages lie both ignored and untapped.
Dr. Divya Pottath maps where we've gone wrong,
and gives us solutions to make amends.
consumables etc.
· Government incentives
· Lower cost of living
These basic criteria served as the first impetus for IT companies and
manufacturing industries to set up their units in tier II and III cities.
High paying IT jobs and the volume of jobs available in manufacturing
industries led to migration of people from the bigger cities to these
smaller, lesser developed areas. But to retain this population and to
incentivise highly skilled personnel, it was important to create a self
sustaining society with good education, healthcare and recreational
facilities. Thus healthcare in these cities saw a new dimension beyond
secondary care with the entry of tertiary care healthcare facilities and
corporate hospital groups providing quality healthcare services
comparable to those provided in the metropolitan cities. A city thus
fortified with industries and these support amenities will progress
towards overall development and growth and become attractive
grounds for investment (national and foreign investors); thus making
it a self sustaining growth cycle which was incentivised by the
visionaries from the public and private sectors of all industries,
including healthcare.
The Gap between Metros and Tier II & III
Although the wheel of fortune for tier II and III cities has begun to
turn, the challenge still remains to bridge the gap between the
metropolitans and these cities with respect to the portfolio and
quality of services being provided.
The table below shows the difference between healthcare resources
available in the metros as compared to the rest of India:
The global standard for number of hospital beds per 1000 population
is 4 (As per the WHO) and India falls far behind this standard at 0.9.
Some of the metropolitan cities, however, come considerably close to
this number with Hyderabad being the closest at 3.17; followed
closely by Bangalore at 3, which is comparable to China's average of 3.
The other metros are also above the Indian average of 0.9 beds/1000
population, with the total average of the metropolitan cities being 2.3
beds/1000 population as against the rest of India at 0.8 beds/1000
population (lower than the Indian average).
This disparity between the distribution of hospital beds shows that
15% of the beds are available among 6% of the population. This also
implies that investments in the healthcare industry as a whole
(including diagnostics, day care, medical insurance, medical
technology etc.) are concentrated or directed more towards the
same 6% metropolitan population.
Also, the total beds in the tier II and III cities mainly comprise of those
from secondary care hospitals whereas those in the metros are
mainly from tertiary care hospitals.
Apart from this, there are other growth impetuses available in the
metros that make them a more favoured investment ground for
healthcare; some of which are listed below:
· Denser population
· Greater paying capacity
· Easily and economically available advanced technology
· Easily available manpower (both skilled and unskilled)
· Better organized healthcare delivery system
· Better insurance penetration
A metro’s advantages also serve as challenges to improve
penetration of healthcare delivery in the tier II and III cities.
The Need – Tier II & III
Saturation of healthcare services in the metros is only relative
because of the polarity between them and the rest of India. In
essence however, these cities too need to strengthen their
healthcare system to match global standards. But the point of
contention here is the distribution of sub-optimal resources and
basic healthcare; where the latter is considered to be the right of the
citizens of a country and should be distributed as equally as possible.
The need for channelizing healthcare services towards the tier II and
III cities is further detailed below:
· Self reliance
Healthcare services, both basic and specialized, should be
made available and accessible for the population living in
cities capable of providing quality services in order to render
them self reliant.
· Double burden of disease
Non-communicable – mostly the population working in the
corporate sector
Communicable – mainly the lower socioeconomic strata
who may be migrants or original inhabitants
Therefore it will be challenging for the existing secondary
care institutions to serve the requirements of the entire
Taking Healthcare beyond the MetrosOur villages lie both ignored and untapped. Dr. Divya Pottath maps where we've gone wrong,and gives us solutions to make amends.
13 14
Region Total Hospital Beds Beds per 1000 pop
Indian 1,063,271 0.9
NCR 37,602 2.13
Mumbai 35,595 1.75
Hyderabad 23,993 3.17
Bangalore
20,938
3
Kolkata
20,508
1.29
Chnnai
162,055
2.52
Total Metropolitan
901,216
2.3
Rest of India 0.8
23.,419
·models
· Lesser competition
· Word of mouth spreads faster and is more important.
Therefore extensive marketing budgets are not required
Challenges – bringing healthcare to Tier II & III
· Different healthcare dynamics
The referral system is general practitioner (GP) driven. The
population first approaches these GPs and the footfalls in
the hospitals are dependent on how many patients they
direct to the hospitals. The GPs also tend to keep the
patients for longer time with them to continue receiving
their consultation fees.
The population is not aware of the gamut of healthcare
services that are available for them at these hospitals and
their significance in faster recovery. The image of hospitals
still remains of an institution where people go when they
are seriously or chronically ill.
· Strengthen Primary and Preventive Healthcare
This has been a major challenge for our government ever
since the time our healthcare delivery system was
structured. Problems range from lack of infrastructure,
technology, skilled manpower to basic support amenities
like electricity, water, sanitation etc.
· Availability of skilled manpower
Skilled medical professionals either receive their training
from bigger metro cities or migrate to such cities in search of
better economic value. Another possible deterrent in
retaining them in the smaller tier cities may be the lack of
support infrastructure and limited career growth potential.
· Investments
Private Investors and funding institutions require
convincing about the commercial feasibility of a project.
The healthcare industry in general has a longer gestation
period, which may be further intensified in smaller towns
Lesser risk in experimenting with new healthcare and therefore act as a additional deterrent for investors.
·
Providing the support infrastructure and the skilled
manpower required to run the advanced technology
systems/machines becomes a challenge with the limited
resources available.
· Very low health insurance penetration
The out of pocket spending on healthcare is very high in the
non metro regions. The people belonging to non metros also
tend to have lesser dispensable income hence unable to pay
that extra premium for better quality services. Value of
money weighs heavier than quality services as long as basic
healthcare needs are met. Low penetration of private
insurance because of high premium and limited success of
social/micro insurance schemes either by the Government
or the private players has made it further difficult to reduce
the burden of healthcare expenses on the population.
Overcome Challenges
· Seize growing connectivity advantage
Transportation — Better roads, new railway lines with
improved frequency, airline connectivity between smaller
cities and the metros and more affordable travel.
All this can be used to encourage visits/consultations by
specialist doctors and transport materials (medical
equipments and consumables; both Indian and imported)
Network connectivity — In terms of telecom, radio,
television, internet accessibility and availability.
It helps in creating awareness among the population about
the services available in other parts of the country or the
world. This empowers them to make informed choices
independent of the local practitioner's guidance. This in fact
will also help the local practitioners be aware of the
developments and options available in healthcare services
across the country giving them options to either replicate
such models or import such services.
Increased options for advertising healthcare services and
hence help target a greater audience using direct marketing
strategies. This also helps to overcome the strong GP driven
referral system prevalent in the smaller tier cities.
· Take advantage of economies of scale
The factors that work towards turning the wheels of
economies of scale are:
· Reduce costs
Many initiatives have been taken by the government and
nonprofit sectors to encourage capital investments in tier II
and III cities. But the key to the success of such projects is the
sustenance of these facilities. Therefore it is equally if not
more important to curb the operating costs of these
facilities.
The strategies that can be adopted for the same are:
· Green initiatives – Help save expenses on power, water
etc. Environment friendly operations to prevent the
Bringing in advanced technology
non metros from going the metro way with respect to
environment contaminants/pollution.
· Standardize operating procedures
· Local tie ups for procuring consumables and drugs
· Strategies for greater footfalls- Camps (in the hospital
premises and neighbouring drainage areas), direct
marketing, clinical seminars in the premises etc.
· Empower local manpower
Train the local population on a continual basis with
competitive incentives for retention .
The Way Ahead
The vision of self sustained cities and towns is not complete unless it
includes its healthcare facilities among other sectors such as
infrastructure and technology. This approach is also critical for the
sustenance of the big metros and to curb the effects of migration
leading to overcrowding and therefore struggle for limited resources
leading to inflated prices, poor hygiene, unemployment, rise in crime
rate, corruption etc.
Some strategies that may help improve the healthcare system in the
tier II and III cities are as folllows:
· The Hub and Spoke model
The Hub is the big hospital that may be in the metros or the
bigger tier II cities where all the high end tertiary care
specialty services are provided whereas the spokes are the
outreach primary or secondary care centers, set up in the
neighbouring smaller cities or towns; where preventive and
curative care is provided. These also serve as feeding centers
for the hub to avail its high end medical services.
This model works better than providing tertiary level care at
population
·
Travel costs – Many families spend a considerable amount of
money in travelling to the metros to avail specialized
healthcare services.
Lost man days – Of the patients and their relatives (mostly
more than one relative per patient)
To nullify/neutralize the monopoly of small hospitals in
these cities to ensure competitive pricing of services and
efforts to deliver promised quality.
Advantage – Tier II & Tier III
· Huge Unexplored potential market
Two thirds of India's middle class population lies outside the
top tier cities Economies of scale works to reduce costs and
increase profit margins.
· Economic Growth Potential
India's total consumption is primarily spearheaded by the
middle class population and is expected to hit $1.5 trillion by
2025. This is further supported by the statistics that 10.7
million of the total population, earning up to about INR 10
lakh per annum, live in smaller cities such as Nagpur,
Vadodara, Ahmedabad, Vijaywada etc.
An ASSOCHAM study report stated that the major
beneficiaries of the current 9% Indian economy growth
curve are the tier II cities, where the total credit availed by
them was calculated to be about INR 2.8 crores, with a
growth rate of 23.7%, with Lucknow and Vishakapatnam
topping the list respectively. It is however observed that the
conversion of money deposited to credit is much lower in
the tier III than the tier II cities (92%). This is mainly because
of the nature of the industries in tier III cities which mainly
comprises of small entrepreneurs, small scale industries,
unorganized retail etc.
· Healthcare delivery advantages
· Lower capital and operational costs
Reduce costs
Growing Economies
15 16
·models
· Lesser competition
· Word of mouth spreads faster and is more important.
Therefore extensive marketing budgets are not required
Challenges – bringing healthcare to Tier II & III
· Different healthcare dynamics
The referral system is general practitioner (GP) driven. The
population first approaches these GPs and the footfalls in
the hospitals are dependent on how many patients they
direct to the hospitals. The GPs also tend to keep the
patients for longer time with them to continue receiving
their consultation fees.
The population is not aware of the gamut of healthcare
services that are available for them at these hospitals and
their significance in faster recovery. The image of hospitals
still remains of an institution where people go when they
are seriously or chronically ill.
· Strengthen Primary and Preventive Healthcare
This has been a major challenge for our government ever
since the time our healthcare delivery system was
structured. Problems range from lack of infrastructure,
technology, skilled manpower to basic support amenities
like electricity, water, sanitation etc.
· Availability of skilled manpower
Skilled medical professionals either receive their training
from bigger metro cities or migrate to such cities in search of
better economic value. Another possible deterrent in
retaining them in the smaller tier cities may be the lack of
support infrastructure and limited career growth potential.
· Investments
Private Investors and funding institutions require
convincing about the commercial feasibility of a project.
The healthcare industry in general has a longer gestation
period, which may be further intensified in smaller towns
Lesser risk in experimenting with new healthcare and therefore act as a additional deterrent for investors.
·
Providing the support infrastructure and the skilled
manpower required to run the advanced technology
systems/machines becomes a challenge with the limited
resources available.
· Very low health insurance penetration
The out of pocket spending on healthcare is very high in the
non metro regions. The people belonging to non metros also
tend to have lesser dispensable income hence unable to pay
that extra premium for better quality services. Value of
money weighs heavier than quality services as long as basic
healthcare needs are met. Low penetration of private
insurance because of high premium and limited success of
social/micro insurance schemes either by the Government
or the private players has made it further difficult to reduce
the burden of healthcare expenses on the population.
Overcome Challenges
· Seize growing connectivity advantage
Transportation — Better roads, new railway lines with
improved frequency, airline connectivity between smaller
cities and the metros and more affordable travel.
All this can be used to encourage visits/consultations by
specialist doctors and transport materials (medical
equipments and consumables; both Indian and imported)
Network connectivity — In terms of telecom, radio,
television, internet accessibility and availability.
It helps in creating awareness among the population about
the services available in other parts of the country or the
world. This empowers them to make informed choices
independent of the local practitioner's guidance. This in fact
will also help the local practitioners be aware of the
developments and options available in healthcare services
across the country giving them options to either replicate
such models or import such services.
Increased options for advertising healthcare services and
hence help target a greater audience using direct marketing
strategies. This also helps to overcome the strong GP driven
referral system prevalent in the smaller tier cities.
· Take advantage of economies of scale
The factors that work towards turning the wheels of
economies of scale are:
· Reduce costs
Many initiatives have been taken by the government and
nonprofit sectors to encourage capital investments in tier II
and III cities. But the key to the success of such projects is the
sustenance of these facilities. Therefore it is equally if not
more important to curb the operating costs of these
facilities.
The strategies that can be adopted for the same are:
· Green initiatives – Help save expenses on power, water
etc. Environment friendly operations to prevent the
Bringing in advanced technology
non metros from going the metro way with respect to
environment contaminants/pollution.
· Standardize operating procedures
· Local tie ups for procuring consumables and drugs
· Strategies for greater footfalls- Camps (in the hospital
premises and neighbouring drainage areas), direct
marketing, clinical seminars in the premises etc.
· Empower local manpower
Train the local population on a continual basis with
competitive incentives for retention .
The Way Ahead
The vision of self sustained cities and towns is not complete unless it
includes its healthcare facilities among other sectors such as
infrastructure and technology. This approach is also critical for the
sustenance of the big metros and to curb the effects of migration
leading to overcrowding and therefore struggle for limited resources
leading to inflated prices, poor hygiene, unemployment, rise in crime
rate, corruption etc.
Some strategies that may help improve the healthcare system in the
tier II and III cities are as folllows:
· The Hub and Spoke model
The Hub is the big hospital that may be in the metros or the
bigger tier II cities where all the high end tertiary care
specialty services are provided whereas the spokes are the
outreach primary or secondary care centers, set up in the
neighbouring smaller cities or towns; where preventive and
curative care is provided. These also serve as feeding centers
for the hub to avail its high end medical services.
This model works better than providing tertiary level care at
population
·
Travel costs – Many families spend a considerable amount of
money in travelling to the metros to avail specialized
healthcare services.
Lost man days – Of the patients and their relatives (mostly
more than one relative per patient)
To nullify/neutralize the monopoly of small hospitals in
these cities to ensure competitive pricing of services and
efforts to deliver promised quality.
Advantage – Tier II & Tier III
· Huge Unexplored potential market
Two thirds of India's middle class population lies outside the
top tier cities Economies of scale works to reduce costs and
increase profit margins.
· Economic Growth Potential
India's total consumption is primarily spearheaded by the
middle class population and is expected to hit $1.5 trillion by
2025. This is further supported by the statistics that 10.7
million of the total population, earning up to about INR 10
lakh per annum, live in smaller cities such as Nagpur,
Vadodara, Ahmedabad, Vijaywada etc.
An ASSOCHAM study report stated that the major
beneficiaries of the current 9% Indian economy growth
curve are the tier II cities, where the total credit availed by
them was calculated to be about INR 2.8 crores, with a
growth rate of 23.7%, with Lucknow and Vishakapatnam
topping the list respectively. It is however observed that the
conversion of money deposited to credit is much lower in
the tier III than the tier II cities (92%). This is mainly because
of the nature of the industries in tier III cities which mainly
comprises of small entrepreneurs, small scale industries,
unorganized retail etc.
· Healthcare delivery advantages
· Lower capital and operational costs
Reduce costs
Growing Economies
15 16
the smaller cities/towns since most medical conditions may
be treated and prevented from becoming critical if taken
care of at the primary stages.
·
Incentivize Indian and Foreign investments in smaller cities
by providing tax incentives.
Encourage funding from Global not for profit organizations
and private investors for private healthcare projects.
Encourage health insurance schemes for ensuring better
penetration.
· Telemedicine projects
With India becoming the second largest wireless network in
the world (overtaking USA); the implementation of
telemedicine facilities, especially mobile telemedicine will
become easier and more affordable.
· Public-Private Partnerships
For projects concerned with healthcare infrastructure, high
end medical technology, medical or social insurance
schemes etc
· Capital flow (public and private)
Public — Greater allocation of funds to healthcare and
ensure efficient utilization
Private — Incentives such as tax holidays, lower interest
rates, incentives for foreign direct investments
· Efficient implementation of National Health Programs
· Education & Training
A literate population is more aware of its healthcare needs
and more capable of making informed decisions. A
functional literacy program should be planned and
implemented especially among the lower socio economic
strata of the society.
Training of local manpower to become skilled healthcare
professionals should be further encouraged by the
Education Councils especially with respect to Nursing,
Paramedics, primary healthcare workers etc.
· Create a Competitive Market
More healthcare providers will make the market
competitive and hence ensure competitive pricing and
quality services
Steps by the Government
care institutions to serve the requirements of the entire
population
The author is a physiotherapist with an MBA in Hospital and
Healthcare from Symbiosis International University. She was
formerly working with HOSMAC as a Management Consultant and
can be reached at [email protected]
17
the smaller cities/towns since most medical conditions may
be treated and prevented from becoming critical if taken
care of at the primary stages.
·
Incentivize Indian and Foreign investments in smaller cities
by providing tax incentives.
Encourage funding from Global not for profit organizations
and private investors for private healthcare projects.
Encourage health insurance schemes for ensuring better
penetration.
· Telemedicine projects
With India becoming the second largest wireless network in
the world (overtaking USA); the implementation of
telemedicine facilities, especially mobile telemedicine will
become easier and more affordable.
· Public-Private Partnerships
For projects concerned with healthcare infrastructure, high
end medical technology, medical or social insurance
schemes etc
· Capital flow (public and private)
Public — Greater allocation of funds to healthcare and
ensure efficient utilization
Private — Incentives such as tax holidays, lower interest
rates, incentives for foreign direct investments
· Efficient implementation of National Health Programs
· Education & Training
A literate population is more aware of its healthcare needs
and more capable of making informed decisions. A
functional literacy program should be planned and
implemented especially among the lower socio economic
strata of the society.
Training of local manpower to become skilled healthcare
professionals should be further encouraged by the
Education Councils especially with respect to Nursing,
Paramedics, primary healthcare workers etc.
· Create a Competitive Market
More healthcare providers will make the market
competitive and hence ensure competitive pricing and
quality services
Steps by the Government
care institutions to serve the requirements of the entire
population
The author is a physiotherapist with an MBA in Hospital and
Healthcare from Symbiosis International University. She was
formerly working with HOSMAC as a Management Consultant and
can be reached at [email protected]
17
IK: When and why did you decide that an NABH accreditation would
be suitable for your hospital?
BKV: The current trend with regard to healthcare in Kerala is that
consumers demand quality in care, irrespective of their economic
status. All strata of society are willing to pay out of their pockets to
receive the best treatment from private hospitals, where the
atmosphere is conceived to be pleasant. Furthermore, the mission
statement of NRHM emphasizes on the provision of quality
healthcare through public healthcare facilities for the masses. The
directive for applying of accreditation came from NRHM in January,
2008 and the process was initiated in August, 2008.
IK: The government played a pivotal role in the success of General
Hospital, Ernakulum receiving accreditation. What kind of support
was offered and how did it aid you?
BKV: We received immense support from all levels of the government
for the project. What strengthened our purpose even further was the
fact that policy decisions were made with speed and problems
received immediate response and correction. For instance, one of the
concerns we faced early on was that our hospital did not meet the
bed space requirement as per NABH standards. The IAS officers-in-
charge immediately arranged for a sum of INR 2 crore to renovate the
inpatient ward and expand it to 25,000 sqft. Not only did we receive
adequate aid from NRHM, but ministers from the state funded a few
of the infrastructure projects as well.
IK: Once a decision was made to achieve NABH standards, what
challenges did you face when you shared your plan with the
hospital staff?
