Budget 2020: What the healthcare sector was expecting from the union budget

Whenever there is a discussion about Healthcare, the views expressed are mainly through the lens of the stake holder. Hence, we miss the big picture and our focus streams towards narrow goals. So, before we express our expectations from the Union Health Budget 2020, let us look at some of the key facts covering the globe and India:

Key facts (Globe): At least half of the world’s population still do not have full coverage of essential health services. About 100 million people are still being pushed into extreme poverty (defined as living on 1.90 USD or less a day) because they have to pay for health care. Over 930 million people (around 12% of the world’s population) spend at least 10% of their household budgets to pay for health care.

All UN Member States, including India, have agreed to try to achieve universal health coverage (UHC) by 2030, as part of the Sustainable Development Goals.

Key facts (India): In 2018-19, the government spending on healthcare in India was only slightly greater than 1% of the GDP; this is very low compared to government spending on healthcare at 7% to 12% of GDP in other developing countries. The expectation is positive steps to move the budget allocation and therefore increased government spending on healthcare.

While the Indian healthcare sector has grown at a healthy double-digit rate, challenges in access to quality and affordable healthcare persist in large parts of the country. With less than 1 physician per 1000 population, India is well behind its peer countries. It needs an additional 3.6 million hospital beds to reach the recommended capacity.

Only about 27% of India’s population is covered around any form of health insurance and the out of pocket expenditure on health is 62.4% in India as compared to the world average of 18.2%.

The medical technology industry plays a crucial role throughout the healthcare lifecycle and has been instrumental in transforming healthcare ecosystems across the world. For India too, the MedTech industry offers the potential to address the healthcare issues by using a mix of existing as well as cutting-edge technologies.

Out-of-pocket (OOP) health expenses drove 55 million Indians- -more than the population of South Korea, Spain or Kenya–into poverty in 2011-12, and of these, 38 million (69%) were impoverished by expenditure on medicines alone, according to calculations by the Public Health Foundation of India (PHFI), an advocacy, which were released on June 6, 2018, and based on the official Indian standard for poverty line–a monthly expenditure of Rs 816 in rural areas and Rs 1,000 in urban areas.

Part of the root cause is low public investment in health. According to WHO, India ranks 184th out of 191 countries in terms of percent-of-GDP spending on health. At around $29 (PPP), Sri Lanka, China, and Thailand all invest three to four times more per capita. The low provision of pro-poor services leads to an undue reliance on out-of-pocket financing for health. Currently, 85.9% of private healthcare is financed out-of-pocket—only Pakistan, Bhutan, Myanmar and Bangladesh have higher rates in South Asia.

Healthcare inflation is about 15 to 17 % hence healthcare costs go up by 15% to 17% annually. The Indian healthcare sector has the potential to be amongst the highest revenue and employment generator for the country. The ability of private healthcare providers to create five direct jobs plus many more indirect jobs per bed and two and half times multiplier on capital invested, should be considered as a positive by the policy makers.

Overview

The answer to India’s Healthcare woes is Universal Health Coverage (UHC): UHC means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.

UHC enables everyone to access the services that address the most significant causes of disease and death, and ensures that the quality of those services is good enough to improve the health of the people who receive them.

Protecting people from the financial consequences of paying for health services out of their own pockets reduces the risk that people will be pushed into poverty because unexpected illness requires them to use up their life savings, sell assets, or borrow – destroying their futures and often those of their children.

Achieving UHC is one of the targets the nations of the world set when adopting the Sustainable Development Goals in 2015. Countries that progress towards UHC will make progress towards the other health-related targets, and towards the other goals. Good health allows children to learn and adults to earn, helps people escape from poverty and provides the basis for long-term economic development.

What UHC is not:

There are many things that are not included in the scope of UHC:

UHC does not mean free coverage for all possible health interventions, regardless of the cost, as no country can provide all services free of charge on a sustainable basis. UHC is not just about health financing. It encompasses all components of the health system: health service delivery systems, the health workforce, health facilities and communications networks, health technologies, information systems, quality assurance mechanisms, and governance and legislation.

UHC is not only about ensuring a minimum package of health services, but also about ensuring a progressive expansion of coverage of health services and financial protection as more resources become available.

UHC is not only about individual treatment services, but also includes population-based services such as public health campaigns, adding fluoride to water, controlling mosquito breeding grounds, and so on. UHC is comprised of much more than just health; taking steps towards UHC means steps towards equity, development priorities, and social inclusion and cohesion.

How can countries like India make progress towards UHC?

Many countries like India are already making progress towards UHC. All countries can take actions to move more rapidly towards it, or to maintain the gains they have already made. In countries where health services have traditionally been accessible and affordable, governments are finding it increasingly difficult to respond to the ever-growing health needs of the populations and the increasing costs of health services.

Moving towards UHC requires strengthening health systems in all countries. Robust financing structures are key. When people have to pay most of the cost for health services out of their own pockets, the poor are often unable to obtain many of the services they need, and even the rich may be exposed to financial hardship in the event of severe or long-term illness. Pooling funds from compulsory funding sources (such as mandatory insurance contributions) can spread the financial risks of illness across a population.

Improving health service coverage and health outcomes depends on the availability, accessibility, and capacity of health workers to deliver quality peoplecentred integrated care. Investments in quality primary health care will be the cornerstone for achieving UHC around the world. Investing in the primary health care workforce is the most cost-effective way to ensure access to essential health care will improve. Good governance, sound systems of procurement and supply of medicines and health technologies and wellfunctioning health information systems are other critical elements.

Why is primary health care the soul of UHC?

Primary health care is an approach to health and wellbeing centred on the needs and circumstances of individuals, families and communities. It addresses comprehensive and interrelated physical, mental and social health and wellbeing. It is about providing whole-person care for health needs throughout life, not just treating a set of specific diseases. Primary health care ensures people receive comprehensive care, ranging from promotion and prevention to treatment, rehabilitation and palliative care as close as feasible to people’s everyday environment.

WHO has developed a cohesive definition of primary health care based on three components: ensuring people’s health problems are addressed through comprehensive promotive, protective, preventive, curative, rehabilitative, and palliative care throughout the life course, strategically prioritizing key system functions aimed at individuals and families and the population as the central elements of integrated service delivery across all levels of care;

Priority sector status must be accorded to the healthcare industry.

