Europe - GIT Verlag

Hospital Post Europe 04/08
What a challenge for public
health – this country sports,
on 3.2 mn km 2 , 28 states and 7
union territories. The number
of official languages total 16;
tax structures and regulatory
frameworks are diverse. Out
of the 1.1 bn population, 600
mn are considered poor; and
the democracy with its difficult
past still struggles with
the traditional caste system.
The economy shows growth
rates of 9 % – rather impressive
to Europeans – accompanied,
however, by an inflation
of 8.1 %.
The spectrum of caregiving ranges from
impressive high-quality, non-profit activities
in, e.g., CVD and oncology, to medical
tourism for elective therapy – e.g. hip replacement,
for patients not only from the
UK and the US. The major push for this
sector comes from a growing middle class
on the subcontinent – a quality and priceconscious
target group of roughly 250 mn.
– Your Hospital Post Europe editor brings
to you this feature based on interviews
with hospital and vendor representatives.
After the independence of India, the
healthcare infrastructure including district
hospitals, community, and primary health
centres was designed in line with WHO
norms; however, availability of staff and
medication was grossly inadequate. The
situation improved when the corporate
sector realized its social responsibilities,
with corporate hospitals mushrooming.
These state-of-the-art facilities, however
– explains Dr. Saurabh Bhatia, a physician
who today provides medical competence
to TietoEnator’s software development
work for the healthcare sector – “were
beyond the reach of the average Indian,”
at an annual per-capita income level of
around US-$ 2,700 (China – 5,300, Germany
– 34,400, US – 46,000; 2007 figures).
The Situation Today
“Traditional India came to rescue,” the expert
continues: Spiritual gurus and trusts
run by them started running charitable
hospitals. The majority of them engaged
in modern medicine, making it available
to the needy. By 2005, the infant mortality
rate, an indicator of the overall health status,
was down to 56 (1960: 146; compare to
China – 23, US – 6, Germany – 4 in 2005),
with average lifetime up significantly.
What is the current situation regarding
healthcare in India – who has access to
care and which groups do not, what are
the differences between urban and rural
areas, who is paying for care?
HealthwareIndia is a major distributor
that started out in 1989 for Dr. Mach (OR
lights) and Blancomed (now Trumpf OR
tables) and gradually specialized first in
Urology (Dornier MedTech, Lisa Laser, B-K
Medical, EMS and Gyrus-ACMI from UK/
US) before adding Surgical (Gyrus-ACMI
and B-K Medical). CEO Konakanchi Ram
Narayan summarizes the present situation:
“Despite the improving health status of the
Indian population, healthcare infrastructure
in the country has a long way to go to-
wards achieving 100 % quality, technology,
and superior healthcare delivery systems.”
While the central government is limited
to family welfare and disease control programs,
the manager goes on to explain,
the state governments are responsible for
primary and secondary medical care, with
a limited role in specialty care.
Governmental share in the healthcare
delivery market is roughly 20 %, while 80 %
is provided through the private sector. The
private healthcare providers consist of private
practitioners, for-profit hospitals and
nursing homes, and charitable hospitals;
this market is now open for foreign investments.
There is a huge difference in the quality
of medical care available to the urban
and rural population. Except for basic
healthcare through the governmental primary
health centres, the rural population
have to go to the nearest city for advanced
care. All governmental hospitals provide
free care to poor patients. Government
employees are covered by insurance (like
CGHS, ESI, etc.) and have access to care either
through governmental or private hospitals.
All other salaried (= urban) patients
either buy private insurance or pay out of
their pockets. Healthcare spending currently
amounts to over 6 % of the GDP, of
which three quarters are “out-of-pocket”:
Health Insurance
Insurance is still in its infancy – in India,
people are not used yet to paying without
receiving, instantly, anything concrete
in return, outlines Dr. Bhatia. Even after
economic liberalization in the 1980’s, multinationals
had to wait for the Indian government
to open up this sector, which
happened after 2000. Now, the market is attracting
significant attention also from international
actors who set up ventures such as
Bajaj Allianz and Apollo DKV Insurance. The
latter, a joint venture of a German payor and
a privately held Indian hospital group, plans
to invest up to 5 bn rupees in the next five
years to increase its market share, according
to Apollo Vice Chairperson Shobana
Kamineni. The health insurer, according to
Kamineni, aims at controlling at least 15 % of
the total health insurance business in India
which she estimates at currently US-$1 bn.
The addressable market is middle class.
Demand for medical and nursing colleges
is also up.
Who Takes Buying Decisions?
Physicians are the decision makers regarding
investment in medical technology – in
particular regarding procurement for the
attractive private caregiving segment which
is not required to issue tenders. There are
roughly 175 associations, and about 250
medical congresses – a difficult environment
for manufacturers and vendors who
wish to present their products, as well as
for organizers of general events for the
hospital sector – as explains Mahesh Gidwani
of Reed Exhibitions India. Only few
multinationals have as yet gone into manufacturing
activities in the country – this is
a new trend in India, presumably sparked
by the 15 – 16 % annual growth in medtech
sales, Gidwani assumes.