BKV: Initially, most of the staff was against our decision. They could
not perceive how NABH would help improve the quality levels and
make a difference to their current working style. They also had
apprehensions about the increased workload and tedious
documentation which would ensue. However, six months into the
program, we were able to gather complete support from our staff as
the results of implementation were evident.
IK: What were the major gaps that were discovered after the gap
analysis was conducted? What strategies did you employ to bridge
them?
BKV: After conducting a gap analysis study in assistance of technical
consultants, we discovered that our hospital lacked grades in
infrastructure, waste management, human resources and
equipment for use. The way out would be to employ an intensive 8-
step approach, beginning with core team-building and committee
formation, followed by development of SOPs, infrastructure
redevelopment, sensitization of staff and so on.
K: Your hospital boasts of a combined strength of 1000 nurses and
doctors. With such a large manpower to train, how were the
training programs designed and assessed later on?
BKV: A training calendar was created; the hospital staff was divided
into smaller groups. All chapters of the NABH guidelines were
covered in this training. A pre-assessment test was conducted to
judge the levels of understanding of the staff after which training was
conducted. A post-assessment test was later taken to ensure the
effectiveness of the training. Subsequent internal audits further
helped in assessing the awareness and learning amongst the staff.
IK: The hospital space is a 170-year old institution; there must have
been several infrastructural changes made to meet the standards.
General Hospital, Ernakulum is one of the largest governmental facilities
in Southeast Asia with 748 beds and 1000 hospital staff. Isha Khanolkar
– Asst. Manager Operations – Hosmac, interviews Dr. Beena K.V.
– District Program Manager – NRHM on her journey to facilitate the
NABH accreditation of the first large hospital in India.
What did they entail?
BKV: The hospital lies in the heart of Cochin, set on six acres of land.
The major renovations that took place were with the inpatient ward,
administration office, outpatient department and operation
theatres. Since only additions were made to the existing facilities, the
construction activity did not hinder the operations of the hospital.
IK: Cost of implementing changes would have been quite high
considering the fact that the hospital was run like a governmental
setup. What quarters were chosen to accumulate funds?
BKV: General Hospital, Ernakulum has a Hospital Development
Committee which was given the responsibility to liaise with various
agencies and raise funds for the infrastructural needs. Our District
Collector also contacted several government, public sector units to
seek sponsorship of individual blocks in the hospital campus. We
were heartened by the support of agencies like GAIL, Lions Club,
Manaseva Trust and others. Our personal acquaintances and
networking also facilitated the receipt of funds for further
development.
IK: What indicators in the hospital showed major improvements
after the implementation of NABH standards?
BKV: The most important indicators of improvement in healthcare
delivery were found to be in the infection control practices of the
hospital. We monitored parameters like needlestick injuries to keep a
watch on the safety methods in use. The average length of a patient’s
stay decreased; conversely, there was an increase in patient
satisfaction levels. Bed occupancy rates increased and resulted in an
increase in turnover.
IK: Quality is ultimately to serve the customer. What has been the
reaction of patients from Ernakulum to the improvement made?
BKV: We have implemented several programs to make our hospital
patient friendly. Project ‘Hunger Free’ was conceptualized to ensure
that all food made available to patients and their relatives would be
free of cost. Auxiliary services such as X-ray and CT scans are being
provided at subsided rates. Several patients were interviewed with
regard to our hospital services, and response was gratifying. One of
our patients once quote, ‘Receiving private hospital like-care at a
governmental hospital for subsidized rates is extraordinary!’
IK: In your opinion, what measures must be instituted to ensure the
success of NABH accreditation?
BKV: To catalyse quality improvement in the healthcare delivery
system of India, QCI (Quality Council of India) along with the NRHM
should take to promoting the accreditation of hospitals and provide
adequate support. Though hospitals as well as the government
knows that implementing quality is a costly affair, in the long run, it
proves quite rewarding.
IK: The accreditation journey for the hospital took two long years to
reach its conclusion. What motivated you to stay relentless in your
effort?
BKV: One is only as successful as the team behind you wants you to
be. I had the good fortune of having built a good rapport with my
hospital team even before NABH came into the picture. My Core
Team consisted of people who were willing to strive for even 24 hours
straight, when required for the quality effort. Another factor was the
relentless support extended by NRHM along with the 5-day NABH
training program, where we learned about the process of
accreditation. Never taking ‘no’ for an answer, we worked our way
through.
IK: What message would you give other government hospitals in
the country trying to achieve NABH accreditation?
BKV: The key to a successful shot at NABH is to plan the approach in
advance. A vital factor is the Core Team that must consist of 3-5
committed members, willing to work long hours. Identification of the
gaps and their categorization according to importance is
instrumental. The correct personnel must administer the quality
assignments. They must be proficient in the assigned area to achieve
the desired results. Perseverance is the key!
The interviewee is a proud recipient of Vocational Excellence Award
from Rotary Club, Women Achiever Award from Sakhi and Best
Hospital Award from Indian Red Cross Society. She may be reached at
To be or not to be — Accredited
Manager – NRHM, on her journey to facilitate the NABH accreditation of General Hospital, Ernakulum.Isha Khanolkar, Asst. Manager Operations – Hosmac, interviews Dr. Beena K.V., District Program
Before
After
Dr. Beena receiving NABH accreditation from QCI
19 20
IK: When and why did you decide that an NABH accreditation would
be suitable for your hospital?
BKV: The current trend with regard to healthcare in Kerala is that
consumers demand quality in care, irrespective of their economic
status. All strata of society are willing to pay out of their pockets to
receive the best treatment from private hospitals, where the
atmosphere is conceived to be pleasant. Furthermore, the mission
statement of NRHM emphasizes on the provision of quality
healthcare through public healthcare facilities for the masses. The
directive for applying of accreditation came from NRHM in January,
2008 and the process was initiated in August, 2008.
IK: The government played a pivotal role in the success of General
Hospital, Ernakulum receiving accreditation. What kind of support
was offered and how did it aid you?
BKV: We received immense support from all levels of the government
for the project. What strengthened our purpose even further was the
fact that policy decisions were made with speed and problems
received immediate response and correction. For instance, one of the
concerns we faced early on was that our hospital did not meet the
bed space requirement as per NABH standards. The IAS officers-in-
charge immediately arranged for a sum of INR 2 crore to renovate the
inpatient ward and expand it to 25,000 sqft. Not only did we receive
adequate aid from NRHM, but ministers from the state funded a few
of the infrastructure projects as well.
IK: Once a decision was made to achieve NABH standards, what
challenges did you face when you shared your plan with the
hospital staff?
BKV: Initially, most of the staff was against our decision. They could
not perceive how NABH would help improve the quality levels and
make a difference to their current working style. They also had
apprehensions about the increased workload and tedious
documentation which would ensue. However, six months into the
program, we were able to gather complete support from our staff as
the results of implementation were evident.
IK: What were the major gaps that were discovered after the gap
analysis was conducted? What strategies did you employ to bridge
them?
BKV: After conducting a gap analysis study in assistance of technical
consultants, we discovered that our hospital lacked grades in
infrastructure, waste management, human resources and
equipment for use. The way out would be to employ an intensive 8-
step approach, beginning with core team-building and committee
formation, followed by development of SOPs, infrastructure
redevelopment, sensitization of staff and so on.
K: Your hospital boasts of a combined strength of 1000 nurses and
doctors. With such a large manpower to train, how were the
training programs designed and assessed later on?
BKV: A training calendar was created; the hospital staff was divided
into smaller groups. All chapters of the NABH guidelines were
covered in this training. A pre-assessment test was conducted to
judge the levels of understanding of the staff after which training was
conducted. A post-assessment test was later taken to ensure the
effectiveness of the training. Subsequent internal audits further
helped in assessing the awareness and learning amongst the staff.
IK: The hospital space is a 170-year old institution; there must have
been several infrastructural changes made to meet the standards.
General Hospital, Ernakulum is one of the largest governmental facilities
in Southeast Asia with 748 beds and 1000 hospital staff. Isha Khanolkar
– Asst. Manager Operations – Hosmac, interviews Dr. Beena K.V.
– District Program Manager – NRHM on her journey to facilitate the
NABH accreditation of the first large hospital in India.
What did they entail?
BKV: The hospital lies in the heart of Cochin, set on six acres of land.
The major renovations that took place were with the inpatient ward,
administration office, outpatient department and operation
theatres. Since only additions were made to the existing facilities, the
construction activity did not hinder the operations of the hospital.
IK: Cost of implementing changes would have been quite high
considering the fact that the hospital was run like a governmental
setup. What quarters were chosen to accumulate funds?
BKV: General Hospital, Ernakulum has a Hospital Development
Committee which was given the responsibility to liaise with various
agencies and raise funds for the infrastructural needs. Our District
Collector also contacted several government, public sector units to
seek sponsorship of individual blocks in the hospital campus. We
were heartened by the support of agencies like GAIL, Lions Club,
Manaseva Trust and others. Our personal acquaintances and
networking also facilitated the receipt of funds for further
development.
IK: What indicators in the hospital showed major improvements
after the implementation of NABH standards?
BKV: The most important indicators of improvement in healthcare
delivery were found to be in the infection control practices of the
hospital. We monitored parameters like needlestick injuries to keep a
watch on the safety methods in use. The average length of a patient’s
stay decreased; conversely, there was an increase in patient
satisfaction levels. Bed occupancy rates increased and resulted in an
increase in turnover.
IK: Quality is ultimately to serve the customer. What has been the
reaction of patients from Ernakulum to the improvement made?
BKV: We have implemented several programs to make our hospital
patient friendly. Project ‘Hunger Free’ was conceptualized to ensure
that all food made available to patients and their relatives would be
free of cost. Auxiliary services such as X-ray and CT scans are being
provided at subsided rates. Several patients were interviewed with
regard to our hospital services, and response was gratifying. One of
our patients once quote, ‘Receiving private hospital like-care at a
governmental hospital for subsidized rates is extraordinary!’
IK: In your opinion, what measures must be instituted to ensure the
success of NABH accreditation?
BKV: To catalyse quality improvement in the healthcare delivery
system of India, QCI (Quality Council of India) along with the NRHM
should take to promoting the accreditation of hospitals and provide
adequate support. Though hospitals as well as the government
knows that implementing quality is a costly affair, in the long run, it
proves quite rewarding.
IK: The accreditation journey for the hospital took two long years to
reach its conclusion. What motivated you to stay relentless in your
effort?
BKV: One is only as successful as the team behind you wants you to
be. I had the good fortune of having built a good rapport with my
hospital team even before NABH came into the picture. My Core
Team consisted of people who were willing to strive for even 24 hours
straight, when required for the quality effort. Another factor was the
relentless support extended by NRHM along with the 5-day NABH
training program, where we learned about the process of
accreditation. Never taking ‘no’ for an answer, we worked our way
through.
IK: What message would you give other government hospitals in
the country trying to achieve NABH accreditation?
BKV: The key to a successful shot at NABH is to plan the approach in
advance. A vital factor is the Core Team that must consist of 3-5
committed members, willing to work long hours. Identification of the
gaps and their categorization according to importance is
instrumental. The correct personnel must administer the quality
assignments. They must be proficient in the assigned area to achieve
the desired results. Perseverance is the key!
The interviewee is a proud recipient of Vocational Excellence Award
from Rotary Club, Women Achiever Award from Sakhi and Best
Hospital Award from Indian Red Cross Society. She may be reached at
To be or not to be — Accredited
Manager – NRHM, on her journey to facilitate the NABH accreditation of General Hospital, Ernakulum.Isha Khanolkar, Asst. Manager Operations – Hosmac, interviews Dr. Beena K.V., District Program
Before
After
Dr. Beena receiving NABH accreditation from QCI
19 20
India is enjoying rapid growth and benefits from a young population.
Its middle class is growing rapidly but 70 percent of the population is
still rural, often very poor, and handicapped by poor health and
health services, and low literacy rates. Although the type of risks
faced by the poor such as that of death, illness, injury and accident
are no different from those faced by others, they are more vulnerable
to such risks because of their economic circumstance. According to a
World Bank study (Peters et al. 2002), about one-fourth of
hospitalized Indians fall below the poverty line because of their stay
in hospitals. The same study reports that more than 40 percent of
hospitalized patients take loans or sell assets to pay for
hospitalization.
Microinsurance, when appropriately designed alongside client
education, can offer poor families valuable protection against these
adverse circumstances. It is the protection of low-income
households against specific perils in exchange for premium
payments proportionate to the likelihood and cost of the risk
involved. It is specifically designed for the protection of low-income
people with affordable insurance products to help them cope with
and recover from common risk.
The Need for Microinsurance
A key strategy for enhancing economic development and alleviating
poverty is to make financial systems more inclusive, for example by
improving access to savings and credit services for un-served and
under-served markets. In part, poverty stems from the fact that low-
income households and markets do not have the same opportunities
to finance investments, accumulate capital or protect assets
(including human assets).
In principle, microinsurance works like any typical insurance
business. However, several things differentiate it from normal
insurance. First, group insurance can cover thousands of customers
under one contract. Second, microinsurance requires an
intermediary between the customer and the insurance company.
Preferably, this intermediary is a non-governmental organization
(NGO) or microfinance institution, for example a rural bank that can
handle the whole distribution and most of the administration
process. The few differences between traditional insurance and
microinsurance are in the table, as follows:
A Bird's-Eye View of Microinsurance
T i n y d r o p s f i l l a n o c e a n – a c o n c e p t t h a t w e c o u l d apply to healthcare, claims Dr. Rahul Garde.
Microinsurance Products in India
Although microinsurance seems to have become the buzzword lately,
it has been practiced in India for quite some time now, even before
the IRDA’s Microinsurance Regulations came about in 2005. These
programmes generally offered primary healthcare services delivered
by NGOs and other similar natured charitable trusts in a localized
geographical area or community. A few such examples are given
below:
Action for Community Organization, Rehabilitation and
Development (ACCORD)
ACCORD has been working among the tribal communities
at Gudalur, a small town, at the area of Nilgiris (bordering
Kerala and Karnataka) in Tamil Nadu. The programme set
up a hospital in 1990 and initiated a ‘composite social
insurance package’ in partnership with an insurance
company. The monthly premium is INR 60 for a family of
five, and it covers the risk of damage to their hut and
belongings (up to INR 1,500), death and permanent
disability of the head of family (INR 3,000), and all illnesses
requiring hospitalisation (up to INR 1,500). This ‘composite
social insurance package’ received an encouraging
response from the tribals but it encounters problems in
collecting regular contributions and in insurance renewals.
It has been suggested that linking up the insurance
programme to the credit fund may ensure regular
collection of premiums.
Association for Sarva Seva Farms (ASSEFA), Hyderabad
It is based in Tamil Nadu and Andhra Pradesh and is working
in five other states. The organization encourages the
formation of people's associations and is running various
development programmes through them. In Hyderabad,
ASSEFA has started a life insurance scheme that covers
natural and accidental death and suicide of the insured
member against an annual premium rate of INR 10 for each
family. The death benefits are a fixed rate of INR 3,000 per
case.
Co-operative Development Foundation (CDF)
CDF was formed in 1982, by an association of primary
agricultural cooperatives in Andhra Pradesh. As part of its
cooperative development work, CDF promotes and
supports thrift cooperatives in the districts of Warangal
and Karimnagar (both are in the state of Andhra Pradesh),
which offer savings and credit services to their members.
By paying an entrance fee of INR 10 and a deposit of
minimum INR 50 along with an application form, a member
or an employee of a thrift cooperative may join the
A Bird's-Eye View of MicroinsuranceTiny drops fill an ocean – a concept that we could apply to healthcare,claims Dr. Rahul Garde.
MAJOR PLAYERS IN MICROINSURANCE
§ Life Insurance Corporation of India (LIC) § ICICI Prudential Life Insurance Company Ltd. § Birla Sun Life Insurance Company Ltd. § Tata AIG Life Insurance Company Ltd.
§ SBI Life Insurance Company Limited § ING Vysya Life Insurance Company Private Limited
§ Allianz Bajaj Life Insurance Company Ltd.
§ Metlife India Insurance Company Pvt. Ltd. § Aviva Life Insurance Company India Limited
§ Sahara India life insurance § Shriram life insurance company
§ IDBI Fortis Life Insurance Company Ltd.
§ DLF Pramerica Life Insurance Co. Ltd.
§ Star Union Dai-ichi Life Insurance Co. Ltd.
Table 1. Comparison between Traditional and Micro-Insurance Schemes
Basis Traditional Insurance Microinsurance
Clients Low risk environment
Established insurance culture
High risk exposure/ high vulnerability
Weak insurance culture
Distribution model Sold by licensed intermediaries or by insurance
companies directly to wealthy clients or
companies that understand insurance
Sold by nontraditional
intermediaries to clients
with little experience of insurance
Policies Complex policy documents with many exclusions Simple language
Few, if any exclusion
Group policies
Premium calculation
Good statistical data
Pricing based on Individual risk
Little historical data
Group pricing
Very price sensitive market
Premium collection
Monthly/quarterly/semi or
annually collection
Frequent or irregular payment adapted to
volatile cash flow of clients
Often linked with other transaction
(e.g. loan repayment
Control of insurance risk(adverse selection, moral hazards, frauds)
Limited eligibility
Significant documentation required
Screening such as medical test is required
Broad eligibility
Limited but effective control
Insurance risk included in premium rather than
exclusion
Linked to other service (like credit)
Claims handling Complicated process
Extensive verification documentation
Simple and fast procedure of small firms
Efficient fraud control
21 22
India is enjoying rapid growth and benefits from a young population.
Its middle class is growing rapidly but 70 percent of the population is
still rural, often very poor, and handicapped by poor health and
health services, and low literacy rates. Although the type of risks
faced by the poor such as that of death, illness, injury and accident
are no different from those faced by others, they are more vulnerable
to such risks because of their economic circumstance. According to a
World Bank study (Peters et al. 2002), about one-fourth of
hospitalized Indians fall below the poverty line because of their stay
in hospitals. The same study reports that more than 40 percent of
hospitalized patients take loans or sell assets to pay for
hospitalization.
Microinsurance, when appropriately designed alongside client
education, can offer poor families valuable protection against these
adverse circumstances. It is the protection of low-income
households against specific perils in exchange for premium
payments proportionate to the likelihood and cost of the risk
involved. It is specifically designed for the protection of low-income
people with affordable insurance products to help them cope with
and recover from common risk.
The Need for Microinsurance
A key strategy for enhancing economic development and alleviating
poverty is to make financial systems more inclusive, for example by
improving access to savings and credit services for un-served and
under-served markets. In part, poverty stems from the fact that low-
income households and markets do not have the same opportunities
to finance investments, accumulate capital or protect assets
(including human assets).
In principle, microinsurance works like any typical insurance
business. However, several things differentiate it from normal
insurance. First, group insurance can cover thousands of customers
under one contract. Second, microinsurance requires an
intermediary between the customer and the insurance company.
Preferably, this intermediary is a non-governmental organization
(NGO) or microfinance institution, for example a rural bank that can
handle the whole distribution and most of the administration
process. The few differences between traditional insurance and
microinsurance are in the table, as follows:
A Bird's-Eye View of Microinsurance
T i n y d r o p s f i l l a n o c e a n – a c o n c e p t t h a t w e c o u l d apply to healthcare, claims Dr. Rahul Garde.
Microinsurance Products in India
Although microinsurance seems to have become the buzzword lately,
it has been practiced in India for quite some time now, even before
the IRDA’s Microinsurance Regulations came about in 2005. These
programmes generally offered primary healthcare services delivered
by NGOs and other similar natured charitable trusts in a localized
geographical area or community. A few such examples are given
below:
Action for Community Organization, Rehabilitation and
Development (ACCORD)
ACCORD has been working among the tribal communities
at Gudalur, a small town, at the area of Nilgiris (bordering
Kerala and Karnataka) in Tamil Nadu. The programme set
up a hospital in 1990 and initiated a ‘composite social
insurance package’ in partnership with an insurance
company. The monthly premium is INR 60 for a family of
five, and it covers the risk of damage to their hut and
belongings (up to INR 1,500), death and permanent
disability of the head of family (INR 3,000), and all illnesses
requiring hospitalisation (up to INR 1,500). This ‘composite
social insurance package’ received an encouraging
response from the tribals but it encounters problems in
collecting regular contributions and in insurance renewals.