A separate bureaucratic cadre christened as “Indian Healthcare Services” on lines like IAS should be established to ensure that Health gets the highest priority.

We need a multi-pronged approach from the government to strengthen and reform the healthcare sector in India. On the one hand, it involves improving the state of public healthcare by increasing budgetary allocation, establishing more Medical/Paramedical/Pharmacy/ Nursing colleges and improving primary healthcare facilities. On the other hand, it involves measures to enable the private sector to spread its presence beyond the urban population. This will help in improving accessibility for secondary and tertiary care in tier 2/3 towns and rural areas. For the latter to happen, the government must offer major incentives and tax breaks to private healthcare organizations setting shop in non-urban areas. These incentives can include income tax breaks for first five years of operations, help in procuring land, making medical equipment GST free for such hospitals and relaxation on service tax on hospital inputs. Similarly, establishing a mechanism to offer fund support or subsidization in treatment cost to private hospitals in smaller towns and rural areas can go a long way in bridging the accessibility gap. This will also help generate jobs and make quality healthcare more accessible.

Home and Ambulatory Healthcare should be recognized as a separate sub-sector of Healthcare as it forms the backbone of primary healthcare and addresses lack of adequate hospital beds especially for rural areas. This should also include increased tax incentives for preventive health checkups under 80D.

Allowing FDI in E-pharmacy sector and recognition of E-pharmacies under Drugs and Cosmetics Act is another impending reform.

The government’s flagship scheme Ayushman Bharat PMJAY, in its first year, has managed to empanel over 15,000 hospitals. Currently only 3.57 crore families of the original 10.74 crore families have been issued golden cards, and this number is expected to go up significantly this year. The government will therefore need to substantially increase its previous year’s allocation of INR 6000 crore as it attempts to expand the scheme’s footprint this year and eventually merge it in the long run with other schemes such as ECHS, ESI, and CGHS.

The government must consider credit guarantee for hospitals under PMJAY and other Government insurance schemes, since payments take time to come to the hospital. The government should incentivize /give credit guarantee to lenders who are willing to fund the receivables.

Challenges across multiple dimensions that were disablers to the growth of indigenous medical devices manufacturing in India need to be addressed. These include aspects around the macroeconomic environment, the medical devices ecosystem and, those specific to the medical devices industry.

Unfavourable duty structure: An unfavourable duty structure in many segments/sub-segments make imports cheaper than manufacturing in India segments/sub-segments make imports cheaper than manufacturing in India.

Lack of comprehensive laws and lax enforcement mechanisms for IP protection: IP protection for novel technology is critical for the success of global medical devices players investing outside their home market. In the absence of enforceable IP laws, global players would lack confidence to invest in manufacturing assets, thus limiting India manufacturing (suppliers, raw material etc.) for medical device manufacturing.

Medical technology has the potential to do the same for healthcare by leapfrogging over the current infrastructural, skill based, geographical and affordability constraints. Medical Technology can bridge the distance between the care provider and the patient thereby helping patients in remote areas access specialist and specializedcould intervene include:  Setting up an independent authority for medical devices and enabling faster grant of patents.

Supporting local demand of medical devices through public health and health insurance programs as well as by collaborating with the private sector through PPP models. Providing relevant financial incentives for the industry.

Ease of doing business: India still lags behind most countries in terms of ease of doing business. Due to complex regulatory requirements, products currently require multiple agency approvals. This leads to time delays at multiple layers, at both the national and state levels.

Limited availability of skilled workforce and restrictive labor laws: Despite sufficient human capital, there are unfavourable labor laws and limited trained workforce in India to install operate, repair and service equipment.

Inadequate ecosystem support (suppliers, raw material etc.) for medical device manufacturing. Medical technology has the potential to do the same for healthcare by leapfrogging over the current infrastructural, skill based, geographical and affordability constraints. Medical Technology can bridge the distance between the care provider and the patient thereby helping patients in remote areas access specialist and specialized equipment present in large cities far away. Technological advancements in the fields of health monitoring and diagnostics can help in detecting health issues early on thereby reducing overall cost of care and enhancing wellness levels of the society. Similarly, technological interventions are rapidly increasing the precision and efficacy of treatment modalities thereby improving clinical outcomes. However, to realize this opportunity at scale rather than as isolated, fragmented initiatives, both the government and the industry will need to make concerted efforts.

Some of the key areas where government could intervene include: Setting up an independent authority for medical devices and enabling faster grant of patents. Supporting local demand of medical devices through public health and health insurance programs as well as by collaborating with the private sector through PPP models. Providing relevant financial incentives for the industry. Supporting innovation in India by providing capital and infrastructure support to MedTech start-ups. In addition, as the road map for medical devices manufacturing is charted, learning that created growth trajectories of other industries can be adopted: Liberalization and opening up of markets policy reforms (ease of doing business).

Financial and non-financial incentives (in terms of import duty, export duty, SEZs). Designing comprehensive laws and a robust regulatory environment for high IP industries. Government expenditure to initiate ecosystem development. Government should also come up with medical innovation fund separately to boost health tech start-ups.

The Government must allocate funds for improving the school infrastructure to ensure hygienic and healthy school environment, improved meal experience, clean hand wash and sanitation facilities. The Government must focus on the convergence of drinking and potable water schemes of the Jal Shakti Ministry with the MidDay Meal Programme by earmarking the budget for the scheme.

The Government must make budgetary allocations for monitoring the growth and development of all the children in Primary and Upper Primary Schools and set up a parallel linkage with the National Health Mission in cases of referrals. We are also hopeful that the MDM Programme will be aligned with the parameters of POSHAN Abhiyan to address child malnutrition using various interventions.

Life saving equipment such as ventilators, BIPAP and CPAP, etc. have been placed under heavy taxes. Even something as basic as crutches and wheelchairs have been put under the 5% to 7.5% GST bracket. These are essentials and should not have been taxed. It is perplexing to see how the medical equipment spare parts are being taxed under the highest slot of 28% GST. This is highly debilitating for the healthcare industry. There should be a critical evaluation of the situation and that there should be serious thought given to make healthcare essential equipment tax free.

AI has the potential to solve many problems of Healthcare Delivery in the country. Access to large volumes of quality data is vital for the success of AI. More budget allocation towards R&D in medical device innovation and digitization of care delivery process through right investment in tools, infrastructure and training will help us to meet some of the challenges in the Healthcare Industry.