Focus on IndIA 5
“Complex Situation, Incredibly Dynamic Outlook”
Caregiving and Technology Penetration in India
Dr. Girish Mehta, Manager,
Wellspring Diagnostic Centre,
Mumbai
(Photos by Michael Waldbrenner
and MR unless noted otherwise)
Services and Technology
in Diagnostics
Piramal Diagnostics, part of a group of
companies, operates about 85 diagnostic
centres across the country. Services for
caregivers include general pathology and
basic blood-based diagnostics; some centres
also carry out sonography, CT, etc.
Asia’s first high-resolution PET-CT is also
operated by Piramal, outlined Dr. Girish
Mehta, who manages the highly reputed
Wellspring Diagnostic Centre in Mumbai’s
Lower Parel district. Wellspring’s many
hospital contracts include, e.g., radiology
outsourcing for the NABA-accredited
Dr. Hiranandani Hospital.
Whereas some centres sport full-time
radiologists, others acquire reports from
such centres in a private broadband teleradiology
network. Difficult cases, too, are
transmitted to specialists, e.g. in Mumbai.
Reports are sent in pdf format; the PACS
used is a proprietary solution, “developed
at a fraction of the cost of a commercial
system”. In total, roughly 4 mn patients
are handled by the diagnostics division
each year, with 150 highly qualified physicians
on staff, summarized Dr. Mehta, with
most devices, and reagents, imported from
Europe – Siemens is the main supplier.
While teleradiology services performed
in the country for, e.g., caregivers in the
US are still not an option due to physician
approval issues, lab tests offer a promising
business case: For European caregivers,
having lab tests carried out in India
Vishal Bali, CEO, Wockhardt
Group (Photo courtesy Wockhardt)
is a huge opportunity for cost savings and
higher throughput, underlined Dr. Mehta
– “we already have, as an example, a US
customer who sends us about 6,000 highend
samples per year. We are accredited by
the American College of Pathologists – the
top-level international accreditation. Quality,
therefore, is sound, and logistics from
and to the UK, France, and Germany – to
name examples – is fast and reliable.”
“In general, the service level in India is
a lot higher compared to Europe (and the
US) – at a fraction of the cost,” is the physician’s
conclusion – “my message to Europeans
and Americans is – we’ve got the best
machines, best people, and best prices.”
Research
This, too, is an area where Indians collaborate
with Europeans, explains Dr. Mehta:
earlier this year, Nicholas Piramal Life Sciences
and Pierre Fabre Laboratories, in
the presence of the French President, had
signed an agreement on research in oncology.
– And clinical studies can be done
in this enormous patient market at a cost
50 – 75 % below European and US levels –
adds Dr. S. K. Gupta, Dean of the Institute
of Clinical Research (India).
High-Level Therapy and
Medical Tourism
To Dr. Mehta, medical tourism is not a topic
– as patients, Westerners come for therapy.
Wockhardt’s CEO Vishal Bali benefits from
this trend: In 2007, more than 3,000 international
patients came for treatment to two
Wockhardt sites, Mumbai and Bangalore.
Around 7 – 10 % of Wockhardt’s revenue
comes from medical tourism, a volume
growing at 35 % annually; for the Apollo
group, corresponding estimates are 12,000
patients p.a., equalling 20 %. The Ministry
of Tourism promotes such activities aggressively
in its “Incredible India” campaign.
Medical tourists largely come from the
US, Canada, and Europe. Why is the US
prevalent? “Healthcare is more privately
driven there,” says Bali. “Those patients
ask for choice, compared to social-driven
caregiving in much of Europe.” JCAHO
accreditation for the two Wockhardt sites
is a key ingredient in this activity, according
to Bali: US patients, or large corporations
handling employee healthcare, take a close
look at quality standards. “US insurers”,
Vishal predicts, will soon offer low-premium
products to their customers which include
care in India; “here, care costs a third
at the most, and can go down to as low as
1/10th in comparison, for ophthalmology
– plus the plane ride”. Out of Europe,
patients from the UK are prevalent; they
have a long tradition of being treated by
Indian physicians, and long wait times are
placing increasing stress on the NHS, with
demographics giving an extra shove.
To Wockhardt, medical tourism focuses
mostly on elective surgery – much in
orthopaedics, such as knee/hip/joint interventions,
as well as spine surgery and cardiac
procedures. The hospital group was
recently awarded a prize for its website
which largely facilitates the gathering of information
to potential patients abroad.
With no international airport until
recently, Pune is no location for medical
tourism. The Jehangir Hospital here was
established in 1946. Today, the general
hospital with 325 beds and a luxury suite
is associated with the private Apollo group,
and handles close to the entire medical
spectrum. The caregiver sports, besides
medical staff with top qualifications, a
64-slice CT and more very modern technology.
The primary reason why many
Indian hospitals would not meet JCAHO
criteria, according to a leading physician, is
restricted space. Increasing awareness of,
and pressure from, patients paying from
their own pockets has led to significant improvements,
the physician continued; e.g.,
“No compromises on quality, and world class equipment” are key at Pune’s Fabiani & Budhrani Heart
Institute (from left): cardiologist Dr. Ritu Dhawan-Bhatia, the reporter, and healthcare expert Dr. Saurabh
Bhatia (TietoEnator)