It has been suggested that linking up the insurance
programme to the credit fund may ensure regular
collection of premiums.
Association for Sarva Seva Farms (ASSEFA), Hyderabad
It is based in Tamil Nadu and Andhra Pradesh and is working
in five other states. The organization encourages the
formation of people's associations and is running various
development programmes through them. In Hyderabad,
ASSEFA has started a life insurance scheme that covers
natural and accidental death and suicide of the insured
member against an annual premium rate of INR 10 for each
family. The death benefits are a fixed rate of INR 3,000 per
case.
Co-operative Development Foundation (CDF)
CDF was formed in 1982, by an association of primary
agricultural cooperatives in Andhra Pradesh. As part of its
cooperative development work, CDF promotes and
supports thrift cooperatives in the districts of Warangal
and Karimnagar (both are in the state of Andhra Pradesh),
which offer savings and credit services to their members.
By paying an entrance fee of INR 10 and a deposit of
minimum INR 50 along with an application form, a member
or an employee of a thrift cooperative may join the
A Bird's-Eye View of MicroinsuranceTiny drops fill an ocean – a concept that we could apply to healthcare,claims Dr. Rahul Garde.
MAJOR PLAYERS IN MICROINSURANCE
§ Life Insurance Corporation of India (LIC) § ICICI Prudential Life Insurance Company Ltd. § Birla Sun Life Insurance Company Ltd. § Tata AIG Life Insurance Company Ltd.
§ SBI Life Insurance Company Limited § ING Vysya Life Insurance Company Private Limited
§ Allianz Bajaj Life Insurance Company Ltd.
§ Metlife India Insurance Company Pvt. Ltd. § Aviva Life Insurance Company India Limited
§ Sahara India life insurance § Shriram life insurance company
§ IDBI Fortis Life Insurance Company Ltd.
§ DLF Pramerica Life Insurance Co. Ltd.
§ Star Union Dai-ichi Life Insurance Co. Ltd.
Table 1. Comparison between Traditional and Micro-Insurance Schemes
Basis Traditional Insurance Microinsurance
Clients Low risk environment
Established insurance culture
High risk exposure/ high vulnerability
Weak insurance culture
Distribution model Sold by licensed intermediaries or by insurance
companies directly to wealthy clients or
companies that understand insurance
Sold by nontraditional
intermediaries to clients
with little experience of insurance
Policies Complex policy documents with many exclusions Simple language
Few, if any exclusion
Group policies
Premium calculation
Good statistical data
Pricing based on Individual risk
Little historical data
Group pricing
Very price sensitive market
Premium collection
Monthly/quarterly/semi or
annually collection
Frequent or irregular payment adapted to
volatile cash flow of clients
Often linked with other transaction
(e.g. loan repayment
Control of insurance risk(adverse selection, moral hazards, frauds)
Limited eligibility
Significant documentation required
Screening such as medical test is required
Broad eligibility
Limited but effective control
Insurance risk included in premium rather than
exclusion
Linked to other service (like credit)
Claims handling Complicated process
Extensive verification documentation
Simple and fast procedure of small firms
Efficient fraud control
21 22
scheme. A member can then make further deposits in
multiples of INR 50. The scheme covers the risk of death
(natural or accidental, up to 60 years old). The debt relief
benefits range from 5 to 20 times the deposits, depending
on the age of the member. The maximum debt relief
benefit payment is INR 10,000.
Integrated Social Security Scheme of SEWA
The Self-Employed Women's Association (SEWA) is a union
of self-employed, low-income women working in the
Indian state of Gujarat. SEWA started as a self-help
movement looking after the rights of women in the
informal sector and it gradually developed new services
such as money lending, education and childcare. In 1992,
SEWA introduced an ‘Integrated Social Security Scheme’
that covers several areas including health insurance. This
social security system is the largest system in India based on
members’ contributions. It has more than 30,000 members
now.
After the advent of the IRDA’s regulations, the microinsurance
market now offers a variety of products that offer a varied range of
insurance services. Some of the current ones are:
Conclusion
Providing healthcare in a developing country like ours is a daunting
task. The products and services are limited and expensive, the
quality is bad, the personnel are under-motivated and there seems
to be a perpetual shortage of staff and supply of affordable
medicines. On top of that, patients are dropping out of the system. To
put it briefly, the overwhelming majority of people in our country are
suffering from the lack of a social protection net. Microinsurance
institutions are being set up in India in response to this ailing
healthcare situation. Some of these institutions are very large, yet
others count their members in the hundreds. These organisations
knit together the local population and make sure that inhabitants
cover themselves against the risk of illness. Micro-insurance
institutions do more than simply pool the financial resources of local
people; they interact with medical personnel or in some cases,
themselves provide medical personnel to improve the quality of the
services provided and give their members advice and information to
create awareness about these options and help them derive the
‘financial’ benefits of good health.
The author is currently working as a Consultant with Hosmac
Consulting Services for the past year and has an overall work
experience of 5 years in the healthcare industry in India in both Public
and Private sectors. He can be reached at
IRDA (MICROINSURANCE) REGULATIONS, 2005
Regulations on micro insurance were officially
gazette by the IRDA on 30 November 2005.
Amongst other things it def ines the micro insurance
·
‘General micro insurance product’
means any
health insurance contract, any contract covering
the belongings, such as, hut, livestock or tools or
instruments or any personal accident contract,
either on individual or gr oup basis, as per terms
stated in Schedule-I appended to these
regulations.
·
‘Life micro insurance product’
means any term
insurance contract with or without return of
premium, and endowment insurance contract or
health insurance contract, with our without
an
accident benefit rider, either on individual or
group basis, as per terms stated in Schedule-II
appended to these regulations.
·
Intermediaries -
for selling and servicing various
micro-insurance products. The regulation also
creates a new intermediary called the micro -
insurance agent. The regulation clearly defines MI
agents and has imposed minima in terms of the
number of years of experience (at least 3) of
working with low income groups.
·
Micro-Finance Institutions (MFI)
means any
institution or entity or association registered
under any law for the registration of societies or
co-operative societies, as the case may be, inter
alia, for sanctioning loan/finance to its members.
products as:
-
Table 2. Few of the Microinsurance schemes available in the market
Name of Insurer
1. AVIVA Life Ins. Co. India Pvt. Ltd. Grameen Suraksha
Name of the Product
2. Bajaj Allianz Life Insurance Co. Ltd Bajaj Allianz Jana Vikas Yojana
Bajaj Allianz Saral Suraksha Yojana
Bajaj Allianz Alp Nivesh Yojana
3. Birla Sun Life Insurance Co. Ltd. Birla Sun Life Insurance Bima Suraksha Super
Birla Sun Life Insurance Bima Dhan Sanchay
4. DLF Pramerica Life Insurance Co. Ltd DLF Pramerica Sarv Suraksha
5. ICICI Prudential Life Insurance Co. Ltd ICICI Pru Sarv Jana Suraksha
6. IDBI Fortis Life Insurance Co. Ltd. IDBI Fortis Group Microsurance Plan
7. ING Vysya Life Insurance Co. Ltd. ING Vysya Saral Suraksha
8. Life Insurance Corporation of India LIC's Jeevan Madhur
LIC's Jeevan Mangal
9. Met Life India Met Vishwas
10. Sahara India Life Insurance Co. Ltd. Sahara Sahayog (Micro Endowment Insurance
without profit plan)
11. SBI Life Insurance Co. Ltd. SBI Life Grameen Shakti
SBI Life Grameen Super Suraksha
12. Shriram Life Insurance Co. Ltd. Shri Sahay
Sri Sahay (AP)
13. Star Union Dai-ichi Life Insurance Co SUD Life Paraspar Suraksha Plan
14. TATA AIG Life Insurance Co. Ltd. Ayushman Yojana
Navkalyan Yojana
Sampoorn Bima Yojana
Tata AIG Sumangal Bima Yojana
23 24
scheme. A member can then make further deposits in
multiples of INR 50. The scheme covers the risk of death
(natural or accidental, up to 60 years old). The debt relief
benefits range from 5 to 20 times the deposits, depending
on the age of the member. The maximum debt relief
benefit payment is INR 10,000.
Integrated Social Security Scheme of SEWA
The Self-Employed Women's Association (SEWA) is a union
of self-employed, low-income women working in the
Indian state of Gujarat. SEWA started as a self-help
movement looking after the rights of women in the
informal sector and it gradually developed new services
such as money lending, education and childcare. In 1992,
SEWA introduced an ‘Integrated Social Security Scheme’
that covers several areas including health insurance. This
social security system is the largest system in India based on
members’ contributions. It has more than 30,000 members
now.
After the advent of the IRDA’s regulations, the microinsurance
market now offers a variety of products that offer a varied range of
insurance services. Some of the current ones are:
Conclusion
Providing healthcare in a developing country like ours is a daunting
task. The products and services are limited and expensive, the
quality is bad, the personnel are under-motivated and there seems
to be a perpetual shortage of staff and supply of affordable
medicines. On top of that, patients are dropping out of the system. To
put it briefly, the overwhelming majority of people in our country are
suffering from the lack of a social protection net. Microinsurance
institutions are being set up in India in response to this ailing
healthcare situation. Some of these institutions are very large, yet
others count their members in the hundreds. These organisations
knit together the local population and make sure that inhabitants
cover themselves against the risk of illness. Micro-insurance
institutions do more than simply pool the financial resources of local
people; they interact with medical personnel or in some cases,
themselves provide medical personnel to improve the quality of the
services provided and give their members advice and information to
create awareness about these options and help them derive the
‘financial’ benefits of good health.
The author is currently working as a Consultant with Hosmac
Consulting Services for the past year and has an overall work
experience of 5 years in the healthcare industry in India in both Public
and Private sectors. He can be reached at
IRDA (MICROINSURANCE) REGULATIONS, 2005
Regulations on micro insurance were officially
gazette by the IRDA on 30 November 2005.
Amongst other things it def ines the micro insurance
·
‘General micro insurance product’
means any
health insurance contract, any contract covering
the belongings, such as, hut, livestock or tools or
instruments or any personal accident contract,
either on individual or gr oup basis, as per terms
stated in Schedule-I appended to these
regulations.
·
‘Life micro insurance product’
means any term
insurance contract with or without return of
premium, and endowment insurance contract or
health insurance contract, with our without
an
accident benefit rider, either on individual or
group basis, as per terms stated in Schedule-II
appended to these regulations.
·
Intermediaries -
for selling and servicing various
micro-insurance products. The regulation also
creates a new intermediary called the micro -
insurance agent. The regulation clearly defines MI
agents and has imposed minima in terms of the
number of years of experience (at least 3) of
working with low income groups.
·
Micro-Finance Institutions (MFI)
means any
institution or entity or association registered
under any law for the registration of societies or
co-operative societies, as the case may be, inter
alia, for sanctioning loan/finance to its members.
products as:
-
Table 2. Few of the Microinsurance schemes available in the market
Name of Insurer
1. AVIVA Life Ins. Co. India Pvt. Ltd. Grameen Suraksha
Name of the Product
2. Bajaj Allianz Life Insurance Co. Ltd Bajaj Allianz Jana Vikas Yojana
Bajaj Allianz Saral Suraksha Yojana
Bajaj Allianz Alp Nivesh Yojana
3. Birla Sun Life Insurance Co. Ltd. Birla Sun Life Insurance Bima Suraksha Super
Birla Sun Life Insurance Bima Dhan Sanchay
4. DLF Pramerica Life Insurance Co. Ltd DLF Pramerica Sarv Suraksha
5. ICICI Prudential Life Insurance Co. Ltd ICICI Pru Sarv Jana Suraksha
6. IDBI Fortis Life Insurance Co. Ltd. IDBI Fortis Group Microsurance Plan
7. ING Vysya Life Insurance Co. Ltd. ING Vysya Saral Suraksha
8. Life Insurance Corporation of India LIC's Jeevan Madhur
LIC's Jeevan Mangal
9. Met Life India Met Vishwas
10. Sahara India Life Insurance Co. Ltd. Sahara Sahayog (Micro Endowment Insurance
without profit plan)
11. SBI Life Insurance Co. Ltd. SBI Life Grameen Shakti
SBI Life Grameen Super Suraksha
12. Shriram Life Insurance Co. Ltd. Shri Sahay
Sri Sahay (AP)
13. Star Union Dai-ichi Life Insurance Co SUD Life Paraspar Suraksha Plan
14. TATA AIG Life Insurance Co. Ltd. Ayushman Yojana
Navkalyan Yojana
Sampoorn Bima Yojana
Tata AIG Sumangal Bima Yojana
23 24
providing emergency medical services – for accidents or sudden
serious illness. Mobile high-end emergency medical services at low
or no cost to medically needy victims could save lives and limbs, and
also serve the purpose of charity.
Given the scenario of public hospitals being over burdened and
unable to provide for all, and corporate hospitals providing
seemingly high quality services at costs affordable only to few, and
charitable hospitals becoming unviable, a ‘sustainable charity’
model was created at Godrej Memorial Hospital.
The Model
Fundamentally, the model in effect provides better services at lesser
cost to patients. The system harnesses the strengths of the public
hospitals with the virtues of the competitive corporate system,
amalgamated with the values of a charitable trust.
The approach is overwhelmingly educative rather than
authoritarian, the system works on incentives rather than targets.
‘Charity’ clearly distinguishes between patient ‘needs’ and ‘wants’. It
operates on mutual trust between all the stakeholders. The vision is
supported by policies that are smoothly implemented through well
set processes and procedures, guided by constantly improving forms
and formats. It grows by meeting aspirations of people, namely
patients, medical professionals and hospital employees, thus
enabling them to grow in turn; it offers unlimited opportunities
rather than careers. The system is robust as a business model; it
rejects the less deserving and ejects the unethical, thus keeping itself
lean, mean and clean. It draws further strength from the weaknesses
of public and corporate healthcare systems. These strategic concepts
form the operating base for Godrej Memorial Hospital.
The thrust of healthcare delivery in cities is through the system of
Public, Corporate and Charitable (Trust) Hospitals — each of which
has its strengths and weaknesses. The primary stakeholders in all the
systems include the community of patients, medical professionals,
especially, senior consultant doctors, hospital employees and, most
importantly, funding agencies such as the government or
corporations, corporate investors and philanthropic donors.
A Public-Private Philanthropic Perspective
The public hospital system provides an excellent front end for
healthcare policy implementation by the state. However, while the
vision and policies are very adequate, implementation perhaps falls
short of expectations. Corporate-style hospitals as well as nursing
homes are largely financial ventures; success or failure is measurable
in terms of profits or losses, and the system is usually target-driven.
Ethics, rationality and transparency are not prominently visible.
Corporate hospitals are often perceived as providing quality at high
cost (five star services at seven star prices).
A renewed sense of charity
Charitable trust hospitals are looked upon as an ideal system for
patients to obtain quality healthcare at an affordable cost. However,
in present times of spiraling costs, the charitable trust system is under
intense pressure to deliver. It is not feasible to provide donations for
setting up as well as meeting costs for running the hospital
indefinitely. Most charitable hospitals today have metamorphosed to
resembling either the public or corporate hospitals. The solution lies
in creating a system of ‘Sustainable Charity’.
Sustainable charity is required to be distinguished from mere charity.
The redefinition in terms of urban needs, for example, could be
Effective Cost TreatmentDr. A.M. Joglekar, CEO - Godrej Memorial Hospital, delineates on how Godrej has overcome the challenge to provide quality service at an affordable cost through better hospital management strategies.
26
providing emergency medical services – for accidents or sudden
serious illness. Mobile high-end emergency medical services at low
or no cost to medically needy victims could save lives and limbs, and
also serve the purpose of charity.
Given the scenario of public hospitals being over burdened and
unable to provide for all, and corporate hospitals providing
seemingly high quality services at costs affordable only to few, and
charitable hospitals becoming unviable, a ‘sustainable charity’
model was created at Godrej Memorial Hospital.
The Model
Fundamentally, the model in effect provides better services at lesser
cost to patients. The system harnesses the strengths of the public
hospitals with the virtues of the competitive corporate system,
amalgamated with the values of a charitable trust.
The approach is overwhelmingly educative rather than
authoritarian, the system works on incentives rather than targets.
‘Charity’ clearly distinguishes between patient ‘needs’ and ‘wants’. It
operates on mutual trust between all the stakeholders. The vision is
supported by policies that are smoothly implemented through well
set processes and procedures, guided by constantly improving forms
and formats. It grows by meeting aspirations of people, namely
patients, medical professionals and hospital employees, thus
enabling them to grow in turn; it offers unlimited opportunities
rather than careers. The system is robust as a business model; it
rejects the less deserving and ejects the unethical, thus keeping itself
lean, mean and clean. It draws further strength from the weaknesses
of public and corporate healthcare systems. These strategic concepts
form the operating base for Godrej Memorial Hospital.
The thrust of healthcare delivery in cities is through the system of
Public, Corporate and Charitable (Trust) Hospitals — each of which
has its strengths and weaknesses. The primary stakeholders in all the
systems include the community of patients, medical professionals,
especially, senior consultant doctors, hospital employees and, most
importantly, funding agencies such as the government or
corporations, corporate investors and philanthropic donors.
A Public-Private Philanthropic Perspective
The public hospital system provides an excellent front end for
healthcare policy implementation by the state. However, while the
vision and policies are very adequate, implementation perhaps falls
short of expectations. Corporate-style hospitals as well as nursing
homes are largely financial ventures; success or failure is measurable
in terms of profits or losses, and the system is usually target-driven.
Ethics, rationality and transparency are not prominently visible.
Corporate hospitals are often perceived as providing quality at high
cost (five star services at seven star prices).
A renewed sense of charity
Charitable trust hospitals are looked upon as an ideal system for
patients to obtain quality healthcare at an affordable cost. However,
in present times of spiraling costs, the charitable trust system is under
intense pressure to deliver. It is not feasible to provide donations for
setting up as well as meeting costs for running the hospital
indefinitely. Most charitable hospitals today have metamorphosed to
resembling either the public or corporate hospitals. The solution lies
in creating a system of ‘Sustainable Charity’.
Sustainable charity is required to be distinguished from mere charity.
The redefinition in terms of urban needs, for example, could be
Effective Cost TreatmentDr. A.M. Joglekar, CEO - Godrej Memorial Hospital, delineates on how Godrej has overcome the challenge to provide quality service at an affordable cost through better hospital management strategies.
26
How do patients benefit?
The hospital's location provides ready accessibility, especially during
medical emergencies. The advanced mobile emergency medical
service is provided free of cost to the community living around the
hospital (around-the-clock). There are no barriers by way of advance
payment for inpatient treatment, greatly facilitating patients,
especially in emergency situations. There is concessional tariff for all,
being 40-60% cheaper in comparison to any other accredited private
hospitals in urban locations. Continuous improvement and
rationality of services offered is driven by patient feedback, and
monitoring of indicators and audits. All this provides quality services
at affordable costs helping a patient centric approach.
The medical professional has much to gain
The hospital provides an opportunity to doctors with excellent
academic records who are in need of a support platform to grow as
professionals. It synergises with good doctors and encourages them
to meet their aspirations. Concessional fees for a high standard of
service make patients flock to GMH doctors, increasing their practice
steadily. Sophisticated instruments and facilities provide a high-
standard, professional environment without any personal monetary
investment. No restriction on respectable places of practice or in-
house competition from full-time employed doctors gives an
accelerated growth prospect. A rational revenue sharing system
based on mutual trust and incentives allows genuinely deserving
doctors to prosper. The freedom to give concessions to needy
patients provides authority, whilst medico-legal support from the
hospital, gives reassurance to good practitioners.