The government should accord due recognition to the emergency medical services (EMS) industry and recognise it as an independent sector within the healthcare industry. 90% of the EMS space is controlled by the government. The sector is in urgent need of impetus in the form of budgetary allocation of funds so that even the remotest parts of the country have access to timely quality medical care. There is a severe demand supply gap when it comes to the availability of ambulances in India with the ratio of ambulances per capita pegged at 1:146249. We need to move to a ratio of 1:60000 and this can only happen if the government incentivises the industry in the form of subsidies. The government should also invest in setting up skill centres for training paramedics and emergency medical technicians. While the government is already taking steps to improve road connectivity, we believe the government should look at increasing the accessibility of emergency medical services through station ambulance services on national highways and medical units on trains.

Globally there is acceptance of the growing significance of molecular genetics in diagnosis as well as clinical management of various cancers. The government should help create a regulatory environment extremely conducive for promoting research in the field of cancer genetics by creating a hub for cancer research. Quality research in cancer genetics will go a long way in making new therapies available to Indian patients at very affordable costs.

The Indian Pharmaceutical industry is a sunrise industry with a competitive advantage for India. We should leverage India’s position by unleashing entrepreneurial spirit through policy stability and ecosystem.

There is an utter need to spread awareness amongst the masses to promote health insurance which has become a must considering the current healthcare cost in the country. Enhancing the tax rebate under Section 80D from the current value of Rs. 25, 000 to Rs. 1,50, 000 can be a great move by the government. Under this year’s budget, the government must waive off the GST charges which are currently 18% on health insurance premiums.

Another expectation in this year’s budget is giving the consumers ability to pay level premiums to 5 years with multiple payment modes as available in other insurance industries like Life Insurance. The payment methods can be extended to monthly, quarterly, half-yearly, and limited pay in order to make the premium payment process convenient for the consumers. This will surely make Healthcare in India affordable and accessible.

Currently, the health insurance industry in India has a long gestation period and it takes a long time for the insurers to achieve a break-even. As per the industry experts, the limit of eight years for carry forward and set-off of business losses is not sufficient. This limit must be increased.

India is the second most populous country in the world. The death rate has declined but birth rates continue to be high in most of the states. Health care structure in the country is overburdened by increasing population Family planning programs need to be (re)activated by the Government.

To boost Quality in Healthcare, the Government must incentivize organizations who have NABH Accreditation; it could be in terms of tax benefits, GST benefits, Local self governments tax benefits, etc.

Composed by Dr. Rajeev Boudhankar, Health Systems Management

Dr. Rajeev Boudhankar has over 30 years of healthcare experience in Hospitals & Health Systems Management. He was instrumental in restarting a tertiary care hospital and supported till its full operationalization after a major natural disaster. He has worked as a consultant in a major Hospital Management Consultancy Company and also as a core team member in setting up Public Health Program in association with an International Agency and State Government.

AI revolution in the field of healthcare

A doctor being counterquestioned by the patient armed with newly acquired knowledge regarding his symptoms through numerous online websites is already a frequent occurrence nowadays. Add to that the apps, which monitor your vital parameters at all times and the scope for further improvements; wherein, the test results can be fed to your app and the diagnosis indicated by the app would usually be pretty accurate. When Artificial Intelligence, Robotics and Big Data analysis is added to this, it just keeps getting bigger and better. Like most of the conventional industry, the healthcare industry is going to see a big disruption soon. Should the doctors be alarmed, may be yes, may be no; should they be excited Yes!

The advances made in the field suggest that AI should be embraced with open arms in the healthcare sector as it would augment the medical practitioners in not only penetrating these services to larger percentage of society, but also utilizing the time more effectively on each patient and arrive at a more accurate diagnosis. The data collected and learnings inferenced can further improve the medical as well as training processes.

The changes in disease profiles in our country and increase in chronic diseases demand (increase in diseases due to pollution is yet to show its real size) that state and central governments collaborate with researchers and healthcare giants to implement suitable programs that improve healthcare and AI can be a force multiplier in this regard. The effect of AI on major problems being encountered in India in healthcare sector will be discussed one by one:

1. Neglect of Rural Population. India faces acute lack of healthcare facilities in rural areas in terms of both quality and quantity. As per information in open domain, the rural population which comprises 75% of total populace have access to only 31.5% hospitals and 16% beds. Only 37% of people were able to access IP facilities within a 5 km distance, and 68% were able to access out-patient facilities due to limitation in number of doctors and lack of infrastructure. Unwillingness of skilled healthcare officials to work in rural areas only compounds the issue. Minimum tenures of officials have been made compulsory in some states; however, the same is grossly inadequate. According to the rural health statistics of the Government of India (2015), about 10.4% of the sanctioned posts of auxiliary nurse midwives are vacant, which rises to 40.7% of the posts of male health workers. 27% of doctor posts at PHCs were vacant, which is more than a quarter of the sanctioned posts. AI based solutions can use this limited infrastructure and manpower much more effectively. The present and predictive analysis of number of patients is one such tool through which the District Administration can keep a tab on actual situation on ground and can even predict the outbreak of an epidemic. The smart use of paramedicals may also be employed. Use of lightweight equipment for measuring ECG, blood pressure, heart rate, auscultation, oxygen saturation and the temperature of a patient which can transmit data wirelessly anywhere is already a reality and is already making big impact through low cost solutions to rural healthcare. ‘A3RMT’ is one such startup which assisted in treatment of more than 56,000 patients in 450 locations in India and saved more than 2,000 lives through emergency intervention.

2. Only Cure Based. Though the old saying preaches that ‘Prevention is better than Cure’, the present trend in India remains cure based. Though the government’s thrust on health with awareness of Yoga and general health is in the right direction, it’s too little too late. With continuous monitoring of health parameters on individuals using AI, the march towards preventive healthcare can become a reality. Also, self medication is very much prevalent in India. To equip personnel to verify the veracity of such remedies, a startup  Myupchar’ has been created. Other such apps can help the users to avoid wrong or non-effective diagnosis, thereby not losing precious time which may prove crucial in certain critical ailments. Also, awareness about health can also be increased by using various tools and apps. Fitness bands have also increased the overall awareness.