Welfare of employees
The hospital has employed younger age groups and policies are
growth oriented. The employees are groomed and trained but no
special moves are made to retain them if they intend on moving on to
seemingly greener pastures. Those who take more responsibility
automatically get more authority, leading to a better position and
returns. Small, subsidized housing is provided by the Godrej
Memorial trust for helping needy staff. Better education for children
by priority admission at Godrej School with concessional fees,
medical treatment through group insurance, etc. all build up towards
a brighter future for employees and their families.
Making quality happen
At Godrej Memorial Hospital, quality is made-to-happen via a well
planned approach. It is conceptualized, defined, implemented,
monitored, measured, reinforced, and constantly improved. All this
has enabled the hospital to achieve and maintain accreditations such
as NABH and NABL.
The Godrej Memorial Hospital model, in a larger sense, is a direct
private-public partnership and could perhaps be replicated under
the leadership of like minded people in any urban centre.
The author has served Dinanath Mangeshkar Hospital, Pune and
Lilavati Hospital and Research Center, Mumbai after a 25-year long
stint with the defence services. He has been associated with building,
commissioning and operating Godrej Memorial Hospital since 2003.
He may be contacted at [email protected]
Smile Train — An initiative of Godrej Memorial
27 28
How do patients benefit?
The hospital's location provides ready accessibility, especially during
medical emergencies. The advanced mobile emergency medical
service is provided free of cost to the community living around the
hospital (around-the-clock). There are no barriers by way of advance
payment for inpatient treatment, greatly facilitating patients,
especially in emergency situations. There is concessional tariff for all,
being 40-60% cheaper in comparison to any other accredited private
hospitals in urban locations. Continuous improvement and
rationality of services offered is driven by patient feedback, and
monitoring of indicators and audits. All this provides quality services
at affordable costs helping a patient centric approach.
The medical professional has much to gain
The hospital provides an opportunity to doctors with excellent
academic records who are in need of a support platform to grow as
professionals. It synergises with good doctors and encourages them
to meet their aspirations. Concessional fees for a high standard of
service make patients flock to GMH doctors, increasing their practice
steadily. Sophisticated instruments and facilities provide a high-
standard, professional environment without any personal monetary
investment. No restriction on respectable places of practice or in-
house competition from full-time employed doctors gives an
accelerated growth prospect. A rational revenue sharing system
based on mutual trust and incentives allows genuinely deserving
doctors to prosper. The freedom to give concessions to needy
patients provides authority, whilst medico-legal support from the
hospital, gives reassurance to good practitioners.
Welfare of employees
The hospital has employed younger age groups and policies are
growth oriented. The employees are groomed and trained but no
special moves are made to retain them if they intend on moving on to
seemingly greener pastures. Those who take more responsibility
automatically get more authority, leading to a better position and
returns. Small, subsidized housing is provided by the Godrej
Memorial trust for helping needy staff. Better education for children
by priority admission at Godrej School with concessional fees,
medical treatment through group insurance, etc. all build up towards
a brighter future for employees and their families.
Making quality happen
At Godrej Memorial Hospital, quality is made-to-happen via a well
planned approach. It is conceptualized, defined, implemented,
monitored, measured, reinforced, and constantly improved. All this
has enabled the hospital to achieve and maintain accreditations such
as NABH and NABL.
The Godrej Memorial Hospital model, in a larger sense, is a direct
private-public partnership and could perhaps be replicated under
the leadership of like minded people in any urban centre.
The author has served Dinanath Mangeshkar Hospital, Pune and
Lilavati Hospital and Research Center, Mumbai after a 25-year long
stint with the defence services. He has been associated with building,
commissioning and operating Godrej Memorial Hospital since 2003.
He may be contacted at [email protected]
Smile Train — An initiative of Godrej Memorial
27 28
PPP models have now become the new mantra for politicians,
bureaucrats and private entrepreneurs alike. A politician earns
recognition for his social commitments, whereas a private
entrepreneur finds route to express his corporate social responsibility
to the community. Even though PPP models were recently unleashed
as an expedient solution to India's scarce healthcare resources, the
mindset of the politician still does not accommodate PPP as a role
model. Besides, the private entrepreneur is yet to change his
mindset. Therein lays the real challenge in running a PPP healthcare
model.
The ‘battle’ begins right from drafting the MOU for the proposed PPP.
The Goverment and the private player both want to take a ‘win-win’
position at this stage itself. Though on paper, this is a partnership in
the interest of the community, it is an entirely different picture in
reality. The bureaucrats drafting the MOU have to keep their political
godfathers happy and hence their objective is to see that maximum
mileage is in favor of their political bosses. Though the constitution
gives bureaucracy an independent stature, in reality, the political
wing drives the real agenda. Hence, PPP is more of a tool for the
politician to gain popularity and, thereby, more votes in the next
election. For the private entrepreneur, PPP is a shortcut to enter new
markets at a very minimal cost or, in some cases, enter an absolutely
virgin market where he has no foothold. With profit as the primary
objective for a private entrepreneur, it becomes difficult for him to
grasp the ‘public interest’ of a PPP model.
In view of the above, drafting an MOU becomes almost a battle
wherein both parties try their level best to gain an upper hand. The
classic example is the politician trying to get maximum number of
free beds for the community and the private entrepreneur trying his
maximum to reduce this number. Generally such MOUs have the
following features:
· About 10-15% of total no. of beds are reserved for poor
patients at no charge
· Cost of diagnostics and investigations available at the
hospital for free or at concessional rates; for diagnostics
and investigations sent outside the hospital, special rates
be negotiated for
· Cost of drugs, medicines and consumables either free or at
concessional rates
· Similarly, implants, stents, ambulance service, food etc. at
free or concessional rates
Since both parties want to extract maximum mileage form the MOU,
a lot of negotiation takes place on the issue of free and concessional
rates. Generally, the acceptable tariff is the one that is charged at the
Government or municipal hospitals for all investigations, diagnostics,
drugs and consumables. However, since most Government hospitals
also order many drugs and implants from outside, this issue becomes
a bone of contention with the bureaucrats asking for concessional
rates and the private entrepreneur asking for the MRP. More often
than not, a fair amount of discount is passed out on all such drugs,
consumables, implants etc. to close the issue.
In due course, when the MOU is drafted, the logistics have to be
structured. For this, a committee is appointed jointly by both sides to
oversee the implementation of the project as well as its operation.
Predominantly, the public body is represented by a bureaucrat and a
few elected representatives, whereas the private entrepreneur by
the hospital CEO and other hospital managers such as the finance
manager and PPP coordinator. But friction is encountered when the
numbers are equal on both sides. Subjects in discussion arrive at an
even number of votes from either side launching the issues up in the
air. Whereas, sometimes carried forward without a final decision but
not without kickbacks.
Gradually, as the MOU is drafted, the challenge is to get it endorsed
by the general body of the elected representative. Since PPP is
mooted by the ruling party, the opposition picks up loopholes in the
draft MOU. Ergo, a lot of political maneuvering is required to get it
passed.
Furthermore, since today’s opposition can become tomorrow's
ruling party, utmost care has to be taken to be affable with all political
parties, which in itself, is a mammoth task since the opposition
parties see you as a friend of the ruling party. To make their
opposition public, the press and electronic media are fed, sometimes
controversial, stories about the PPP by the opposition party. This calls
for preemptive good relations with the press and media. The help of a
good PR agency should be sought to keep the press and electronic
media on the side of the PPP.
Care should be taken that our approach is transparent, and all clauses
of the draft MOU are put across factually and with proper reasoning
to them, so that unnecessary ammunition is not provided to the
press. This again becomes a difficult task because certain sections of
the press and media are actually owned by opposition parties.
Once the actual MOU is passed by the General Body, it has also to be
endorsed by the standing committee of the elected representatives
which goes into the final details for the agreement. Here too a lot of
political maneuvering is required and a good PR agency would
definitely help the purpose. If need be, local political bigwigs should
also be approached to ensure smooth sailing through the Standing
Committee. Once across, the final agreement is drafted by the Head
of the bureaucracy, in consultation with the legal department of the
public body. Here too a lot of back end maneuvering is required with
the concerned HoDs e.g. Engineering Department, Health
Department, Legal Department etc.
At the project stage, the necessary permissions have to be taken from
the public body so that there are no hiccups during the completion of
the project. The agencies that are to be chased are the Development
Plan Officer, City Engineering Office, Health Department, Fire
Department and the Commissioner’s Office. Nearing completion,
the other departments such as the Assessor and Collection
Department for Property Tax and the Ward Office for local issues
must be followed up with.
Once the hospital starts operations, the bigger challenge is the SOPs
that are formulated for the referral patients. The SOP should clearly
mention the process flow, eligibility of patients, the signatory for
reference, documents to be carried by patients, reference for
particular specialty etc.
In many cases, the elected representative refers the patients straight
to the PPP on their respective letterheads without any endorsement
or signature from the public body authorized signatory. This is very
common as the elected representative feels it his right to refer
patients to PPP directly as s/he considers the PPP as his/her ‘own’
hospital. The most important aspect is the tariff that has to be clearly
defined in the HMIS master; this has to be signed by both parties.
Since tariff is concessional for diagnostics, drugs, consumables etc., a
daily interim bill must be issued to the referral patients; the entire
hospital stay would otherwise be considered free by them. To steer
clear of such situations, the most prudent step would be to counsel
patients before admission and clearly define the charges, albeit at
concessional rates. Though this practice is followed, patients
principally demand free services and often refuse to pay even the
concessional rates. To add to this, elected representatives
sometimes ‘advocate’ the case of the patient by writing off these
charges. The ‘advocate’ may even go to the extent of using violent
and undemocratic means to force their point of view on hospital
management.
The challenges of a PPP further extend to the references by all and
sundry of the public body asking for heavy discounts for patients who
don’t even fall under the category of poor patients. Thus, besides the
officially referred patients that are given discounts and free
treatment, a big chunk of ‘non-eligible patients’ are also given
discounted rates, thereby hitting the profit of the hospital from the
business entrepreneur’s point of view. The entrepreneurs, in spite of
all these difficulties, want to ‘break even’ at the earliest; almost in the
same time frame as any other non-PPP hospital, which is a big
challenge for the Hospital Administrator. The job of the hospital
administrator is literally a tight rope walk — trying to balance the
demands of the public representatives, opposition parties and
bureaucrats on one hand and his employer on the other. Needless to
mention, many PPP projects are frequently in the public news for
reasons beyond the control of hospital administration.
For a PPP to pay off, the private entrepreneur must ideally view it as a
true CSR activity, and the elected representatives must not demand
unrealistic deliverables from the undertaking. If a pragmatic sense is
adopted by India’s public and private players, PPPs can assuredly be
an answer to enhance and evolve our pre-eminent healthcare sector.
The author has over 24 years of healthcare experience in Hospitals &
Health Systems management. He is recipient to several awards and
has published several papers on healthcare. He is also a guide and
faculty member at several esteemed healthcare institutions. He may
be reached at . [email protected]
PPP: Is it really the Solution?PPPs have been regarded as the way out for the healthcare delivery system in India but there's more to it, Dr. Rajiv Boudhankar, Vice President – Kohinoor Hospital, sheds light.
29 30
PPP models have now become the new mantra for politicians,
bureaucrats and private entrepreneurs alike. A politician earns
recognition for his social commitments, whereas a private
entrepreneur finds route to express his corporate social responsibility
to the community. Even though PPP models were recently unleashed
as an expedient solution to India's scarce healthcare resources, the
mindset of the politician still does not accommodate PPP as a role
model. Besides, the private entrepreneur is yet to change his
mindset. Therein lays the real challenge in running a PPP healthcare
model.
The ‘battle’ begins right from drafting the MOU for the proposed PPP.
The Goverment and the private player both want to take a ‘win-win’
position at this stage itself. Though on paper, this is a partnership in
the interest of the community, it is an entirely different picture in
reality. The bureaucrats drafting the MOU have to keep their political
godfathers happy and hence their objective is to see that maximum
mileage is in favor of their political bosses. Though the constitution
gives bureaucracy an independent stature, in reality, the political
wing drives the real agenda. Hence, PPP is more of a tool for the
politician to gain popularity and, thereby, more votes in the next
election. For the private entrepreneur, PPP is a shortcut to enter new
markets at a very minimal cost or, in some cases, enter an absolutely
virgin market where he has no foothold. With profit as the primary
objective for a private entrepreneur, it becomes difficult for him to
grasp the ‘public interest’ of a PPP model.
In view of the above, drafting an MOU becomes almost a battle
wherein both parties try their level best to gain an upper hand. The
classic example is the politician trying to get maximum number of
free beds for the community and the private entrepreneur trying his
maximum to reduce this number. Generally such MOUs have the
following features:
· About 10-15% of total no. of beds are reserved for poor
patients at no charge
· Cost of diagnostics and investigations available at the
hospital for free or at concessional rates; for diagnostics
and investigations sent outside the hospital, special rates
be negotiated for
· Cost of drugs, medicines and consumables either free or at
concessional rates
· Similarly, implants, stents, ambulance service, food etc. at
free or concessional rates
Since both parties want to extract maximum mileage form the MOU,
a lot of negotiation takes place on the issue of free and concessional
rates. Generally, the acceptable tariff is the one that is charged at the
Government or municipal hospitals for all investigations, diagnostics,
drugs and consumables. However, since most Government hospitals
also order many drugs and implants from outside, this issue becomes
a bone of contention with the bureaucrats asking for concessional
rates and the private entrepreneur asking for the MRP. More often
than not, a fair amount of discount is passed out on all such drugs,
consumables, implants etc. to close the issue.
In due course, when the MOU is drafted, the logistics have to be
structured. For this, a committee is appointed jointly by both sides to
oversee the implementation of the project as well as its operation.
Predominantly, the public body is represented by a bureaucrat and a
few elected representatives, whereas the private entrepreneur by
the hospital CEO and other hospital managers such as the finance
manager and PPP coordinator. But friction is encountered when the
numbers are equal on both sides. Subjects in discussion arrive at an
even number of votes from either side launching the issues up in the
air. Whereas, sometimes carried forward without a final decision but
not without kickbacks.
Gradually, as the MOU is drafted, the challenge is to get it endorsed
by the general body of the elected representative. Since PPP is
mooted by the ruling party, the opposition picks up loopholes in the
draft MOU. Ergo, a lot of political maneuvering is required to get it
passed.
Furthermore, since today’s opposition can become tomorrow's
ruling party, utmost care has to be taken to be affable with all political
parties, which in itself, is a mammoth task since the opposition
parties see you as a friend of the ruling party. To make their
opposition public, the press and electronic media are fed, sometimes
controversial, stories about the PPP by the opposition party. This calls
for preemptive good relations with the press and media. The help of a
good PR agency should be sought to keep the press and electronic
media on the side of the PPP.
Care should be taken that our approach is transparent, and all clauses
of the draft MOU are put across factually and with proper reasoning
to them, so that unnecessary ammunition is not provided to the
press. This again becomes a difficult task because certain sections of
the press and media are actually owned by opposition parties.
Once the actual MOU is passed by the General Body, it has also to be
endorsed by the standing committee of the elected representatives
which goes into the final details for the agreement. Here too a lot of
political maneuvering is required and a good PR agency would
definitely help the purpose. If need be, local political bigwigs should
also be approached to ensure smooth sailing through the Standing
Committee. Once across, the final agreement is drafted by the Head
of the bureaucracy, in consultation with the legal department of the
public body. Here too a lot of back end maneuvering is required with
the concerned HoDs e.g. Engineering Department, Health
Department, Legal Department etc.
At the project stage, the necessary permissions have to be taken from
the public body so that there are no hiccups during the completion of
the project. The agencies that are to be chased are the Development
Plan Officer, City Engineering Office, Health Department, Fire
Department and the Commissioner’s Office. Nearing completion,
the other departments such as the Assessor and Collection
Department for Property Tax and the Ward Office for local issues
must be followed up with.
Once the hospital starts operations, the bigger challenge is the SOPs
that are formulated for the referral patients. The SOP should clearly
mention the process flow, eligibility of patients, the signatory for
reference, documents to be carried by patients, reference for
particular specialty etc.
In many cases, the elected representative refers the patients straight
to the PPP on their respective letterheads without any endorsement
or signature from the public body authorized signatory. This is very
common as the elected representative feels it his right to refer
patients to PPP directly as s/he considers the PPP as his/her ‘own’
hospital. The most important aspect is the tariff that has to be clearly
defined in the HMIS master; this has to be signed by both parties.
Since tariff is concessional for diagnostics, drugs, consumables etc., a
daily interim bill must be issued to the referral patients; the entire
hospital stay would otherwise be considered free by them. To steer
clear of such situations, the most prudent step would be to counsel
patients before admission and clearly define the charges, albeit at
concessional rates. Though this practice is followed, patients
principally demand free services and often refuse to pay even the
concessional rates. To add to this, elected representatives
sometimes ‘advocate’ the case of the patient by writing off these
charges. The ‘advocate’ may even go to the extent of using violent
and undemocratic means to force their point of view on hospital
management.
The challenges of a PPP further extend to the references by all and
sundry of the public body asking for heavy discounts for patients who
don’t even fall under the category of poor patients. Thus, besides the
officially referred patients that are given discounts and free
treatment, a big chunk of ‘non-eligible patients’ are also given
discounted rates, thereby hitting the profit of the hospital from the
business entrepreneur’s point of view. The entrepreneurs, in spite of
all these difficulties, want to ‘break even’ at the earliest; almost in the
same time frame as any other non-PPP hospital, which is a big
challenge for the Hospital Administrator. The job of the hospital
administrator is literally a tight rope walk — trying to balance the
demands of the public representatives, opposition parties and
bureaucrats on one hand and his employer on the other. Needless to
mention, many PPP projects are frequently in the public news for
reasons beyond the control of hospital administration.
For a PPP to pay off, the private entrepreneur must ideally view it as a
true CSR activity, and the elected representatives must not demand
unrealistic deliverables from the undertaking. If a pragmatic sense is
adopted by India’s public and private players, PPPs can assuredly be
an answer to enhance and evolve our pre-eminent healthcare sector.
The author has over 24 years of healthcare experience in Hospitals &
Health Systems management. He is recipient to several awards and
has published several papers on healthcare. He is also a guide and
faculty member at several esteemed healthcare institutions. He may
be reached at . [email protected]
PPP: Is it really the Solution?PPPs have been regarded as the way out for the healthcare delivery system in India but there's more to it, Dr. Rajiv Boudhankar, Vice President – Kohinoor Hospital, sheds light.
29 30
Some years ago, the WHO’s polio vaccine drive to dispense a critical
multi-state polio vaccination in India faced a particularly vexing
challenge: Muslim religious leaders in two states prohibited the
faithful from administering their infants with the polio vaccine
because, as they had told the trusting folk, the polio vaccine was ‘an
evil plot by the West to destroy the reproductive system of their
infants from developing correctly, and prevent them from having
children when they grow up’.
Fortunately, we were in close contact with Indian film star Aamir
Khan, being as we were in the middle of the giant ‘Thanda Matlab
Coca-Cola’ campaign. Aamir instantly agreed to help, gratis, with
anything and everything we could do to encourage these parents to
have their infants vaccinated. With reference to his suggestions, we
developed a campaign to respond to this bizarre challenge; to
encourage people to visit the medical camps and assure them that
the vaccine had no ‘side effects’ to fear.
However, a strategic decision was taken: while Aamir’s beaming,
welcoming, reassuring face appeared on each and every
communication, the perverse issue that had stymied the program
was ignored completely. Aamir’s fabulous star power was pressed
into play, and it worked like a charm. Thousands of Indians flocked to
the camps, they arrived grinning at the Aamir overdose all around
them, whooping and laughing, they took pictures next to the giant
Aamir cutouts dotted all over the camp, and had their babies
confidently vaccinated.
It is an interesting episode to relate to in the challenge of caring for
Indians who have been marginalised in India’s Great Leap Forward.