3. Low Budget on Healthcare. The present allocation of about 1% of GDP to healthcare budget is way below what is needed. Though the government plans to increase this to 2.5% by 2025, it is still way below the required mark of 5 to 6%. The entry of AI into healthcare also means that the Government healthcare schemes would have much larger coverage with the same budget. The lower and effective medical help would mean lowering of costs of medical insurance thereby making it more affordable. At present 76% of Indians do not have any health insurance. This in turn should bring in more people to buy medical insurance and providing healthcare protection to larger sections of society. This would increase the overall load on the healthcare infrastructure of the country and thus cheaper medical education to churn out more doctors and nurses with effective use of AI and robotics would become a necessity. As the numbers increase the costs should slide down further.

4. Shortage of Healthcare Officials. A 2011 study estimated that India has roughly 20 health workers per 10,000 population, with allopathic doctors comprising 31% of the workforce, nurses and midwives 30%, pharmacists 11%, AYUSH practitioners 9%, and others 9%. The resource and knowledge sharing in between healthcare organisations can become online and instant depending on present usage of the resources. If the resource can be more effectively (or profitably) utilised by another organisation through virtual allocation by AI, the overall working efficiency would be higher. This is especially important in a country like ours where the infrastructure and number of healthcare specialists are far lesser than the need. Simple example of the same is sharing of ambulances.

5. Lack of Medical Research. The international pharmaceutical companies have for long neglected research in medicines for tropical diseases due to low profitability and the Indian companies have been limited in success in this area due to prohibitive costs of R&D. With the latest amendment in the rules for CSR by the government, the money can now be utilised for R&D and this would mean that the pharmaceutical giants would be pumping in large amounts of money into research in India. This would mean significant increase in the clinical trials in the country. The AI tools can make the clinical trials more effective and result oriented and would be able to indicate the side effects on the subject much earlier than otherwise.

6. Alternative forms of Medicine.  AI tools can be utilised to monitor the results of medical practices like Allopathy, Ayurveda, Unani and Homeopathy. The data on successful diagnosis through these could be compared for various diseases and most effective form of medicine for each type of disease can be computed for further analysis.

7. High Cost of Healthcare. The high cost of healthcare is prohibitive for majority of Indian population and thus proper healthcare facilities remain out of their reach. The factors listed above will bring down the overall costs of healthcare.

8. Awareness. A study in urban Haryana found that only 11.3% of the adolescent girls studied knew correctly about key reproductive health issues. Since the same is a difficult topic to cover for parents as well as teachers, AI based training modules can be used to teach certain sensitive issues.

9. Accountability. With better data logging and AI based approach, the responsibility can be determined for various actions. Last year, a dengue patient was billed around Rs.16 lakh by Fortis Hospital, Gurugram for 15 days treatment in its ICU despite the death of the patient. Inspite of having the best of the doctors and latest technology, cases of medical negligence are reported frequently. In another case, an alive baby was declared dead by Max Hospital, Shalimar. With better use of AI tools, accountability in such cases can be fixed. However, for this, complete legal framework will have to be prepared to ensure that only those are punished who are proven guilty of intentional malpractice beyond doubt. Also, the data once stored should be protected to ensure that no tampering can be done even at back end. The privacy of data also needs to be taken into account.

10. Home Care. Avenues of patients being treated at home also need to be explored. This would ease the load on limited hospital infrastructure and reduce the chances of secondary infection to the patient. This also eases the life of attendants of patients, usually the close relatives. Start-ups like ‘PORTEA’ are working in this field and providing such avenues with mush lesser costs.

The doctors should also be excited as by intelligent use of AI, the major problems faced by them in India could be eased in a limited manner:

1. Understaffing. The doctors are overworked and often complain of fatigue. The problem is compounded due to poor infrastructure and support facilities. A human is after all a human and human fatigue of doctors in hospitals can be brought down with the use of AI tools effectively. The number of specialist doctors and nursing staff on duty can be brought down with AI machines acting as assistants to the duty staff. The AI machine with complete history of each patient and earlier diagnosis by the specialist can be of great help to the duty staff. This would also mean that time spent on each patient by the doctor reduces significantly thus giving doctors and staff to utilise this time effectively in upskilling themselves. The monitoring of patients with critical illness and assistance provided to them can be greatly enhanced. The use of AI tools in hospital administration would bring up the overall efficiency and hence reduce time spent on avoidable tasks.

2. Troublesome Patient and Relatives. With better sampling of data in case of each patient and data being available for analysis in future, the number of cases of malpractices would significantly come down. This would vastly improve the trust factor between the doctor and the patient, which would eventually bring down the cases in which the relatives manhandle the doctor and damage the hospital property. ‘Credihealth’ is one of the medical support startup that gives guidance to the patient regarding finding the right doctor to guiding them in admission to discharge process based on disease to be treated and even give cost estimates for every process. The policy and rules would have to be amended accordingly to cover the legal aspects of medical cases with the availability of AI and big data. All this would also require a
framework where the data is protected and reproduced as required without any chances of tampering at back end.

3. Expectations of Instant Relief. Use of AI tools could help convince the patients better regarding the diagnosis administered and time to recover. A predictive graph of such ailments and dosage would greatly dispense fears amongst patients and their relatives.

4. High Medicinal Costs and Charges by Hospitals. Doctors have often complained that whilst patients bear huge medicinal costs, the consultation costs in India remain very low. With the use of AI tools, the exact dosage for patients can be worked out, which will bring down the medicinal costs borne by the patients. Further weaning off of a patient from medicines could be predicted. Also, as the working of hospitals and organisations could be automated with use of AI, the total operating costs of hospitals could be significantly lowered. This would reduce the total cost burden on a patient and thus higher consultation costs of doctors could be facilitated. The option of choosing between a non-emergency plan and emergency plan of medical cover is also being provided through smart solutions. ‘Afforplan’ is a startup that gives plans where one could plan, save and pay for non-emergency planned procedures like pregnancy.

5. Non-compliance by Patients. In instances where the patients do not comply to the instructions of doctors, the blame still comes to the doctor. With better recording of parameters and use of AI tools, the monitoring of patients can improve significantly, thereby reducing the blame on doctors.