And it is an interesting learning we can bring to bear in solving what is
not just one of the most pressing needs of the country, but one of the
most promising growth segments for the many providers of India’s
infrastructure.
And one of the most important dynamics in this emerging new sector
is health. In fact, India’s health universe, central to powering and
sustaining India’s leap into the fraternity of first world nations, needs
to be communicated, understood and appreciated accurately by all
its constituencies.
At the top end, the knowing constituencies need no persuasion:
seeped in market and profit realities, they can easily see the road
ahead. The challenge here lies in convincing market-oriented
businesses and organisations to commit to setting up health facilities
in places where the profit margin is not so high, or the initial set-up
financing and revenue possibility is linked to the capriciousness of
Just What the Future Ordered financing from the government.
Private pharmaceutical companies have shown initiative in this area.
Recognising the very long term potential of providing diagnostic,
preventive and medical services to the poorest of the poor, they have
long since begun a variety of imaginative and effective exercises in
reaching out to impoverished Indians in benighted internal areas,
thus laying the foundations of good health. From the openly visible
population control exercises by NGOs to a variety of programs that
deal with women’s issues, vision problems, TB and diarrhoea, good
nutrition and vaccination exercises, companies are deploying armies
of doctors, medical workers, and organising camps… all ensuring that
a fresh wave of ‘inclusive’ medical possibility touches the lives of
Indians who would otherwise have no hope for it.
Herein lays another challenge: communication. This kind of
communication has proven to present some of the most unique
challenges and each campaign results in fresh learnings that must be
shared.
The most important thing to remember is that any communication
faces ‘competition’ from erroneous beliefs, erroneous practices, and
insecure village doctors. Indeed, as in the WHO’s case, it was the
religious authorities that presented the problem. As in the case of all
such groups, their yen for exercising their power, however
capriciously, and their need to show and feel that they still wield
some clout, all play a part.
One learning is, paradoxically, to present an overwhelming
distraction to a false issue. As with Aamir Khan, the positive
assurance of Aamir’s star power overrode not just any hesitation but
gave people the gumption to defy the religious leaders. To the
religious leaders, Aamir Khan is a checkmate issue and they cannot
risk the possibility of looking foolish.
Another learning is that when communicating to people who,
unfortunately, cannot read or write, merely giving them
communication to look at doesn’t suffice. Getting them to cotton on
is crucial; hence the imagination with which the communication
depicts people, illnesses, and manifestations of disease is important.
The key here is that positive imagery draws people into a
communication and negative imagery (pictures of disease of inflicted
people) repels them, so it should be placed either inside the location
or should be in the hands of medical personnel, to take away the
repulsion factor.
Wherever the communication is being displayed, a recognition of the
local folk aesthetic also plays a make or break factor. Idiom, colour,
local folk arts are key elements. Because many communications need
to be centrally produced to ensure economy and accuracy, they can
be strangely off-putting when they appear in their final intended
location. An extra effort to add a layer of ‘localising’ can make all the
difference. For example, ‘city’-esque pictures don’t go far with
villagers when you want them to change a lifelong unhygienic habit
because they seem to think that this kind of ‘cleanliness luxury’ is for
the city folk, who have the time and money to indulge in these things!
Above all, go bearing gifts. It’s not just the thought (or the campaign)
that counts. To touch their hearts shows a smidgen of affection and
generosity. To get your communication ready and shining is all good
and dandy, but if you want people to look at it with favour and co-
operation, remember that you have to earn their pleasure.
The author began his career in 1982 at JWT as a copywriter, and has
been Creative Director with Rediffusion DY&R, Vice President and
Executive Creative Director with the McCann Worldgroup. He can be
reached at [email protected]
Just What the Future OrderedMarketing to India's rural population has to be as distinct as the population that it approaches. Alvin Saldanha, makes a point.Chief Creative Officer — Idea Domain,
31 32
Some years ago, the WHO’s polio vaccine drive to dispense a critical
multi-state polio vaccination in India faced a particularly vexing
challenge: Muslim religious leaders in two states prohibited the
faithful from administering their infants with the polio vaccine
because, as they had told the trusting folk, the polio vaccine was ‘an
evil plot by the West to destroy the reproductive system of their
infants from developing correctly, and prevent them from having
children when they grow up’.
Fortunately, we were in close contact with Indian film star Aamir
Khan, being as we were in the middle of the giant ‘Thanda Matlab
Coca-Cola’ campaign. Aamir instantly agreed to help, gratis, with
anything and everything we could do to encourage these parents to
have their infants vaccinated. With reference to his suggestions, we
developed a campaign to respond to this bizarre challenge; to
encourage people to visit the medical camps and assure them that
the vaccine had no ‘side effects’ to fear.
However, a strategic decision was taken: while Aamir’s beaming,
welcoming, reassuring face appeared on each and every
communication, the perverse issue that had stymied the program
was ignored completely. Aamir’s fabulous star power was pressed
into play, and it worked like a charm. Thousands of Indians flocked to
the camps, they arrived grinning at the Aamir overdose all around
them, whooping and laughing, they took pictures next to the giant
Aamir cutouts dotted all over the camp, and had their babies
confidently vaccinated.
It is an interesting episode to relate to in the challenge of caring for
Indians who have been marginalised in India’s Great Leap Forward.
And it is an interesting learning we can bring to bear in solving what is
not just one of the most pressing needs of the country, but one of the
most promising growth segments for the many providers of India’s
infrastructure.
And one of the most important dynamics in this emerging new sector
is health. In fact, India’s health universe, central to powering and
sustaining India’s leap into the fraternity of first world nations, needs
to be communicated, understood and appreciated accurately by all
its constituencies.
At the top end, the knowing constituencies need no persuasion:
seeped in market and profit realities, they can easily see the road
ahead. The challenge here lies in convincing market-oriented
businesses and organisations to commit to setting up health facilities
in places where the profit margin is not so high, or the initial set-up
financing and revenue possibility is linked to the capriciousness of
Just What the Future Ordered financing from the government.
Private pharmaceutical companies have shown initiative in this area.
Recognising the very long term potential of providing diagnostic,
preventive and medical services to the poorest of the poor, they have
long since begun a variety of imaginative and effective exercises in
reaching out to impoverished Indians in benighted internal areas,
thus laying the foundations of good health. From the openly visible
population control exercises by NGOs to a variety of programs that
deal with women’s issues, vision problems, TB and diarrhoea, good
nutrition and vaccination exercises, companies are deploying armies
of doctors, medical workers, and organising camps… all ensuring that
a fresh wave of ‘inclusive’ medical possibility touches the lives of
Indians who would otherwise have no hope for it.
Herein lays another challenge: communication. This kind of
communication has proven to present some of the most unique
challenges and each campaign results in fresh learnings that must be
shared.
The most important thing to remember is that any communication
faces ‘competition’ from erroneous beliefs, erroneous practices, and
insecure village doctors. Indeed, as in the WHO’s case, it was the
religious authorities that presented the problem. As in the case of all
such groups, their yen for exercising their power, however
capriciously, and their need to show and feel that they still wield
some clout, all play a part.
One learning is, paradoxically, to present an overwhelming
distraction to a false issue. As with Aamir Khan, the positive
assurance of Aamir’s star power overrode not just any hesitation but
gave people the gumption to defy the religious leaders. To the
religious leaders, Aamir Khan is a checkmate issue and they cannot
risk the possibility of looking foolish.
Another learning is that when communicating to people who,
unfortunately, cannot read or write, merely giving them
communication to look at doesn’t suffice. Getting them to cotton on
is crucial; hence the imagination with which the communication
depicts people, illnesses, and manifestations of disease is important.
The key here is that positive imagery draws people into a
communication and negative imagery (pictures of disease of inflicted
people) repels them, so it should be placed either inside the location
or should be in the hands of medical personnel, to take away the
repulsion factor.
Wherever the communication is being displayed, a recognition of the
local folk aesthetic also plays a make or break factor. Idiom, colour,
local folk arts are key elements. Because many communications need
to be centrally produced to ensure economy and accuracy, they can
be strangely off-putting when they appear in their final intended
location. An extra effort to add a layer of ‘localising’ can make all the
difference. For example, ‘city’-esque pictures don’t go far with
villagers when you want them to change a lifelong unhygienic habit
because they seem to think that this kind of ‘cleanliness luxury’ is for
the city folk, who have the time and money to indulge in these things!
Above all, go bearing gifts. It’s not just the thought (or the campaign)
that counts. To touch their hearts shows a smidgen of affection and
generosity. To get your communication ready and shining is all good
and dandy, but if you want people to look at it with favour and co-
operation, remember that you have to earn their pleasure.
The author began his career in 1982 at JWT as a copywriter, and has
been Creative Director with Rediffusion DY&R, Vice President and
Executive Creative Director with the McCann Worldgroup. He can be
reached at [email protected]
Just What the Future OrderedMarketing to India's rural population has to be as distinct as the population that it approaches. Alvin Saldanha, makes a point.Chief Creative Officer — Idea Domain,
31 32
Brief outline about Nuclear Medicine
Nuclear medicine is a sub-specialty of medicine, which uses minute
amounts of radioisotopes to image various organs of the human body
and to treat specific disease conditions.
In fact, nuclear medicine imaging's superiority is marked by its
physiological basis and ability to identify diseases at an early stage,
much before anatomical imaging modalities like ultrasound, CT and
MRI. However, the very name ‘nuclear’ has negative connotations
with the general public. Attempts to minimise this have led to the
introduction in recent years of the term ‘molecular imaging’.
Nuclear medicine is not only used in diagnosis but has an important 131contribution in therapy as well. For example, Radioactive Iodine ( I)
is used in the treatment of differentiated thyroid cancer and also 89 32 153hyperthyroidism. Strontium, Phosphorus and Samarium are
other isotopes used to alleviate bone pains in terminally ill cancer
90patients. Glass or resin impregnated Yttrium is indicated for liver
carcinoma management and Erbium / Yttrium radioactive colloids
for the treatment of arthritis like Rheumatoid. 99mTechnetium-99m ( Tc)
99mTc Technetium is the most extensively used diagnostic medical
isotope (over 30 million medical imaging procedures a year). Its use is
seen growing by 3-5% annually. It provides doctors high-quality
image mapping e.g. blood flow to the heart or the spread of cancer to 99mbones, while delivering only low radiation doses to patients. Tc is
an artificially produced radioisotope i.e. a decay product of another 99reactor produced radioactive element Molybdenum Mo. Given its
99rapid rate of radioactive decay, Mo is produced and supplied as a 99 99mMolybdenum - Tc generator on a weekly basis to satisfy the
99mworldwide demand of Tc. 99mPresent status of Tc generators in India
99mToday, the most widely used diagnostic radioisotope, Tc, is in short
supply because it relies on an unsustainably low number of 99production nuclear reactors. Most of the world's supply of Mo is
obtained from only five ageing nuclear reactors and availability has
been much reduced in recent times owing to problems at the largest
reactors in Chalk River, Canada and Petten, in the Netherlands. 70% 99mof world’s Tc need is met by these two reactors. A few other
reactors have been decommissioned and not replaced. This situation
has improved recently, but it can still be jeopardized when there is an
emergency shutdown of any of the presently working reactors. 99mThis worldwide Tc resource crunch and subsequent increase in the
99 99mprice of Mo Tc generators (a 300% increase per weekly
consignment) has put a lot of financial strain on Indian nuclear-
Hands-on Nuclear MedicineDr. Shanmuga Sundaram, Amrita Institute of Medical Sciences, talks about the problems faced by nuclear medicine providers.
medical centres. Europe, the major hub of air traffic in the transport
of these weekly generators to India, has, in recent times, faced
natural calamities like snowfall, volcanic ash and the shutting down of
airports. The situation is beginning to stabilise, but we are not out of
the woods yet. Nuclear medical departments are functioning
overtime when isotopes are available and trying to use positron
emitting isotopes as substitutes to tide over the crisis.
Problem faced by the Indian Nuclear medicine society with
reference to general Nuclear medicine imaging and therapy, and
probable solutions for the same99 99mIt appears that this Mo Tc generator crisis may not be completely
solved even if existing nuclear reactors restart their production. It is
high time for a nuclear empowered country like India to have its own 99nuclear reactor capable of producing not only Mo Molybdenum but
67 201also other medically useful isotopes like Gallium, Thallium etc.
India can take the lead of supplying these medically useful
radioisotopes to many other developing countries like Sri Lanka,
Bangladesh etc.
Also, it will be desirable to have regional radiopharmacy centres (the
existing BRIT- Board of Radiation and Isotope Technology, Mumbai,
an Indian Government organisation can have regional centres or it
can also be in the Private Public Sector). This will ensure the easy,
affordable and uninterrupted supply of radiopharmaceuticals and
isotopes for nuclear medicine.
PET CT Imaging
An exciting, newer imaging modality called PET CT (Positron Emitting
Tomography with Computed Tomography) has been added to the
powerful armamentarium of existing nuclear medicine imaging
techniques. Hailed as the ‘Investigation of this Century’, the PET CT
modality has revolutionized cancer care by its ability to detect early
malignancy. It is also extremely useful for cancer staging its response
to therapy and for radiation therapy planning etc. PET CT is also found
to be useful in diagnosing several non-oncological conditions in
cardiology and neurology. Ours is the first and only centre in the state
of Kerala performing PET CT studies.
By tagging a Glucose molecule (the basic substrate of any rapidly 18dividing cell) with a positron isotope (in this case an F Fluorine
isotope), it is possible to localize the malignant lesion. The most 18
commonly used radiopharmaceutical in PET CT imaging is F Flouro
Deoxy Glucose (FDG), with a half-life of only 110 minutes.
The flip side of PET CT imaging is the high cost of a PET CT scanner and
the short half-life of almost all PET isotopes.
These PET isotopes are produced in a cyclotron (Cyclotrons
accelerate charged particles using high frequency alternating
voltages and bombard targets, producing desired PET isotopes). 11Many short lived radionuclides can be produced, like Carbon,
15 82 18Oxygen, Rubidium, but Fluorine is only transportable due to its
'longer half-life' (110 minutes vs. less than 20 minutes) compared to
the other mentioned isotopes.
Establishing and maintaining a cyclotron is a financially challenging
and daunting task. This is exemplified by the limited number of
cyclotrons (located mainly in metro cities like New Delhi, Mumbai,
Bangalore, Hyderabad and Chennai) in India.
It is a prerequisite to ensure an uninterrupted supply of PET isotopes 18(primarily F labelled FDG) to have a successful PET CT centre in a
peripheral city like Cochin. As FDG has a half-life of 110 minutes, it is
possible to transport FDG from a remote cyclotron either by road or
by air. PET CT centres in cities with a cyclotron in them or in their
vicinity (within 150kms) are served better by land transport but a
centre like ours has to depend on efficient air transport.
FDG transport is a logistical nightmare based on the following
constraints
Being a radioactive material, FDG containers needs to be
transported on large aircraft with exclusive cargo carriage
sections (i.e. not on smaller ATR flights)
Also, being categorized under ‘Dangerous Goods
Regulations (DGR)’, FDG can be transported only if both
pilots of the transporting carrier are ‘DGR certified’. If even
one has not undergone a DGR renewal course, the
consignment would be offloaded.
FDG has a mandatory cooling period in the cargo area of
the airport before being moved into the aircraft. Precious
time can be lost in this process.
There needs to be a smooth workflow within the FDG
production team
At the cyclotron facility (need to ensure the right
quantity of FDG is produced, quality controlled and
packed),
33 34
Brief outline about Nuclear Medicine
Nuclear medicine is a sub-specialty of medicine, which uses minute
amounts of radioisotopes to image various organs of the human body
and to treat specific disease conditions.
In fact, nuclear medicine imaging's superiority is marked by its
physiological basis and ability to identify diseases at an early stage,
much before anatomical imaging modalities like ultrasound, CT and
MRI. However, the very name ‘nuclear’ has negative connotations
with the general public. Attempts to minimise this have led to the
introduction in recent years of the term ‘molecular imaging’.
Nuclear medicine is not only used in diagnosis but has an important 131contribution in therapy as well. For example, Radioactive Iodine ( I)
is used in the treatment of differentiated thyroid cancer and also 89 32 153hyperthyroidism. Strontium, Phosphorus and Samarium are
other isotopes used to alleviate bone pains in terminally ill cancer
90patients. Glass or resin impregnated Yttrium is indicated for liver
carcinoma management and Erbium / Yttrium radioactive colloids
for the treatment of arthritis like Rheumatoid. 99mTechnetium-99m ( Tc)
99mTc Technetium is the most extensively used diagnostic medical
isotope (over 30 million medical imaging procedures a year). Its use is
seen growing by 3-5% annually. It provides doctors high-quality
image mapping e.g. blood flow to the heart or the spread of cancer to 99mbones, while delivering only low radiation doses to patients. Tc is
an artificially produced radioisotope i.e. a decay product of another 99reactor produced radioactive element Molybdenum Mo. Given its
99rapid rate of radioactive decay, Mo is produced and supplied as a 99 99mMolybdenum - Tc generator on a weekly basis to satisfy the
99mworldwide demand of Tc. 99mPresent status of Tc generators in India
99mToday, the most widely used diagnostic radioisotope, Tc, is in short
supply because it relies on an unsustainably low number of 99production nuclear reactors. Most of the world's supply of Mo is
obtained from only five ageing nuclear reactors and availability has
been much reduced in recent times owing to problems at the largest
reactors in Chalk River, Canada and Petten, in the Netherlands. 70% 99mof world’s Tc need is met by these two reactors. A few other
reactors have been decommissioned and not replaced. This situation
has improved recently, but it can still be jeopardized when there is an
emergency shutdown of any of the presently working reactors. 99mThis worldwide Tc resource crunch and subsequent increase in the
99 99mprice of Mo Tc generators (a 300% increase per weekly
consignment) has put a lot of financial strain on Indian nuclear-
Hands-on Nuclear MedicineDr. Shanmuga Sundaram, Amrita Institute of Medical Sciences, talks about the problems faced by nuclear medicine providers.
medical centres. Europe, the major hub of air traffic in the transport
of these weekly generators to India, has, in recent times, faced
natural calamities like snowfall, volcanic ash and the shutting down of
airports. The situation is beginning to stabilise, but we are not out of
the woods yet. Nuclear medical departments are functioning
overtime when isotopes are available and trying to use positron
emitting isotopes as substitutes to tide over the crisis.
Problem faced by the Indian Nuclear medicine society with
reference to general Nuclear medicine imaging and therapy, and
probable solutions for the same99 99mIt appears that this Mo Tc generator crisis may not be completely
solved even if existing nuclear reactors restart their production. It is
high time for a nuclear empowered country like India to have its own 99nuclear reactor capable of producing not only Mo Molybdenum but
67 201also other medically useful isotopes like Gallium, Thallium etc.
India can take the lead of supplying these medically useful
radioisotopes to many other developing countries like Sri Lanka,
Bangladesh etc.
Also, it will be desirable to have regional radiopharmacy centres (the
existing BRIT- Board of Radiation and Isotope Technology, Mumbai,
an Indian Government organisation can have regional centres or it
can also be in the Private Public Sector). This will ensure the easy,
affordable and uninterrupted supply of radiopharmaceuticals and
isotopes for nuclear medicine.
PET CT Imaging
An exciting, newer imaging modality called PET CT (Positron Emitting
Tomography with Computed Tomography) has been added to the
powerful armamentarium of existing nuclear medicine imaging
techniques. Hailed as the ‘Investigation of this Century’, the PET CT
modality has revolutionized cancer care by its ability to detect early
malignancy. It is also extremely useful for cancer staging its response
to therapy and for radiation therapy planning etc. PET CT is also found
to be useful in diagnosing several non-oncological conditions in
cardiology and neurology. Ours is the first and only centre in the state
of Kerala performing PET CT studies.
By tagging a Glucose molecule (the basic substrate of any rapidly 18dividing cell) with a positron isotope (in this case an F Fluorine
isotope), it is possible to localize the malignant lesion. The most 18
commonly used radiopharmaceutical in PET CT imaging is F Flouro
Deoxy Glucose (FDG), with a half-life of only 110 minutes.