6. Prohibitively High Training Costs. The training costs for doctors especially for specialisation are prohibitively high. Presently average cost of completing MBBS from a private college is approximately 25 Lakh and for MD it is almost three times or more. These training costs can be brought down significantly with the use of AI-based training and college administration tools. The automotive and other industries have already started moving towards AI-based training making it more personalized and focussed.

The net throughput to every student in such cases is also higher resulting in better skill of every trainee. Reduction in training costs should also be utilised to educate the young trainees to the financial aspects of the healthcare (both the public and the private sectors) in low-income countries result in gaps between providers’ knowledge and the care provided, this is known as “knowdo gaps” and is a serious concern in delivery of proper healthcare services. Start-ups like ‘Timble Tech’ are working in the field of training using AI tools, the same company is presently also working with AIIMS on mapping the symptoms and response to certain kinds of diseases. a delivery system so as to bring in behavioral change towards cost-consciousness in the implementation of governmental schemes. Also, low knowledge by the providers

7. Poor Working Conditions. Majority of the government infrastructure, especially rural lack good infrastructure, proper management, dedicated staff and many other things which are required to provide reasonable and appropriate healthcare. The AI based tools can help this on multiple accounts. The tools can help in better reporting and monitoring of the issues. Also, the staff responsible for administration can be better trained with special emphasis on implications of poor hygiene and infrastructure and finally in better accountability. In 2017, 300 infants were reported to have died in Baba Raghav Das Medical College, Gorakhpur due to shortage of oxygen supply, indicating poor management. There is little evidence to indicate that the lessons learnt have been implemented or rather lessons have even been learnt.

The fear of AI taking away all the jobs should be dispensed with as the machines cannot think, not yet. All they can do is learn from previous results. Thus, large sample size is a pre-requisite for better estimate of probability and hence better inferences by AI operated machines; however, the results differ with different algorithm used on the same data sample. This difference in results based on different algorithms is called the algorithm bias. This issue is compounded by the problem that the healthcare data gathered through various tools may be inaccurate and the same is mostly not counterchecked. The AI operated machine once fed with such skewed interpretations can create havoc if left unsupervised. Thus, for a long time to come, these biases would ensure that the final decision making remains out of the control of machines. The healthcare industry thus needs to upskill themselves to be able to utilise the AI tools more effectively. Even with the use of AI, more health officials are required to be able to provide adequate medical coverage to the citizens of this country. The legal framework to cover aspects of AI based health coverage and training thus form the most important tasks ahead.

The decision making on use of AI in healthcare sector should be based on penetration of quality healthcare facilities rather than profitability. As the affluence in the populace increases, the profits would eventually rise too. Though AI is not a ‘one solution to all problems’ remedy, it can facilitate improving the conditions in the healthcare sector significantly. Each AI based solution will have to be built carefully and incrementally to ensure low investment. The study of functioning of each organisation could reveal the areas where the AI based tools should be employed the first; however, it is felt the hospital administration and training are the areas where its demand is going to be highest. Integrating of every individual’s data from smart watches/ fitness bands could come in next followed by intelligent resource sharing amongst various organisations.

Further advancements could be decided on the Return on Investments on the ones quoted above. There are numerous start-ups in India working in the field of AI being incubated under the ‘Make in India’ program and should be able to partly meet demands of healthcare sector to move towards AI. The Government and the healthcare sector need to factor the opportunity costs of loosing global business by not moving towards AI at the right time. The medical tourism in India is a significant contributor of revenue in this sector. Improved facilities and care could significantly increase the medical tourism in the coming years.

Composed by Gaurav Sharma

Gaurav Sharma holds M. Tech from IIT Delhi and is a keen observer on the effects of Artificial Intelligence in the field of HR.

Indian healthcare towards global leadership

Healthcare innovation at national level in terms of Infrastructure as Smart & Green Hospitals, Processes & Outcomes can obviously be the reason of making India as the destination of choice for healthcare services. Healthcare contributes significantly to the overall service sector of India through service export, FDI inflow, Foreign exchange & Job creation. With a view to strengthen the healthcare innovation, bodies like Services Export Promotion Council (SPEC) & Associated Chambers of Commerce and Industry of India (ASSOCHAM) are working independently as well as with the government by giving special recognition to Healthcare Sector as one of the Champion Service Sector.

India has emerged as one of the most credible and cost-effective destination for medical tourism especially for curative treatment. Medical Value Travel (MVT) in India has been spearheaded by large corporate hospitals who have created strong global equity areas like cardio surgery, orthopaedic surgery etc. Majority of MVT is accounted by SAARC countries such as Bangladesh, Maldives and Afghanistan and East African countries such as Kenya, South Africa as well as Nigeria. Under the fresh leadership of SEPC-Healthcare Sector & ASSOCHAM, the said bodies are creating a platform for enclaving the hospitals to showcase the overall healthcare paradigm of India to the world.

With the given scale of healthcare infrastructure and the projected growth, India can further strengthen its standing among the current popular MVT destinations like Thailand, Singapore, Malaysia, Mexico, etc. In order to strengthen its position, India would need to focus on dual objectives of ‘tourism friendliness’ and ‘patient-centricity’. However, achieving the vision of being the Provider to the World would necessitate coordinated efforts by all key stakeholders be it government, providers, facilitators, regulators, insurers, etc.

In fact, we can say with reasonable confidence that success in attaining MVT leadership will have a rub-off effect on transforming the entire Indian healthcare setup with innovations & by overcoming the challenges like – cultural dissimilarities with India; lack of awareness and acceptability of India as a medical tourism destination providing affordable high-quality healthcare; UHC excludes medical travel; strong competition from nearby countries like Thailand and Singapore because of relaxed visa norms and good flight connectivity; visa issues; business practices and excessive dependency on medical facilitators; lack of promotion of India as a medical tourism destination; geographical distance and poor air connectivity; difficult & delayed licensing process for medical training of foreign doctors; issues of remittance of payments with certain countries; penetration of health insurance and their reluctance to provide international treatment is a dampener.

Key aspects that have a major bearing on the ‘tourist friendliness’ of a country include aviation infrastructure, amenities at the airport, proper transport infrastructure, affordable accommodation, good food, adequate cleanliness, hygiene, safe drinking water, and overall safety concern. The same has been addressed appropriately by the Indian authorities in recent times.