The flip side of PET CT imaging is the high cost of a PET CT scanner and
the short half-life of almost all PET isotopes.
These PET isotopes are produced in a cyclotron (Cyclotrons
accelerate charged particles using high frequency alternating
voltages and bombard targets, producing desired PET isotopes). 11Many short lived radionuclides can be produced, like Carbon,
15 82 18Oxygen, Rubidium, but Fluorine is only transportable due to its
'longer half-life' (110 minutes vs. less than 20 minutes) compared to
the other mentioned isotopes.
Establishing and maintaining a cyclotron is a financially challenging
and daunting task. This is exemplified by the limited number of
cyclotrons (located mainly in metro cities like New Delhi, Mumbai,
Bangalore, Hyderabad and Chennai) in India.
It is a prerequisite to ensure an uninterrupted supply of PET isotopes 18(primarily F labelled FDG) to have a successful PET CT centre in a
peripheral city like Cochin. As FDG has a half-life of 110 minutes, it is
possible to transport FDG from a remote cyclotron either by road or
by air. PET CT centres in cities with a cyclotron in them or in their
vicinity (within 150kms) are served better by land transport but a
centre like ours has to depend on efficient air transport.
FDG transport is a logistical nightmare based on the following
constraints
Being a radioactive material, FDG containers needs to be
transported on large aircraft with exclusive cargo carriage
sections (i.e. not on smaller ATR flights)
Also, being categorized under ‘Dangerous Goods
Regulations (DGR)’, FDG can be transported only if both
pilots of the transporting carrier are ‘DGR certified’. If even
one has not undergone a DGR renewal course, the
consignment would be offloaded.
FDG has a mandatory cooling period in the cargo area of
the airport before being moved into the aircraft. Precious
time can be lost in this process.
There needs to be a smooth workflow within the FDG
production team
At the cyclotron facility (need to ensure the right
quantity of FDG is produced, quality controlled and
packed),
33 34
Local transport team (ensuring the prompt transport
of FDG from the cyclotron facility to airport cargo
section),
Air cargo ground staff (they need to ensure that it is
handed over to the aircraft); and
Once the consignment arrives at the destination (i.e.
Cochin), the ground cargo handling staff has to ensure the
fast tracking of this consignment after mandatory security
clearances are completed.
There is also a greater responsibility from the end user to
ensure that this consignment is received and immediately
checked for any damage. An exclusive vehicle should be
used for prompt transport of FDG to the PET CT centre.
At the user department also, it is to be ensured that all
planned patients are prepared for the procedure (we need
to ensure a normal fasting blood sugar range so that there
is an optimum FDG uptake in the malignant tissue) and,
needless to say, there should be a clear-cut idea for the
nuclear medicine physician regarding the number of
patients undergoing the PET procedure on that day.
Let us look into the logistics of this air transport from Mumbai’s
cyclotron to our centre
It is possible to transport FDG from Chennai and Bangalore, provided
we have ideal connectivity. However, Mumbai is preferred by us for
its better air connectivity to Cochin.
Preferably, an early morning flight is favoured for FDG transport as
patients fast overnight and FDG production at a cyclotron facility is
conventionally in the early morning (between 1-3 AM). It is also easy
to transport the consignment from the cyclotron facility to Mumbai
domestic airport by road at this time of the day due to there being
lesser traffic on the streets.
Problems faced by our PET CT centre in FDG supply and transport
logistics
Only one cyclotron facility is ideally located and able to
supply FDG through air, not only to us but to other
peripheral cities.
Time chart of our FDG consignment production and transport:
Although Hyderabad, Chennai and Bangalore are nearby,
there is no ideal air connectivity in terms of aircraft size,
departure time etc. To add to these limitations, only a
couple of air carriers are interested in carrying these
radioactive consignments classified under ‘Dangerous
Goods’. Even though the DGCA has accorded a blanket
permission to all, only Air India and Jet carry radioactive
material.
Effectively, these limitations have made us depend on one
FDG supplier, thus attributing a monopoly status to
Mumbai’s cyclotron and creating an unlevel playing field
for nearby facilities.
An encumbrance in the production and transport logistics
(i.e. cyclotron breakdown, quality control failure, late
arrival at Mumbai airport, non availability of a DGR
certified pilot on the flight, any security alert etc.)
ultimately leads to postponement of scheduled patients
for the day.
Possible Solutions
We need to have regional cyclotrons in Government and
Public-Private sectors so that FDG is supplied at an
affordable price.
All carrier aircraft should carry radioisotopes routinely
with commitment. On specific routes and specific flights
carrying radioactive substances, it should be ensured that
DGR certified pilots are available.
There should be a better understanding and awareness of
this precious consignment’s transport by ground handling
and other airport authorities so that there are no
unwarranted hassles in its smooth transport.
Conclusion
With newer radiopharmaceuticals and advancements in
instrumentation like PET MR, Molecular Imaging is looking to be the
future of oncology imaging. In spite of all these existing problems, we
must strive to make nuclear medicine services available and
affordable to all our patients.
The author is the Clinical Professor and Head of the Department of
Nuclear Medicine and PET CT at the Amrita Institute of Medical
Sciences in Cochin, Kerala. He can be reached at
35 36
1-3 AM Production, quality control and Packaging of FDG
3-4 AM Local transport from cyclotron facility to airport cargo terminal
4-5 AM
5-5.30 AM
Cooling time
Aircraft loading
5.30-7.20 AM In flight
7.20-7.40AM Clearance and handing over of FDG consignment to hospital staff waiting at Cochin airport
7.40-8.15 AM Road transport of FDG from Cochin airport to PET CT Centre
8.15-11.15 AM Injection of FDG to patients in batches
Local transport team (ensuring the prompt transport
of FDG from the cyclotron facility to airport cargo
section),
Air cargo ground staff (they need to ensure that it is
handed over to the aircraft); and
Once the consignment arrives at the destination (i.e.
Cochin), the ground cargo handling staff has to ensure the
fast tracking of this consignment after mandatory security
clearances are completed.
There is also a greater responsibility from the end user to
ensure that this consignment is received and immediately
checked for any damage. An exclusive vehicle should be
used for prompt transport of FDG to the PET CT centre.
At the user department also, it is to be ensured that all
planned patients are prepared for the procedure (we need
to ensure a normal fasting blood sugar range so that there
is an optimum FDG uptake in the malignant tissue) and,
needless to say, there should be a clear-cut idea for the
nuclear medicine physician regarding the number of
patients undergoing the PET procedure on that day.
Let us look into the logistics of this air transport from Mumbai’s
cyclotron to our centre
It is possible to transport FDG from Chennai and Bangalore, provided
we have ideal connectivity. However, Mumbai is preferred by us for
its better air connectivity to Cochin.
Preferably, an early morning flight is favoured for FDG transport as
patients fast overnight and FDG production at a cyclotron facility is
conventionally in the early morning (between 1-3 AM). It is also easy
to transport the consignment from the cyclotron facility to Mumbai
domestic airport by road at this time of the day due to there being
lesser traffic on the streets.
Problems faced by our PET CT centre in FDG supply and transport
logistics
Only one cyclotron facility is ideally located and able to
supply FDG through air, not only to us but to other
peripheral cities.
Time chart of our FDG consignment production and transport:
Although Hyderabad, Chennai and Bangalore are nearby,
there is no ideal air connectivity in terms of aircraft size,
departure time etc. To add to these limitations, only a
couple of air carriers are interested in carrying these
radioactive consignments classified under ‘Dangerous
Goods’. Even though the DGCA has accorded a blanket
permission to all, only Air India and Jet carry radioactive
material.
Effectively, these limitations have made us depend on one
FDG supplier, thus attributing a monopoly status to
Mumbai’s cyclotron and creating an unlevel playing field
for nearby facilities.
An encumbrance in the production and transport logistics
(i.e. cyclotron breakdown, quality control failure, late
arrival at Mumbai airport, non availability of a DGR
certified pilot on the flight, any security alert etc.)
ultimately leads to postponement of scheduled patients
for the day.
Possible Solutions
We need to have regional cyclotrons in Government and
Public-Private sectors so that FDG is supplied at an
affordable price.
All carrier aircraft should carry radioisotopes routinely
with commitment. On specific routes and specific flights
carrying radioactive substances, it should be ensured that
DGR certified pilots are available.
There should be a better understanding and awareness of
this precious consignment’s transport by ground handling
and other airport authorities so that there are no
unwarranted hassles in its smooth transport.
Conclusion
With newer radiopharmaceuticals and advancements in
instrumentation like PET MR, Molecular Imaging is looking to be the
future of oncology imaging. In spite of all these existing problems, we
must strive to make nuclear medicine services available and
affordable to all our patients.
The author is the Clinical Professor and Head of the Department of
Nuclear Medicine and PET CT at the Amrita Institute of Medical
Sciences in Cochin, Kerala. He can be reached at
35 36
1-3 AM Production, quality control and Packaging of FDG
3-4 AM Local transport from cyclotron facility to airport cargo terminal
4-5 AM
5-5.30 AM
Cooling time
Aircraft loading
5.30-7.20 AM In flight
7.20-7.40AM Clearance and handing over of FDG consignment to hospital staff waiting at Cochin airport
7.40-8.15 AM Road transport of FDG from Cochin airport to PET CT Centre
8.15-11.15 AM Injection of FDG to patients in batches
At a time in India when the provision of healthcare is rapidly
expanding, reaching out from beyond the metro cities and
mushrooming in smaller cities and towns across the country, it seems
appropriate to ask a question that any architect commissioned to
design a healthcare facility would be interested in mooting:
In a healthcare facility design consulting firm that offers vertically
integrated consulting services ranging from surveying the potential
market for the project through architectural design consulting till
advising on standard operating procedures and recruitment of staff,
is the physical facility design (the architecture) positively impacted?
In my experience in our firm, HOSMAC India, which offers such
vertically integrated services, described by us as a ‘one-stop shop’ for
healthcare facility design, there seems little doubt that it is.
Immediately I hear the cry from my fraternity (fellow architects),
what do you mean by ‘architecture’, define your terms! How can a
medical doctor add value to architectural design; how would a profit
and loss statement for the proposed hospital projected into the
foreseeable future help you (me!) to achieve Commodity, Firmness
and (especially!) Delight?
Bob Dylan sang about it years back (albeit nasally): …the times they
are a-changin’…Is it possible for us architects to accept that Vitruvius
may not have much value to add to the design of an allopathic
healthcare delivery facility in 2011?
This would bring us back to our aggrieved cry: how then would I
define ‘architecture’ in this context? Am I disposing of ‘Delight’ in my
proposed hospital’s proposed incinerator? This would be, to my
mind, a simplistic way of viewing the problem solving process related
to the design of this building type; the issue is complex and involves
opening a Pandora’s Box of medical, architectural, engineering,
social, emotional and moral issues. How all of us professionals in
HOSMAC India with varying academic backgrounds and skill sets go
about chasing all these creepy-crawlies, trying to catch them and
stuff them back into their box is what I am going to go on to discuss.
Hopefully during the course of this discussion I will be able to give
some definition to my viewpoint on the subject and to the positive
impact that I know it has on the architectural design of healthcare
facilities, large or small, across the country, in the new millennium.
If you were to ask an architect in India today what is the single most
important design factor he/she would consider while designing a
hospital, the chances are the reply you would get would be ‘the
functional requirements’. They well might say that the ‘form’ of their
design solution would be derived from an analysis of
medical/technical requirements of the hospital, that is, the
‘function’.
Form follows Function?
‘Form follows Function’ is an architectural dictum laid down by one
of the Modern Movement in Architecture’s most well known
practitioners, Ludwig Mies van der Rohe. He was born in Aachen,
Germany in 1886. A little simplistically put, he means that a building
should be designed taking as the starting point for its design the
activities that that building is meant to house. Hence the final shape
(or ‘form’) of the building would be directly derived from its intended
use (or ‘function’).
Le Corbusier, another famous Modernist architect, talked of a house
as a ‘machine for living in’.
If Le Corbusier had been a healthcare architect, maybe he would
have talked about designing hospitals as ‘machines for healing in’.
We all have an idea about the complexity of the functional needs of a
modern hospital, and the specialized knowledge needed by its
designer with respect to its engineering services and the needs of the
medical equipment it houses. So we can see how a hospital,
especially one being built in the 2000’s, could well be considered to
be ‘a machine for healing in’.
In fact, many (if not most) hospitals built in India during the latter part
of the last century seem to have been designed to provide a roof over
the increasingly complex medical procedures being performed
within, with their architects being little more than ‘doctor’s
draftsmen’, translators of medical and technological requirements
into built form. The result: grim and cheerless buildings that cannot
be dignified with the word ‘architecture’.
What has changed in recent times is the very definition of the word
‘healing’, moving away from medical interventions to embrace a
more holistic meaning, the focus moving away from treating ‘illness’
to creating ‘wellness’.
When healthcare designers now conceptualize hospitals, they need
to think of them as buildings designed to promote the ‘wellness’ of
not only the ‘patient’ (replace with: ‘healthcare consumer’), but also
of his/her family, and friends who visit, and the staff who provide the
care.
In conceptualizing hospitals today, we need to take our cue from the
hospitality industry. The patient needs to be treated as a guest,
someone who is to be informed about what he/she will undergo
during his/her stay in the hospital, and should be enabled to take an
active and meaningful part in taking decisions about his/her
treatment. In metro’s today, doctors are no longer seen to be the
demi-gods that they were in the past. It is not at all unusual for
patients to enter the doctors consulting rooms armed with an inch-
thick file of internet downloads pertaining to their problem. The net
has been the great leveler between quality of information available in
even remote areas of the country. As the general public becomes
more aware of the world that surrounds them, healthcare providers
need to sit up and take note.
‘Form’ could still follow ‘function’, providing we redefine the function
of a hospital as an institution built to create a more holistic ‘wellness’,
to consider the dignity, emotional needs and mental state of our
‘patient/guest’ to be every bit as important as his/her physical health.
We do not need more echoing green painted hallways with harsh,
unforgiving fluorescent lights. Controlling noise, using pleasant
colors, sufficient and comfortable waiting spaces, clarity in way
finding, using natural light and greenery judiciously are just some of
the imperatives in ‘patient-friendly design’. Polite and helpful staff,
the ready availability of information about the status of the patient to
their family and friends and concern about the patient’s mental state
are just some of the imperatives in ‘patient-focused care’.
Healthcare Providers and their Social Conscience
Many successful new healthcare projects are taking shape
throughout the developed Western world today, calling into question
the performance levels of more typical healthcare construction
endeavors, both in the West and in India. This prompts us to ask just
how far our conventional healthcare buildings are falling short of the
mark, judged by the standards of ‘green’ architecture, the popular
name given to environmentally responsive and ecologically
sustainable building.
What we are discussing here is the social responsibility that
healthcare providers need to feel for the community that houses
their facility and provides them with their patients/profits. At the
stage of conceptualization of the proposed facility, thought needs to
be given to the environmental effects the proposal will have on its
surroundings. Architects have always been taught that the buildings
they design need to be ‘good neighbors’, but their clients, the
healthcare providers or individual doctors at a smaller scale, need to
understand this in the macro and micro sense.
Healthcare institutions’ core mission of protecting human health
provides the basis for them to speak with their words and actions on
the health implications of building construction and operation. The
healthcare industry has a leadership opportunity to move the larger
building industry to a healthier approach by demonstrating the best
in healthy, sustainable design, construction, operations and
maintenance practices in its own facilities.
This approach to design is known as ‘green’ architecture. This design
approach addresses concerns such as energy efficiency, the use of
clean energy resources, an improved indoor environment through
usage of green building materials and maximizing the use of
controlled daylighting, encouraging recycling and waste
prevention/management strategies and designing in ways that
promote good building operations practices.
Healthcare architects need to redefine the facilities they design as
healthy parts of a healthy regional ecosystem. The full range of
practices to be followed in the pursuit of these socially responsible
goals are beyond the scope of this article. HOSMAC works closely
with an NGO named Hosmac Foundation on promoting this ‘green’
initiative in healthcare delivery as a whole.
Hosmac Foundation is networked with a global movement called
Healthcare Without Harm, involving more than 300 NGOs and
professional organizations spread over 50 countries, working
towards establishing environmentally sound healthcare practices
and healthcare facility design and construction.
Moral Issues in Healthcare Facility Design
Every sensitive designer of buildings knows that during this process
In what way is architecture impacted? Mr. Hussain Varawalla, Design Mentor — Architecture Services — Hosmac, finds out.
Vertically Integrated Facility Design
37 38
At a time in India when the provision of healthcare is rapidly
expanding, reaching out from beyond the metro cities and
mushrooming in smaller cities and towns across the country, it seems
appropriate to ask a question that any architect commissioned to
design a healthcare facility would be interested in mooting:
In a healthcare facility design consulting firm that offers vertically
integrated consulting services ranging from surveying the potential
market for the project through architectural design consulting till
advising on standard operating procedures and recruitment of staff,
is the physical facility design (the architecture) positively impacted?
In my experience in our firm, HOSMAC India, which offers such
vertically integrated services, described by us as a ‘one-stop shop’ for
healthcare facility design, there seems little doubt that it is.
Immediately I hear the cry from my fraternity (fellow architects),
what do you mean by ‘architecture’, define your terms! How can a
medical doctor add value to architectural design; how would a profit
and loss statement for the proposed hospital projected into the
foreseeable future help you (me!) to achieve Commodity, Firmness
and (especially!) Delight?
Bob Dylan sang about it years back (albeit nasally): …the times they
are a-changin’…Is it possible for us architects to accept that Vitruvius
may not have much value to add to the design of an allopathic
healthcare delivery facility in 2011?
This would bring us back to our aggrieved cry: how then would I
define ‘architecture’ in this context? Am I disposing of ‘Delight’ in my
proposed hospital’s proposed incinerator? This would be, to my
mind, a simplistic way of viewing the problem solving process related
to the design of this building type; the issue is complex and involves
opening a Pandora’s Box of medical, architectural, engineering,
social, emotional and moral issues. How all of us professionals in
HOSMAC India with varying academic backgrounds and skill sets go
about chasing all these creepy-crawlies, trying to catch them and
stuff them back into their box is what I am going to go on to discuss.
Hopefully during the course of this discussion I will be able to give
some definition to my viewpoint on the subject and to the positive
impact that I know it has on the architectural design of healthcare
facilities, large or small, across the country, in the new millennium.
If you were to ask an architect in India today what is the single most
important design factor he/she would consider while designing a
hospital, the chances are the reply you would get would be ‘the
functional requirements’. They well might say that the ‘form’ of their
design solution would be derived from an analysis of
medical/technical requirements of the hospital, that is, the
‘function’.
Form follows Function?
‘Form follows Function’ is an architectural dictum laid down by one
of the Modern Movement in Architecture’s most well known
practitioners, Ludwig Mies van der Rohe. He was born in Aachen,
Germany in 1886. A little simplistically put, he means that a building
should be designed taking as the starting point for its design the
activities that that building is meant to house. Hence the final shape
(or ‘form’) of the building would be directly derived from its intended
use (or ‘function’).
Le Corbusier, another famous Modernist architect, talked of a house
as a ‘machine for living in’.
If Le Corbusier had been a healthcare architect, maybe he would
have talked about designing hospitals as ‘machines for healing in’.
We all have an idea about the complexity of the functional needs of a
modern hospital, and the specialized knowledge needed by its
designer with respect to its engineering services and the needs of the
medical equipment it houses. So we can see how a hospital,
especially one being built in the 2000’s, could well be considered to
be ‘a machine for healing in’.
In fact, many (if not most) hospitals built in India during the latter part
of the last century seem to have been designed to provide a roof over
the increasingly complex medical procedures being performed
within, with their architects being little more than ‘doctor’s
draftsmen’, translators of medical and technological requirements
into built form. The result: grim and cheerless buildings that cannot
be dignified with the word ‘architecture’.
What has changed in recent times is the very definition of the word
‘healing’, moving away from medical interventions to embrace a
more holistic meaning, the focus moving away from treating ‘illness’
to creating ‘wellness’.
When healthcare designers now conceptualize hospitals, they need
to think of them as buildings designed to promote the ‘wellness’ of
not only the ‘patient’ (replace with: ‘healthcare consumer’), but also
of his/her family, and friends who visit, and the staff who provide the
care.
In conceptualizing hospitals today, we need to take our cue from the
hospitality industry. The patient needs to be treated as a guest,
someone who is to be informed about what he/she will undergo
during his/her stay in the hospital, and should be enabled to take an
active and meaningful part in taking decisions about his/her
treatment. In metro’s today, doctors are no longer seen to be the
demi-gods that they were in the past. It is not at all unusual for
patients to enter the doctors consulting rooms armed with an inch-
thick file of internet downloads pertaining to their problem. The net
has been the great leveler between quality of information available in
even remote areas of the country. As the general public becomes
more aware of the world that surrounds them, healthcare providers
need to sit up and take note.
‘Form’ could still follow ‘function’, providing we redefine the function
of a hospital as an institution built to create a more holistic ‘wellness’,
to consider the dignity, emotional needs and mental state of our
‘patient/guest’ to be every bit as important as his/her physical health.
We do not need more echoing green painted hallways with harsh,
unforgiving fluorescent lights. Controlling noise, using pleasant
colors, sufficient and comfortable waiting spaces, clarity in way
finding, using natural light and greenery judiciously are just some of
the imperatives in ‘patient-friendly design’. Polite and helpful staff,
the ready availability of information about the status of the patient to
their family and friends and concern about the patient’s mental state
are just some of the imperatives in ‘patient-focused care’.
Healthcare Providers and their Social Conscience
Many successful new healthcare projects are taking shape
throughout the developed Western world today, calling into question
the performance levels of more typical healthcare construction
endeavors, both in the West and in India. This prompts us to ask just
how far our conventional healthcare buildings are falling short of the
mark, judged by the standards of ‘green’ architecture, the popular
name given to environmentally responsive and ecologically
sustainable building.
What we are discussing here is the social responsibility that
healthcare providers need to feel for the community that houses
their facility and provides them with their patients/profits. At the
stage of conceptualization of the proposed facility, thought needs to
be given to the environmental effects the proposal will have on its
surroundings. Architects have always been taught that the buildings
they design need to be ‘good neighbors’, but their clients, the
healthcare providers or individual doctors at a smaller scale, need to
understand this in the macro and micro sense.
Healthcare institutions’ core mission of protecting human health
provides the basis for them to speak with their words and actions on
the health implications of building construction and operation. The
healthcare industry has a leadership opportunity to move the larger
building industry to a healthier approach by demonstrating the best
in healthy, sustainable design, construction, operations and
maintenance practices in its own facilities.
This approach to design is known as ‘green’ architecture. This design
approach addresses concerns such as energy efficiency, the use of
clean energy resources, an improved indoor environment through
usage of green building materials and maximizing the use of
controlled daylighting, encouraging recycling and waste
prevention/management strategies and designing in ways that
promote good building operations practices.
Healthcare architects need to redefine the facilities they design as
healthy parts of a healthy regional ecosystem. The full range of
practices to be followed in the pursuit of these socially responsible
goals are beyond the scope of this article. HOSMAC works closely
with an NGO named Hosmac Foundation on promoting this ‘green’
initiative in healthcare delivery as a whole.
Hosmac Foundation is networked with a global movement called
Healthcare Without Harm, involving more than 300 NGOs and
professional organizations spread over 50 countries, working
towards establishing environmentally sound healthcare practices
and healthcare facility design and construction.
Moral Issues in Healthcare Facility Design
Every sensitive designer of buildings knows that during this process
In what way is architecture impacted? Mr. Hussain Varawalla, Design Mentor — Architecture Services — Hosmac, finds out.
Vertically Integrated Facility Design
37 38
HOSPITALMANAGEMENTC O N F E R E N C E
27 - 28 May 2011 Hotel The Westin Mumbai • •
27 - 28 May 2011 • Hotel The Westin Mumbai •
Knowledge Partner
Organised byProduced by
Some Keynote potential Speakers include: Enterprises Limited
? Mr. Amitabh Saxena, CEO, Anexas Consultancy (India)?
? Dr. Vivek Desai, MD, HOSMAC India Pvt Ltd.? Mr . Anupam Sibal, Group Medical Director, Indraprastha Apollo
Hospitals ? Mr. Rajendra Prasad Gupta, International Healthcare Policy
E x p e r t &? Dr . A M Joglekar, CEO, Godrej Memorial HospitalFounding President - DMAI
? Dr. Pervez Ahmed, CEO, Max Healthcare Institute Limited In two days of HOSPITAL MANAGEMENT CONFERENCE 2011 all
? Mr. Joy Chakraborty, Director, Administration and Materials, attendees will:
H i n d u j a H o s p i t a l? Gain insights to the key success factors of Hospital Operationsand Medical Research Centre
? Dr. B S. Ajaikumar, Founder & Chairman, H C G - Healthcare ? Understand the patient satisfaction through Lean and Six Sigma
G l o b a l implementation in Hospital
Mr. Vishal Bali, CEO, Fortis Hospital
Hospital Management Conference (HMC) is a research based content driven conference program that is specially designed in a unique two-
day format to bring up-to-date worldwide hospital management thinking and experience to senior hospital and healthcare managers in India.
This conference will feature senior levels experts from the hospital and healthcare industry sharing their experiences and insights on steps taken to
improve patient flow, safety and workflow processes. There will be case studies; interactive panel discussions on trends, challenges, solutions and
PLUS - gain tips from leading Hospitals via case studies and networking sessions
Registration Fees Details:
* 10.3% Service Tax Applicable, amount mentioned above are per delegate rate.
Category
1 Delegate
2 and More Delegates
*Early Bird Rate
Book and pay before30th April 2011
@ INR 10,000
@ INR 9,000
@ US$ 220
@ US$ 198
International DelegateIndian Delegate
*Standard Rate
1st May 2011 Onwards
Indian Delegate
@ INR 12,000
@ INR 10,800
International Delegate
@ US$ 264
@ US$ 238
Website - www.hmcindia.in
Telephone - +91 22 66122658 Mobile - + 91 99203 34407
Email - [email protected]
Mail - UBM Medica India Pvt. Ltd to 611-617, Sagar Tech
Plaza - A , Saki Naka Junction , Andheri -Kurla
4 Easy ways to Register :
they are constantly called upon to lay their values on the line. This
anyway sticky issue becomes positively gooey when designing
healthcare facilities.
For example: A disquieting trend in the future of healthcare delivery
systems – healthcare on a cost-versus-benefit equation. The
physician’s Hippocratic Oath prevents them from putting any kind of
price on human life. Until some time back, to do ‘everything possible’
for a patient cost very little more than to do nothing at all, simply
because there was not much that could be done.
To be sure, the ambition to do all one could to save a life is a noble
one. In the past, it was also economically feasible. Today, however,
there is much, much more that can be done for any given patient –
and each of these procedures, drugs and interventions comes with a
price tag, which the individual and ultimately society must pay.
Indiscriminately paying ‘for it all’ has already become crippling to
society, and insurance providers and government agencies are now
acknowledging that it is not merely crippling, but fatal. Outside the
metros the ability of patients’ families to pay these costs is limited,
and we have all heard stories of people selling their land to pay
doctors bills.
Diagnosis Related Groups (DRGs) are already expressions of
judgment about the effectiveness of procedures. Insurance providers
and government agencies are saying that they will pay for procedures
proven to be effective, but they will not pay for unproven or
marginally effective treatments. Such cost-versus-benefit judgments
will play a greater role in the delivery of healthcare, no matter who is
paying for the treatment. No longer will healthcare providers have
sacrosanct license to do ‘whatever is necessary’ in each and every
case.
The cost-versus-benefit goes beyond rupees and paise. Healthcare
consumers will increasingly weigh the prospective benefit of a given
treatment against the quality of life they may expect as a result of it. It
is not only likely that more patients will opt out of treatments that
prolong misery in order to merely prolong basic life processes, but
that life termination will become a viable medical option. Passive
euthanasia has lately been legalized by none other than the Supreme
Court of India itself, a visionary decision in my opinion.
No doubt the above is an issue involving medical ethics rather than
design. However, if we consider ‘healthcare facility design’ in it’s
larger context, beyond physical facility design (architecture), in the
context of overall conceptualization of the entire project, in which
the architect is but a team member rather than being in his/her
traditional role as team leader, he may be called upon to contribute
to a discussion on trade-offs in allocation of usually limited funds in
which the above issue will very much play on the mind of the client,
though it may remain unarticulated. It would be time then, for that
architect, to search his conscience for the right answer. His calculator
may not be of much help to him in that situation. Doctors constantly
make decisions involving life and death, many times with a very
practical basis, like on a battlefield. The healthcare architect too has
to realize that he is right there too on the front line; he has to make
tough calls without the crutch of a dramatic situation. Moral issues
are to be resolved between an individual and his conscience; no
article in a magazine can help you do that. All the best! Hopefully
there will be no more than one sleepless night per tougher decision.
I hope there is some better understanding of the medical,
architectural, engineering, social, emotional and moral issues, and
that this understanding is helping you to define ‘architecture’ as I
experience it day after day in our office. (Engineering issues, of
course, I have not discussed, best left to those specialists in the
know.) There is a complex web of interactions between all of these,
and the idea is that a positive change or contribution in one strand of
this web should send a ripple effect of positive changes throughout.
The task is to create an understanding within the organization of
individual responsibilities and how these impact their colleagues’
work within this mesh of causes and effects. Ideally the whole team
should work seamlessly, the project when built being the end result
of a smooth, cohesive effort. We at HOSMAC strive towards this goal.
The Consulting Services Marketplace
There are forces at work in society today which seek to reduce all
things to the marketplace in which the cheapest objects and services
are assumed to offer the best value. My experience in this
marketplace gives me little reason to support the view that the
cheapest and quickest design process is necessarily the best. Our by-
line in HOSMAC’s design team is ‘value addition through specialized
knowledge’, and I mean ‘value’ as in ‘VALUE!’ We are involved in a
search for continuously adding to this ‘specialized knowledge’
through a process of solving other people’s problems. It can be
painful and often frustrating, but it is ultimately an extremely
satisfying process involving substantial intellectual commitment on
our part. It flourishes best when there is an equal commitment from
the client and clearly benefits from a close and trusting relationship
between client and consultant.
The process of designing anything can be likened to a journey. As
seasoned travelers will know, many things can go wrong on journeys.
It helps if the territory is charted, and if you have made similar
journeys before, you know what to pack! The relief of arriving is of
course, welcome, and much anticipated, but we at HOSMAC agree
with Robert Louis Stephenson’s famous assertion that ‘to travel
hopefully is a better thing than to arrive, and the true success is to
labor’.
The author has had 20 years of rich experience in healthcare design
building, and has worked with Reliance Healthcare Ventures Ltd. He
can be reached at [email protected]
39
HOSPITALMANAGEMENTCONFERENCE
27 - 28 May 2011 Hotel The Westin Mumbai • •
27 - 28 May 2011 • Hotel The Westin Mumbai •
Knowledge Partner
Organised byProduced by
Some Keynote potential Speakers include: In two days of HOSPITAL MANAGEMENT CONFERENCE 2011 all attendees will:
� � Gain insights to the key success factors of Hospital Operations
� Mr . Anupam Sibal, Group Medical Director, Indraprastha Apollo Hospitals � Understand the patient satisfaction through Lean and Six Sigma
implementation in Hospital � Dr . A M Joglekar, CEO, Godrej Memorial Hospital
� Find out the Hyperbaric & Diving Medicine - A frontline Hospital Service � Dr. Pervez Ahmed, CEO, Max Healthcare Institute Limited
� Acquire the quality methodologies and applying accreditation� Mr. Joy Chakraborty, Director, Administration and Materials, Hinduja Hospital
and Medical Research Centre � Learn innovative practices to increase patient safety & satisfaction
� Dr. B S. Ajaikumar, Founder & Chairman, H C G - Healthcare Global� Discover the roadmap to an effective healthcare system
Enterprises Limited� Leverage the emerging technologies to build an effective healthcare system
� Mr. Amitabh Saxena, CEO, Anexas Consultancy (India)� Recognize the change management and other strategic management tools
� Dr. Vivek Desai, MD, HOSMAC India Pvt Ltd.� Successfully identify the quality improvement In healthcare
� Mr. Rajendra Prasad Gupta, International Healthcare Policy Expert &
Founding President - DMAI
Mr. Vishal Bali, CEO, Fortis Hospital
Hospital Management Conference (HMC) is a research based content driven conference program that is specially designed in a unique two-day format to bring up-to-
date worldwide hospital management thinking and experience to senior hospital and healthcare managers in India.
This conference will feature senior levels experts from the hospital and healthcare industry sharing their experiences and insights on steps taken to improve patient flow, safety
and workflow processes. There will be case studies; interactive panel discussions on trends, challenges, solutions and technologies that will help keep the industry in line with
current and future progress.
PLUS - gain tips from leading Hospitals via case studies and networking sessions
Hear inside success stories on Best Practices by Indraprastha Apollo, Godrej Memorial, Hinduja, Healthcare Global Enterprises Limited (HCG) and Max Healthcare
Registration Fees Details:
* 10.3% Service Tax Applicable, amount mentioned above are per delegate rate.
Category
1 Delegate
2 and More Delegates
*Early Bird Rate
Book and pay before30th April 2011
@ INR 10,000
@ INR 9,000
@ US$ 220
@ US$ 198
International DelegateIndian Delegate
*Standard Rate
1st May 2011 Onwards
Indian Delegate
@ INR 12,000
@ INR 10,800
International Delegate
@ US$ 264
@ US$ 238
Website - www.hmcindia.in
Telephone - +91 22 66122658 Mobile - + 91 99203 34407
Email - [email protected]
Mail - UBM Medica India Pvt. Ltd to 611-617, Sagar Tech Plaza - A ,
Saki Naka Junction , Andheri -Kurla Road, Andheri East, Mumbai
400 072. Maharashtra (India). Attn: Yogeeta Sant
4 Easy ways to Register :
About MES
The Government of India has launched a unique and elaborate
scheme for skill development – the Modular Employable Skills (MES)
scheme that is being implemented across India. The innovative
design of this scheme creates scope to include sections of society that
are outside the mainstream of education and vocational training.
Thus, school leavers and goers, casual workers, semi-skilled and
skilled labourers get an opportunity to develop and upgrade their
skills. More than 1200 trades in 90 sectors have been designed in a
modular fashion. Accordingly, every trade has a matrix of courses at
various levels of proficiency. A candidate successfully completes a
module to be able to move vertically or laterally to upgrade his or her
skills.
A key element around which the scheme revolves is ‘employability’.
This segregates it from other regular vocational training
programmes. Employability is assured through making the training
output-oriented. Every course therefore has a terminal competency
that the candidate has to achieve. This is ascertained through
external assessments of candidates, based on which the certificates
are issued to them. This way, unlike other vocational training courses
where the trainer, assessor and certifier were all in one, here the
three become separate agencies.
Other features of the scheme are:
· It provides the candidate a ‘minimum skills set’ required for
gainful employment in the industry.
· The scheme equips the candidate with employable skills in
a short span of time.
· The flexibility of the scheme enables lifelong learning with
multi entry and exit.
· It provides modular training in various levels of
competency.
· Terminal competency for every level is achieved by
focusing on employability through output oriented
training.
· The scheme has a flexible mechanism for the delivery of
training like part time, full time, weekends etc. offered by
Vocational Training Providers to suit the needs of various
target groups.
· External assessment of the candidates is conducted by
independent assessing bodies.
· The scheme also provides certification for skills acquired
informally.
The essence of the scheme is in the certification, which is recognized
nationally as well as internationally.
The MES Model
The 3 components of the MES model are: Training, External
Assessment, and Certification. Training is provided by existing
institutions of the government that are designated as Vocational
Training Providers (VTPs) or by private institutions and Industrial
Training Centers who apply to register as VTPs with the Directorate
General of Education and Training in their respective states.
Assessing bodies have been identified for various sectors over India.
They have a panel of assessors who have specific areas of expertise.
Based on their assessment, successful candidates are certified by the
National Council for Vocational Training (NCVT)
With inputs from Ms. Sumita Chakravarty, Ms. Punam Sah discusses the Minimum Employable
Skills programme and how it could play a vital role in solving India's healthcare problems.
Tapping the Opportunity of MES
Industry Engagement in MES
CII is one of the assessing bodies for all the sectors, pan-India. Its key
role is to organise assessments in an impartial manner. As an
assessing body, it has set up a panel of assessors who are experts in
the relevant sectors that they evaluate. Since the thrust of MES is on
employability, CII has to ensure that industry standards and
expectations are met. There are various avenues for industry
engagement to ensure employability for the workforce through the
MES:
· Companies/institutions can become Vocational Training
Providers to improve the employability of the candidates.
They can utilize their existing training facilities and
infrastructure.
· Companies/institutions can sign up as an off-base training
center by linking up with an existing VTP. Under this model,
candidates are registered with the VTP but undergo
training at the off-base training centre at the company.
· Existing or retired employees can conduct an assessment
by becoming assessors on CII’s panel thereby setting
acceptable standards for their sector.
· The industry can develop courses that are relevant to
them, which CII can facilitate to integrate with the MES
curriculum. They can also become a member of trade
committees for curriculum development whereby they can
integrate their own course or suggest and approve new
ones.
The Opportunity for Healthcare
Taking this lead, the CII Healthcare Sub-Committee, developed 7
modular courses for the Medical-Nursing sector which were recently
approved by the NCVT, and have now been integrated into the MES
course matrix:
1. Medical Record (MRD) Technician (MED 132)
2. Central Sterile Supply Department (CSSD) Technician (MED
240)
3. Dialysis Technologist (MED 238)
4. Radiology Technician (MED 239)
5. Nursing Aides (MED 134)
6. Operation Theatre (OT) Assistant (MED 241)
7. Infection Control Assistant (Level 1) (MED 135)
These courses can be viewed at
Four members of the subcommittee are hospitals with training
facilities. They have applied to be registered as VTPs to train their
existing staff and external candidates. The four prospective VTPs are:
1. Sir H. N. Hospital
2. Holy Family Hospital
3. Prince Aly Khan Hospital
4. S. L. Raheja (A Fortis Associate) Hospital
If more hospitals came forth to contribute towards strengthening
this scheme, training in the healthcare sector could be transformed
and that too in a short span of time.
The MES scheme has been launched by the Directorate General of
Employment and Training (DGE&T), the Ministry of Labour &
Employment (MoLE), the Government of India. Details of the
programme can be viewed on .
http://www.dget.nic.in/mes/curricula/Medical-Nursing.pdf
www.dget.nic.in/mes
The contributors work with CII Western Region as Deputy Directors.
For further information, contact .
41 42
About MES
The Government of India has launched a unique and elaborate
scheme for skill development – the Modular Employable Skills (MES)
scheme that is being implemented across India. The innovative
design of this scheme creates scope to include sections of society that
are outside the mainstream of education and vocational training.
Thus, school leavers and goers, casual workers, semi-skilled and
skilled labourers get an opportunity to develop and upgrade their
skills. More than 1200 trades in 90 sectors have been designed in a
modular fashion. Accordingly, every trade has a matrix of courses at
various levels of proficiency. A candidate successfully completes a
module to be able to move vertically or laterally to upgrade his or her
skills.
A key element around which the scheme revolves is ‘employability’.
This segregates it from other regular vocational training
programmes. Employability is assured through making the training
output-oriented. Every course therefore has a terminal competency
that the candidate has to achieve. This is ascertained through
external assessments of candidates, based on which the certificates
are issued to them. This way, unlike other vocational training courses
where the trainer, assessor and certifier were all in one, here the
three become separate agencies.