India has built strong credibility in curative treatment and is positioning itself as the holistic destination for alternative medicine on account of its strength in AYUSH i.e. ayurveda, yoga, unani and homeopathic treatment. Hence, AYUSH Tourism should be given serious consideration parallel to other modalities of treatment since we are already the global leader in AYUSH.

In the end, it is conclusively said that potential of medicare service runs into billions of dollars and over the years, India, given the professional skills of its medical personnel, can become the preferred destination for medical treatment. Such a development will create significant employment opportunities in the country & abroad.

Composed by Upasana Arora, Yashoda Super Specialty Hospitals

Upasana Arora is a dynamic leader in the Indian healthcare industry. She has led Yashoda Super Specialty Hospitals (NABH & NABL accredited) and is the First Indian to be awarded the prestigious Fellowship of ISQua (International Society for Quality and accreditation). She has been awarded at multiple forums for her contribution to the field of Ethical Healthcare Practices, Affordability, Community Empowerment and Women Leadership.

Innovation for hospitals during COVID-19

In India, the healthcare industry is one of the fastest growing sectors in terms of investments, employment, etc. It comprises many sectors under it such as the hospitals (public, private), public health, wellness centres, medical devices, medical tourism, clinical trials, medical devices, health insurance, health IT, telemedicine, medical equipment and much more. The sectors expand all over the country and covers both the rural as well the urban areas with the help of primary, secondary, tertiary and quaternary healthcare institutions and hospitals.

The Covid-19 pandemic which started in China in December 2019 and hit India in late January 2020 has made the whole world come to a standstill, harming literally everything ranging from the economy to every individual’s life. It has locked almost one-third of the population indoors. The sector which is facing a major damage due to the pandemic is hospitals, both public as well as private. The number of Covid-19 cases continue to grow worldwide and many hospitals are struggling to deal with the situation of treating patients and other aspects of running the hospitals. The three main challenges faced by the hospitals are: finding additional beds, ventilators, creating new spaces for the increased number of patients. Apart from this, there are several others on the list as follows.

Some of the major challenges faced by the hospitals:

• One of the major challenges faced by hospitals due to this pandemic is the lack of infrastructure. Although private hospitals make up the majority of the healthcare system in India, still they lack the preparedness to handle a sudden outbreak of a pandemic like this and provide for the health needs for every individual of the large population such as ours. Many of the hospitals especially in states like Bihar, Odisha, etc. are not well-equipped to cover their population and detect cases efficiently. Many hospitals lack testing kits and supplies which brings down their efficiency in covering the population for testing.
• There is also a shortage of beds and ventilators for new patients to admit because of the burden of the existing patients which are already admitted for treatment. Expanding capacity and creating space for new patients has therefore become a major challenge.
• Hospitals have also reported a shortage of personal protective equipment (PPE) for their staff. Due to a sudden increase in the demand of the testing kits and PPEs in this outbreak, the supply chains have faced many issues which has also depleted the reserves of the PPEs of the hospitals.
• Apart from the shortage of beds and doctors, hospitals are also facing the shortage of medical equipment like ventilators due to which many of them are not able to treat patients efficiently.
• Another main issue faced by the hospitals is difficulty in maintaining adequate staff (both medical and para-medical as well as administrative staff). Most of the hospital staff specially those of managerial and administrative background are preferring to not actively get involved in handling the hospital systems mainly due to fear and concern. Therefore, there is a sudden rise in the requirement of manpower specially during this crisis because these are the people who are required to take the charge of running and managing the hospitals while the doctors and the nurses take up the forefront role of treating the patients.
• Also, along with testing and treating the patients for COVID-19, it is essential to keep the hospital staff safe from contracting the virus and getting infected which might lead to the shortage of staff even more. This is a challenge too for the hospitals.
• There also exists a major challenge of high run for revenues and cost control. If we see hospitals as a business, the patients are its customers. Due to the pandemic, there is a decrease in the patient visits to the hospitals because people try to avoid going to hospitals due to the fear of contracting the virus. This has led to a downfall in the revenue generation for the hospitals and hence, difficulty in operations. This has also led to many people losing their jobs or salary cuts in some cases because hospitals are not able to pay them their salaries.
• Hospitals like AIIMS and many others had to cancel or postpone the surgeries of their previous patients because they are under the pressure to free up bed space for COVID-19 patients. They are unable to handle the unmanageable patient load due to the pandemic. Every other department of the hospitals are experiencing reduction in patient visits due to reduced admissions.
• Patient safety and hazardous waste management are the other two major issues faced by hospitals as this may lead to other concerns like hospital acquired infections, rise and spread of other diseases, etc. Also, an obvious downfall in the quality of services is also seen.

Possible innovative solutions for hospitals:

A large number of hospitals and the whole healthcare sector are moving towards the machines and trying to incorporate technology into their working and systems in order to deal with the emergency situation that is prevalent right now. They plan to use automated tools to help them manage the Covid-19 pandemic. In the light of the need at this time, many innovations are happening around the world to come up with solutions to create tools and technologies so as to help us combat the virus and increase efficiency of the existing healthcare system at the same time.

Around 25-30 startups were studied and their innovations and tools related to Covid-19 were identified. The ones which concerned healthcare and hospitals were selected and a database was prepared. The products that can be deployed in hospitals to deal with the pandemic were studied and were categorized using various criterias under categories like Artificial Intelligence, telemedicine services, screening, diagnostics, monitoring, tracing and tracking.

The study shows the percentage of the innovations made in specific areas. The selection was made restricted to India to understand the progress and scope of innovations happening in the country to assist us fight the pandemic.

Many start-ups like RIoT solutions, Practo and Thyrocare are helping with the testing and care of the coronavirus patients. Leveraging Artificial Intelligence (AI) to build highly accurate respiration monitoring systems that will work as a mini ICU monitoring unit to allow doctors and other health professionals to track multiple patients and at the same time ensure safety of health workers.

Some of the big hospitals like Apollo hospitals have tied up with Zomato, OYO hotels and homes and many other organizations to provide isolation and virtual care.

DaytoDay Health which is an MIT-incubated start-up, has started a virtual healthcare system for patients who tested positive for coronavirus. The company helps people manage complex health issues, manage their medicine schedule, record their progress data, tracking, etc. These activities are done with the help of an app which has been designed to have live chats, calls, consultations. Working with few hospitals in different parts of India, they are helping in early containment of the coronavirus with the help of IT by managing asymptomatic and non-critical coronavirus patients.

Another Indian based IoT startup called HELYXON uses AI-enabled devices for better management of the pandemic by constantly monitoring the vital parameters of patients or suspects. 98.6 Fever Watch is another innovation which is useful particularly for unwell children in whom continuous monitoring of temperature is a vital parameter in disease management. It connects to hospitals systems or personal systems and keeps transferring patient information to a central dashboard.

Some of the health-tech start-ups including Dozee, Qure.ai, Log 9, MyLab and Biodesign Innovation Labs are providing solutions which range from prevention mechanisms and testing to monitoring and manufacturing medical equipment. For example, Dozee’s device is used for medical-grade remote monitoring of vital parameters including heart rate and respiratory rate to monitor vulnerable patients in their homes, or in hospitals that are facing manpower shortages.

Qure.ai has partnered with Italian San Raffaele University Hospital to deploy new solutions that automatically read and interpret chest X-Ray scans for COVID-19 in seconds. This tool quantifies how much of the patient’s lungs have been affected, enabling the clinicians to monitor disease progression more effectively.

Another start-up Log 9 claims that its device can completely neutralize Covid-19 and other pathogens on surfaces of masks, hospital PPE and groceries in less than 10 minutes.

Pune based company MyLabs has come up with Covid-19 diagnostic test kits which are priced at around 1200 rupees which saves the testing cost by many times as compared to the present cost of 4500 rupees.

Medtech startup Docturnal has proposed a solution-based product called the ‘COVID-19 Innovation’ which screens the sound of a person’s cough from home with the help of an app and identifies the suspected lung diseases.

AI Highway provides pre-screening and triage tools that are based on risk-assessment scores for Covid-19, linked to symptoms, contact history and more.

Biodesign Innovation Labs has developed ‘RespirAID’, an automated respiratory assist device, which is an alternative for prolonged manual ventilation of AMBU bags or BVM used during hospital transit of patients or transit in ambulances, and operation theatres.

Bengaluru start-up Predible Health is using AI-based radiology solutions to pre-screen COVID-19 patients with the help of a tool LungIQ, which can measure percentage of lung damage in patients through CT scans & help doctors understand how badly a patient is affected and if he needs a ventilator or not.

Cardiac Design Labs has come up with a ‘Telemetric Patient Monitoring System’. It is a centralised vitals monitoring system, which allows frontline workers to monitor multiple patients simultaneously from a central location. The system has wearable devices, which are put onto the chest of the patient. The data collected is then shared with the nursing station, which can be located out of the COVID-19 wards. It also has algorithms to alert the healthcare professionals if something goes wrong with any particular patient.

Many companies like Invento, Asimov Robotics have been building humanoid robots which can help in lessening the exposure between Covid-19 patients and the caregivers. The robots can carry food, medical or clinical consumables for the patients and navigate freely within the hospitals decreasing the burden on the healthcare staff. These are also capable of collecting patients’ information and monitoring them. Others like Diagnostic.AI, PerSapien have developed robots that can help in the sanitation of the areas in hospitals or even in the public using ultraviolet rays.

Companies like AgVa solutions, Big Band Boom Solutions, Aerobiosys, etc. are building cost-effective portable ventilators. They are also lending a helping hand in ramping up the production and supply of ventilators to the hospitals.

Clearly, most of the innovations and solutions coming up are based on technology or are related to it in some way or the other. This shows that the IT sector is incorporating itself into healthcare and is proving to provide immense help with regards to ideas and solutions to deal with the pandemic and restore the world. Telemedicine is going to be a major field in the future on which literally every sector will depend and operate.

“Care is shifting from the hospital to the clinic, from the clinic to the home and from the home to a 24/7, ubiquitous access to care, driven by the mobile phone.”

–Sangita Reddy, joint managing director of Apollo Hospitals

The remote screening solution supports healthcare institutes to diagnose and treat patients at alternative points of care and is helping to safeguard the scarce critical care capacity. AI systems that have been trained via machine learning to offer clinical decision support may play an important role in the COVID-19 crisis, helping to keep hospitals functional and patients alive.

Composed by Anamika Gandhi, InnovatioCuris

The responses have been given by Ankur Gigras, VP, E-commerce of 1mg

What are the objectives and your vision to start this organization?

1mg was launched in 2015 with a vision to make healthcare accessible, understandable and affordable. In the last five years, we’ve fundamentally disrupted healthcare in India and have emerged as clear leaders of the fast evolving digital health ecosystem.

Here is a look at what we have achieved so far:

• ~35% share of category amongst medical apps; 350m monthly page views on 1mg platform
• Integrated Healthcare Platform: “Wiki” for healthcare information & India’s largest ePharmacy, eDiagnostics and eConsultation lines of business
• Strong supply chain across India and a fast growing profitable B2B business line [Pharma distribution & Phlebotomist network]
• Strong ecosystem partnerships with unique integrations with Insurance, Hospitals & Pharmacos to deploy novel models of healthcare delivery to patients across India

Patient centricity forms the core of our values. In the times that we are currently in, a digital healthcare platform is incomplete without online consults or telemedicine. We believe in offering our users a complete treatment cycle: from online consultations to ePharmacy and Lab tests.

What do you think needs to change in the health sector?

In healthcare, the information around our medicines and lab tests is either unavailable or incomprehensible to us, and that is the biggest change the sector needed to go through. Hence, with an aim to democratise healthcare, we decided to create a platform that stood for transparent, authentic and accessible information for all.

Unavailability of doctors due to a low patient to doctor ratio is another issue faced by the healthcare sector, especially in rural areas. With our video, audio and chat consultations, we hope to reduce that gap.

What tools and resources do you propose to bring these shifts in healthcare delivery?

In addition to the transaction & information services, we have built and launched many popular digital health tools such as medicine reminders, digital health locker, emergency profile etc. We also work on several unique models for patient support programs, digital health education programs, insurance solutions etc;

eConsults or telemedicine is another tool that we believe can bring about this shift. With most people practicing social distancing and minimizing contact, online doctor consultations, as per the guidelines issued by the Government of India, seem to be the safest option of seeking expert medical opinion and diagnosis.

Can you share about your business model?