Other features of the scheme are:
· It provides the candidate a ‘minimum skills set’ required for
gainful employment in the industry.
· The scheme equips the candidate with employable skills in
a short span of time.
· The flexibility of the scheme enables lifelong learning with
multi entry and exit.
· It provides modular training in various levels of
competency.
· Terminal competency for every level is achieved by
focusing on employability through output oriented
training.
· The scheme has a flexible mechanism for the delivery of
training like part time, full time, weekends etc. offered by
Vocational Training Providers to suit the needs of various
target groups.
· External assessment of the candidates is conducted by
independent assessing bodies.
· The scheme also provides certification for skills acquired
informally.
The essence of the scheme is in the certification, which is recognized
nationally as well as internationally.
The MES Model
The 3 components of the MES model are: Training, External
Assessment, and Certification. Training is provided by existing
institutions of the government that are designated as Vocational
Training Providers (VTPs) or by private institutions and Industrial
Training Centers who apply to register as VTPs with the Directorate
General of Education and Training in their respective states.
Assessing bodies have been identified for various sectors over India.
They have a panel of assessors who have specific areas of expertise.
Based on their assessment, successful candidates are certified by the
National Council for Vocational Training (NCVT)
With inputs from Ms. Sumita Chakravarty, Ms. Punam Sah discusses the Minimum Employable
Skills programme and how it could play a vital role in solving India's healthcare problems.
Tapping the Opportunity of MES
Industry Engagement in MES
CII is one of the assessing bodies for all the sectors, pan-India. Its key
role is to organise assessments in an impartial manner. As an
assessing body, it has set up a panel of assessors who are experts in
the relevant sectors that they evaluate. Since the thrust of MES is on
employability, CII has to ensure that industry standards and
expectations are met. There are various avenues for industry
engagement to ensure employability for the workforce through the
MES:
· Companies/institutions can become Vocational Training
Providers to improve the employability of the candidates.
They can utilize their existing training facilities and
infrastructure.
· Companies/institutions can sign up as an off-base training
center by linking up with an existing VTP. Under this model,
candidates are registered with the VTP but undergo
training at the off-base training centre at the company.
· Existing or retired employees can conduct an assessment
by becoming assessors on CII’s panel thereby setting
acceptable standards for their sector.
· The industry can develop courses that are relevant to
them, which CII can facilitate to integrate with the MES
curriculum. They can also become a member of trade
committees for curriculum development whereby they can
integrate their own course or suggest and approve new
ones.
The Opportunity for Healthcare
Taking this lead, the CII Healthcare Sub-Committee, developed 7
modular courses for the Medical-Nursing sector which were recently
approved by the NCVT, and have now been integrated into the MES
course matrix:
1. Medical Record (MRD) Technician (MED 132)
2. Central Sterile Supply Department (CSSD) Technician (MED
240)
3. Dialysis Technologist (MED 238)
4. Radiology Technician (MED 239)
5. Nursing Aides (MED 134)
6. Operation Theatre (OT) Assistant (MED 241)
7. Infection Control Assistant (Level 1) (MED 135)
These courses can be viewed at
Four members of the subcommittee are hospitals with training
facilities. They have applied to be registered as VTPs to train their
existing staff and external candidates. The four prospective VTPs are:
1. Sir H. N. Hospital
2. Holy Family Hospital
3. Prince Aly Khan Hospital
4. S. L. Raheja (A Fortis Associate) Hospital
If more hospitals came forth to contribute towards strengthening
this scheme, training in the healthcare sector could be transformed
and that too in a short span of time.
The MES scheme has been launched by the Directorate General of
Employment and Training (DGE&T), the Ministry of Labour &
Employment (MoLE), the Government of India. Details of the
programme can be viewed on .
http://www.dget.nic.in/mes/curricula/Medical-Nursing.pdf
www.dget.nic.in/mes
The contributors work with CII Western Region as Deputy Directors.
For further information, contact .
41 42
A very famous quote by one of our founding fathers, Mahatma
Gandhi, comes to mind: “India lives in her villages, not in her cities.”
The 2001 census tells us that 74.24% of our population lives in rural
India, while only about 25.73% it lives in urban India. Despite these
statistics, rural India receives only about 15% share of healthcare
resources. According to the review of Healthcare in India, 2005, the
rural population has only 9.85 beds per lakh population, 0.36
hospitals per lakh population, and 1.49 dispensaries per lakh
population. Studies have shown that about 46% of the rural
population travels to cities for medical treatment.
To link the urban and rural divide, new healthcare models are the
need of the hour. India has developed considerably in the last few
years but it has left the development of healthcare in rural areas far
behind. To bridge this gap, new proposals for healthcare
development should be created; the healthcare industry should
evolve in a new way. Along with education, every individual should
have access to quality healthcare in all parts of the country; it should
be a constitutional right of every citizen of India. Under new systems,
healthcare should be treated as infrastructure and the government
should play a very active role in supporting and aiding upcoming
hospitals. This status of ‘infrastructure’ would translate to more
private players being encouraged to enter the industry. India spends
less than 2% of its GDP on health, compared to a 73% out-of-pocket
spending; this is much lower in comparison to many developing and
developed countries. Most European countries spend about 9%-11%
of their GDP on public health, while the United States of America
spends about 18% of their GDP on public health. Government
expenditure as a share of the total health expenditure in India is even
less than what Asian countries such as China and Indonesia spend on
healthcare. This has a direct impact on maternal and child mortality.
Globally, it is estimated that an annual rate of decline of 4.4% is
needed to reduce deaths of children below 5 years of age by two-
thirds by 2015. In India, the annual rate of decline in child mortality
between 1990 and 2008 is 2.25%. As per the 2015 target, the
required rate of decline from 2009 to 2015 per year must be 6.28%.
In the recent union budget, a 5% service tax had been imposed on all
services provided by private hospitals with at least 25 beds and
central air-conditioning and also on all diagnostic tests. However,
due to a huge outcry from consumers and doctors alike, this tax was
later withdrawn. If such taxes are implemented they will have a
negative impact on the growing healthcare sector. A large number of
hospitals will be affected and the brunt of taxes imposed on them will
eventually be passed on to the consumer. As a result, patients may
defer their treatments and there may be a drop in the elective and
What India needs is a healthcare revolution. Lisha Ruparel finds out how with insights from
Mr. Narendra Karkera, Director — Finance — Hosmac.
Healthcare For All preventive healthcare demand.
In order to increase the efficiency and reach of healthcare in all parts
of India, the Government could encourage privatisation in the
healthcare sector.
Privatisation of Healthcare in India
The Government should bring about more privatisation in the
healthcare sector even at the primary and secondary level. As of now,
the Government provides primary healthcare in the country, but
faces many problems like inadequacy, inefficiency and improper
utilization of resources. Studies in other countries have shown that
the cost of primary and secondary medical treatment decreased by
about 30% when it was managed by the private sector. There was also
higher patient satisfaction. The private sector brings about
demonstrable efficiency benefits that can outweigh the higher costs
of private capital. Private players are driven by their financial interests
to deliver on time, while also meeting budgets and optimising cost
benefit ratios. The government should encourage privatisation by
making new policies that will encourage private players to enter the
healthcare industry. The Government can aid by reforming policies in:
Taxation
New tax laws should be made and implemented in which
new, upcoming hospitals in rural areas should be given tax
holidays for a decade. The Government can also aid them
by providing long term loans at very low interest rates.
Providing Land at Subsidized Rates
Even land in rural areas should be provided at subsidized
rates. Stamp duty and registration fees should also be
decreased.
Medical Equipment
Import taxes on medical equipment should be decreased.
Other taxes such as VAT, sales tax should also be decreased.
Power at Subsidized Rates
Power supplied to hospitals should be highly subsidized.
The Government should also help in setting up alternate
sources of energy like solar panels for electricity generation
and setting up windmills wherever possible.
All these incentives will encourage doctors, individuals and
corporates to set up more hospitals in rural areas instead of urban
areas, where cost of land and construction is very high.
The Government should also encourage more private players to enter
the healthcare industry in these rural areas. The role of the
Government should change from being the provider to the
moderator. We could also turn to Private-Public Partnerships for
maximum utilization of all resources.
Schools, colleges and healthcare institutions should be set up in all
villages. This will encourage more people to migrate to villages
instead of flocking to cities, large towns or metros. The availability of
cheap yet good quality healthcare and education in villages could
bring about this ‘reverse migration’.
The Effect of Insurance
As of now, the penetration of insurance in the healthcare industry is
very low. Most of the population is not aware of health insurance, or
they feel that they don’t require it. Recently schemes have been
started by the Government in which vouchers are provided to people
below the poverty line by means of which they can claim medical
treatments. This scheme has been started only in few states as of
now, and could be implemented in all parts of India. A healthcare cess
should be created by which funds for healthcare can be generated.
People above poverty line should also be given health insurance at
subsidized rates.
Schemes such as the Yeshasvini Health Insurance Scheme were
introduced in rural Karnataka in the year 2003. For a premium
payment of INR 5 per month or INR 60 per year people could avail for
comprehensive coverage of all surgical procedures and outpatient
care. This scheme was very successful and similar models have been
implemented in parts of Gujarat. Similarly the Arogyasri Community
Health Insurance Scheme was made available in a few districts in
Andhra Pradesh to the population below the poverty line. Under this
scheme, the Government pays the insurance premium to the private
insurance company.
The Rashtriya Swasthya Bima Yojna scheme was launched in 2007 to
provide a smart card-based, cashless health insurance cover of INR
30,000 per family, for a unit of 5, for below poverty line families in the
unorganised sector. The premium is shared by the Central and State stGovernment. As of 31 January 2011 this scheme has been
implemented in 25 states and union territories.
Such programs have been tried in various states and have been found
to be successful and it high time that they be implemented
throughout India.
To Look After
Hospitals in the rural areas should be developed to not only to cater
to health needs but also to look after social, mental and physical well-
being of the individual. They can provide all forms of medicine like
Ayurveda, homeopathy, yoga retreats, spas etc. People from cities
43 44
A very famous quote by one of our founding fathers, Mahatma
Gandhi, comes to mind: “India lives in her villages, not in her cities.”
The 2001 census tells us that 74.24% of our population lives in rural
India, while only about 25.73% it lives in urban India. Despite these
statistics, rural India receives only about 15% share of healthcare
resources. According to the review of Healthcare in India, 2005, the
rural population has only 9.85 beds per lakh population, 0.36
hospitals per lakh population, and 1.49 dispensaries per lakh
population. Studies have shown that about 46% of the rural
population travels to cities for medical treatment.
To link the urban and rural divide, new healthcare models are the
need of the hour. India has developed considerably in the last few
years but it has left the development of healthcare in rural areas far
behind. To bridge this gap, new proposals for healthcare
development should be created; the healthcare industry should
evolve in a new way. Along with education, every individual should
have access to quality healthcare in all parts of the country; it should
be a constitutional right of every citizen of India. Under new systems,
healthcare should be treated as infrastructure and the government
should play a very active role in supporting and aiding upcoming
hospitals. This status of ‘infrastructure’ would translate to more
private players being encouraged to enter the industry. India spends
less than 2% of its GDP on health, compared to a 73% out-of-pocket
spending; this is much lower in comparison to many developing and
developed countries. Most European countries spend about 9%-11%
of their GDP on public health, while the United States of America
spends about 18% of their GDP on public health. Government
expenditure as a share of the total health expenditure in India is even
less than what Asian countries such as China and Indonesia spend on
healthcare. This has a direct impact on maternal and child mortality.
Globally, it is estimated that an annual rate of decline of 4.4% is
needed to reduce deaths of children below 5 years of age by two-
thirds by 2015. In India, the annual rate of decline in child mortality
between 1990 and 2008 is 2.25%. As per the 2015 target, the
required rate of decline from 2009 to 2015 per year must be 6.28%.
In the recent union budget, a 5% service tax had been imposed on all
services provided by private hospitals with at least 25 beds and
central air-conditioning and also on all diagnostic tests. However,
due to a huge outcry from consumers and doctors alike, this tax was
later withdrawn. If such taxes are implemented they will have a
negative impact on the growing healthcare sector. A large number of
hospitals will be affected and the brunt of taxes imposed on them will
eventually be passed on to the consumer. As a result, patients may
defer their treatments and there may be a drop in the elective and
What India needs is a healthcare revolution. Lisha Ruparel finds out how with insights from
Mr. Narendra Karkera, Director — Finance — Hosmac.
Healthcare For All preventive healthcare demand.
In order to increase the efficiency and reach of healthcare in all parts
of India, the Government could encourage privatisation in the
healthcare sector.
Privatisation of Healthcare in India
The Government should bring about more privatisation in the
healthcare sector even at the primary and secondary level. As of now,
the Government provides primary healthcare in the country, but
faces many problems like inadequacy, inefficiency and improper
utilization of resources. Studies in other countries have shown that
the cost of primary and secondary medical treatment decreased by
about 30% when it was managed by the private sector. There was also
higher patient satisfaction. The private sector brings about
demonstrable efficiency benefits that can outweigh the higher costs
of private capital. Private players are driven by their financial interests
to deliver on time, while also meeting budgets and optimising cost
benefit ratios. The government should encourage privatisation by
making new policies that will encourage private players to enter the
healthcare industry. The Government can aid by reforming policies in:
Taxation
New tax laws should be made and implemented in which
new, upcoming hospitals in rural areas should be given tax
holidays for a decade. The Government can also aid them
by providing long term loans at very low interest rates.
Providing Land at Subsidized Rates
Even land in rural areas should be provided at subsidized
rates. Stamp duty and registration fees should also be
decreased.
Medical Equipment
Import taxes on medical equipment should be decreased.
Other taxes such as VAT, sales tax should also be decreased.
Power at Subsidized Rates
Power supplied to hospitals should be highly subsidized.
The Government should also help in setting up alternate
sources of energy like solar panels for electricity generation
and setting up windmills wherever possible.
All these incentives will encourage doctors, individuals and
corporates to set up more hospitals in rural areas instead of urban
areas, where cost of land and construction is very high.
The Government should also encourage more private players to enter
the healthcare industry in these rural areas. The role of the
Government should change from being the provider to the
moderator. We could also turn to Private-Public Partnerships for
maximum utilization of all resources.
Schools, colleges and healthcare institutions should be set up in all
villages. This will encourage more people to migrate to villages
instead of flocking to cities, large towns or metros. The availability of
cheap yet good quality healthcare and education in villages could
bring about this ‘reverse migration’.
The Effect of Insurance
As of now, the penetration of insurance in the healthcare industry is
very low. Most of the population is not aware of health insurance, or
they feel that they don’t require it. Recently schemes have been
started by the Government in which vouchers are provided to people
below the poverty line by means of which they can claim medical
treatments. This scheme has been started only in few states as of
now, and could be implemented in all parts of India. A healthcare cess
should be created by which funds for healthcare can be generated.
People above poverty line should also be given health insurance at
subsidized rates.
Schemes such as the Yeshasvini Health Insurance Scheme were
introduced in rural Karnataka in the year 2003. For a premium
payment of INR 5 per month or INR 60 per year people could avail for
comprehensive coverage of all surgical procedures and outpatient
care. This scheme was very successful and similar models have been
implemented in parts of Gujarat. Similarly the Arogyasri Community
Health Insurance Scheme was made available in a few districts in
Andhra Pradesh to the population below the poverty line. Under this
scheme, the Government pays the insurance premium to the private
insurance company.
The Rashtriya Swasthya Bima Yojna scheme was launched in 2007 to
provide a smart card-based, cashless health insurance cover of INR
30,000 per family, for a unit of 5, for below poverty line families in the
unorganised sector. The premium is shared by the Central and State stGovernment. As of 31 January 2011 this scheme has been
implemented in 25 states and union territories.
Such programs have been tried in various states and have been found
to be successful and it high time that they be implemented
throughout India.
To Look After
Hospitals in the rural areas should be developed to not only to cater
to health needs but also to look after social, mental and physical well-
being of the individual. They can provide all forms of medicine like
Ayurveda, homeopathy, yoga retreats, spas etc. People from cities
43 44
can visit rural areas for vacations along with attending to their
medical needs; a concept known as ‘medical tourism’.
Alternate forms of treatments like Ayurveda, homeopathy etc. could
be encouraged to look after the primary healthcare needs of the
population at a moderate cost so as to decrease the load on allopathy.
This way, only patients requiring secondary medical care will be sent
to hospitals, thus reducing the burden on them.
The Government should also set up medical and nursing colleges to
train paramedical staff and nurses, since, according to the McKinsey
report, there is a shortage of 1.4 million doctors and 2.8 million
nurses in India
Price Control Mechanism
The cost record rule must be implemented in all hospitals as a
statutory requirement. The costs in the hospitals should be subject to
cost audits by cost accountants. Hence, this price control mechanism
will help in determining the costs for all treatments. Hospitals should
declare the rates for all their treatments; this will correspond to the
pharmaceutical industry, too. Such measures will help in bringing
more quality to the healthcare sector.
The Effect on Economy
With all the subsidies and help the Government will provide in setting
up hospitals, more private players will enter the healthcare industry,
thus translating to more profit and cash generation.
Thus the role of the Government will change from provider to
facilitator. Hence Government funding for running hospitals will
decrease.
As a result of privatisation, there will be efficiency, profitability and
overall growth of the sector. This will also give a boost to the
healthcare insurance sector. As of now, healthcare in India is
segmented; health is a state matter, so there are very few centralised
policies. New centralised policies and reforms should be created and
implemented so there is a penetration of healthcare in all parts of
India.
As a country that has exhibited its prowess and intellectual capability
in numerous knowledge-based sectors to emerge as a frontrunner
worldwide, we have the unique opportunity to design viable and
sustainable healthcare delivery models. We therefore need
‘Healthcare in India’ to be a priority.
Mr. Karkera has served the finance and administration departments
in leading healthcare organizations for over37 years. He can be
reached at [email protected]
45
can visit rural areas for vacations along with attending to their
medical needs; a concept known as ‘medical tourism’.
Alternate forms of treatments like Ayurveda, homeopathy etc. could
be encouraged to look after the primary healthcare needs of the
population at a moderate cost so as to decrease the load on allopathy.
This way, only patients requiring secondary medical care will be sent
to hospitals, thus reducing the burden on them.
The Government should also set up medical and nursing colleges to
train paramedical staff and nurses, since, according to the McKinsey
report, there is a shortage of 1.4 million doctors and 2.8 million
nurses in India
Price Control Mechanism
The cost record rule must be implemented in all hospitals as a
statutory requirement. The costs in the hospitals should be subject to
cost audits by cost accountants. Hence, this price control mechanism
will help in determining the costs for all treatments. Hospitals should
declare the rates for all their treatments; this will correspond to the
pharmaceutical industry, too. Such measures will help in bringing
more quality to the healthcare sector.
The Effect on Economy
With all the subsidies and help the Government will provide in setting
up hospitals, more private players will enter the healthcare industry,
thus translating to more profit and cash generation.
Thus the role of the Government will change from provider to
facilitator. Hence Government funding for running hospitals will
decrease.
As a result of privatisation, there will be efficiency, profitability and
overall growth of the sector. This will also give a boost to the
healthcare insurance sector. As of now, healthcare in India is
segmented; health is a state matter, so there are very few centralised
policies. New centralised policies and reforms should be created and
implemented so there is a penetration of healthcare in all parts of
India.
As a country that has exhibited its prowess and intellectual capability
in numerous knowledge-based sectors to emerge as a frontrunner
worldwide, we have the unique opportunity to design viable and
sustainable healthcare delivery models. We therefore need
‘Healthcare in India’ to be a priority.
Mr. Karkera has served the finance and administration departments
in leading healthcare organizations for over37 years. He can be
reached at [email protected]
45
Head Office
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Cover StoryPg. 11
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Taking Healthcare Beyond The Metros
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