1mg operates on a marketplace model where we have tie ups with licensed pharmacies, accredited diagnostic labs and with registered doctors/medical professionals. 1mg is an information technology platform on a digital and electronic network and acts as a facilitator between a buyer and a seller. The business model of 1mg is tied to the online transactions completed by consumers for Pharmacy and Diagnostics. The partners pay a small commission to us for bringing them orders and as volumes drive up, so will the profitability. As consumer usage increases, we would try and also introduce other monetization models through advertising. However, we are going to keep the offering free for consumers. [ lil’ bit on how econsults operates]

As mentioned earlier, patient centricity has always been our focus. 1mg believes in taking care of the needs of the patients, bringing about transparency and making healthcare accessible to all. We started out as a content platform for all health and medicine related information and later on went on to become an ecommerce platform.

What is the key strategy you adopted for acquisition?

1mg is a leader in the industry, with a ~35% share of category amongst all medical apps in India. So far, we have received over 350m monthly page views on our digital platform. Our app downloads have crossed 33 million till date.

It was possible for us to acquire such a huge user base only after we built enough trust among the people with the authentic information we provided. A major chunk of our customers are those users who came to our platform to consume health content.

What are the factors that influence market innovation and its impact on your organization?

To put it simply, the needs of the customers impact market innovation. For example, in the current times as the world is battling COVID-19, there is an urgent need for authentic and updated information around the same. So, we took it upon us to keep people informed. We experimented with different forms of content like ebooks, mailers, app notifications, website landing pages and more to help people consume as much authentic and medically accurate information as possible.

What are your strategies to deal with your competitor and what makes you different from others?

Being an integrated healthcare platform, 1mg enjoys leadership position and is driving the digital healthcare innovation in the country. Today, 1mg has become the most preferred integrated healthcare app for consumers/patients, and we clearly stand-out in the competition in terms of

• Relevance and speed of search results for users
• Quality of medical data/content available on our platforms, which is kept up-to-date at all times
• Predictive algorithms and machine learning

We have great respect for our competitors but our qualities and values set us apart from the pack:

• Clarity of vision – Since day one, 1mg has believed in integrated healthcare as the only model of healthcare that works for a consumer. We believed in it even before it was fashionable and for the last 5 years, we have worked very hard to make it happen. Our thought process, our innovation is naturally ahead of time.
• Superlative team – We have one of the best teams in the Indian internet space, with leaders who have built and led large consumer businesses or healthcare divisions. We have also had the good fortune of having worked (or known) each other for a really long period of time. As a result, our team has a very high degree of trust and works in a very agile and collaborative fashion to achieve quick results.
• Clarity in values – Since the very beginning, we have been clear about the values we want to uphold at 1mg:
  • Our value of “done is better than perfect” enables us to rapidly innovate and test real products out in the market
  • Our value of “Be CEO” empower individuals to take charge and do what’s right without an organizational bureaucracy holding them back
  • Our value of “accountability with empathy” ensures meritocracy
  • And our value of “team before individual” enshrines collaboration

We strongly believe that this is our winning formula.

With respect to telemedicines, we are one of the firsts to introduce audio and video consults, as well as COVID-19 specific consults.

What were the challenges you faced in initial days and how are they different today’s scenario, especially during this pandemic and what is your role in that?

Access to healthcare has been a challenge even before the pandemic, and health tech companies have tried everything to knit the gap existing in the healthcare system, be it telemedicine, online doctor consultation, mobile hospitals, etc. But, with the demand surging due to Covid-19 across different parts of the country, health tech companies are witnessing a new behavioural shift in Tier 2 and Tier 3 cities, which is here to stay.

Do you see any major growth opportunity in the post COVID-19 world?

Doctors have now started recognising the need for technology to engage better with their patient base. Hospitals too have become receptive of the change, as most of them are seeing a 40%-50% reduction in footfall. Suddenly they have started to feel the pain that they are not connected with the patient when they are at home. Onboarding doctors on telemedicine platforms has been a major challenge in the sector. Realising which, existing telemedicine companies have even adapted to models like collaborating with hospitals, or local pharmacy chains.

In the post-COVID-19 world, we believe that consumer behaviour would shift towards teleconsultations. The consumer’s fundamental pain point has never been about saving money on healthcare or ignoring it, it’s always about access. Going to a doctor’s clinic, waiting for two hours, and having to leave work early is often seen as an inconvenience. But with telemedicine they can consult the doctor anywhere without having to go through the hassle of visiting a clinic.

Further, the involvement of corporates and insurance companies in digital healthcare is also expected to go up.*

Share a bit more about the culture and values of your company? What is important to you and why?

• Our value of “done is better than perfect” enables us to rapidly innovate and test real products out in the market.
• Our value of “Be CEO” empowers individuals to take charge and do what’s right without an organizational bureaucracy holding them back.
• Our value of “accountability with empathy” ensures meritocracy.
• And our value of “team before individual” enshrines collaboration

We strongly believe that this is our winning formula.

What are your Future plans and any message for our readers?

Since the inception of 1mg we have always believed that technology and data will fundamentally change healthcare delivery. 1mg has already changed the healthcare landscape by making consumer centric integrated healthcare real. Over the years we have invested significantly in product and supply chain and most of the investments will continue or get accelerated. Some areas which will see disproportionate investment will be the ones below:

• AI and Machine Learning – Artificial Intelligence will fundamentally change healthcare and will make it personalized, predictive and preventive. With billions of healthcare data points, 1mg is already working on cutting edge AI models and we will continue to accelerate work in that direction. Our most recent peer review journal publication on teleconsultation is proof of our deep capabilities.
• New healthcare models – It’s clear that at 1mg’s scale, we now have the ability to enable new healthcare models for the ecosystem. These models, such as smart hospitals, outpatient insurance etc. will be the models of the future and will make healthcare accessible and affordable. Accessibility and affordability are 2 core pillars of 1mg’s vision.
• Integrated Care plans – Using the 1mg platform, our goal is to enable truly integrated outpatient care in the country. Such a plan will provide a patient with continuity of care both online and offline and across all their healthcare service needs.

We strongly believe that product and technology are our core strengths at 1mg and ones that have and will continue to help us deliver superlative value to a healthcare consumer.

Interviewed by Disha Soni & Dr Prateek Malhotra