Democratization of Healthcare: An Evolving Trend Driven By Cutting-Edge Technology

Posted on February 15, 2016 by Tapan Ray

We have stepped on to a fascinating era of yet another disruptive innovation in a newly carved out space of the healthcare domain.

Such initiatives are driven by path breaking ideas, which are being translated into reality with the application of cutting-edge technology. All these are aimed at providing a plethora of unique healthcare related solutions in the cyberspace to various stakeholders, especially to patients through inexpensive smartphones of various types.

Although the process has just begun, but is moving at a rapid pace. In virtually no time, as it were, it is showing a great potential of delivering more accurate and affordable healthcare solutions to a large number of the population globally, particularly in the developing nations.

‘Democratization of Healthcare’:

The ‘patient empowerment’ of such kind, with technology enabled the power of personalized healthcare knowledge and information in an organized manner, has been termed as ‘The Democratization of Healthcare.’

The critical point to ponder, therefore, whether this fast developing state of art technological advancement has the potential of delivering a novel and much affordable process of disease treatment and management, in the real world. As it happens, the new paradigm would shift the focus of key stakeholders from doctors to patients, in a genuine sense, and almost irreversibly.

In this article, I shall deliberate on this wonderful emerging scenario.

A recent reiteration raises hope:

The following reiteration of one of the largest and most reputed tech giant of the world raises general hope that this process would soon come to fruition:

‘The democratization potential of healthcare interests most of us, as the injustice of fantastic healthcare available in some parts of the world, and others suffering needlessly.”

The above profound comment was made on a radio show – ‘Conversations on Health Care’, by none other than the Chief Operating Officer, Jeff Williams of Apple Inc. on January 4, 2016 and was reported accordingly by ‘appleinsider.com’ on January 06, 2016.

Jeff Williams also indicated in his talk, how smartphone technology can be harnessed for therapeutic purpose in disease treatment, as well. Citing an example, he said, detecting autism at an early age is a key to future treatment, as doctors can intervene – albeit to a limited degree – as long as the brain is still developing.

He referred to a study that found not just the potential in app-based smartphone screening of children, but can even go much further by delivering therapy and treatment.

The rapid progress of technology in this direction is very real, as ‘Apple’ and other smartphone health app developers are stretching the commoditization of computer technology to serve health sciences. In not so distant future, with relatively inexpensive smartphones and supporting health apps – the doctors and researchers can deliver better standards of living in severely under-served areas like Africa, where there are only 55 trained specialists in autism, Williams said.

Triggers a key shift in focus:

As I said before, unleashing the power of technology in healthcare solutions through smartphones will bring a fundamental shift in focus of all concerned, from medical doctors to ordinary patients.

This transformation seems to be rather imminent now, as equipped with detailed knowledge of various types of individual health and disease related information through their smartphones, the patients would position themselves in the driver’s seat, demanding more for affordable treatment of diseases.

Dr. Eric Topol, the author of the book titled, “The Patient Will See You Now”, thus very appropriately said, “MDs will no longer be considered ‘medical deities’, but rather professionals with whom patients will consult to get the proper treatment on the path of least resistance.”

Consequently, the pharma players and other related service providers would require to ‘walk the talk’ by being ‘patient centric’ in the true sense, and definitely not by using this profound term, as one of the tools of their mostly self-serving, advocacy campaigns.

Empowering patients:

As Dr. Eric Topol said, smartphone applications that can monitor throughout the day, such as, heart rate and rhythm, blood pressure, take and interpret an electrocardiogram, capture X-rays and analyze ultrasound, have the potential to reduce patient visits to doctors, cut costs, speed up the pace of care and give more power to patients. He emphasized though, digital apps won’t replace physicians. The patients would still be seeing doctors, but the doctor-patient relationship will ultimately be radically altered.

As an illustration, it is worth mentioning here, that taking a significant step forward in this direction, the U.S. Food and Drug Administration (USFDA) has already approved ECG apps by for consumers, which have been validated in many clinical studies.

Examples of Smartphone Apps for patients:

Smartphone apps are now available for different user segments. In this section, I shall focus only on patient-centered apps capable of performing a wide array of functions, such as managing chronic disease, lifestyle management, smoking cessation and even self-diagnosis.

I am quoting below just a few of these interesting apps, as reported in an article published by ‘The Online Journal of Public Health Informatics (OJPHI)’ on February 5, 2014:

A. For diabetic patients, over 80 apps on the Android platform alone, offer a variety of functions. These include self-monitoring blood glucose recording, medication or insulin logs, and prandial insulin dose calculators.

Yet another diabetes intervention app integrated communication between patients and a healthcare provider. Here, the patient would log fasting blood sugars, daily eating behaviors, medication compliance, physical activity and emotions into a mobile online diary. A remote therapist with access to these diaries would then formulate personalized feedback to the patient.

‘WellDoc’ is reportedly one such company that has already received approval of the US FDA for its mobile-enabled diabetes management program, and is being paid for by health insurers as they would for a pharmaceutical product.

B. For smoking cessation and alcohol addiction apps are also available. At least 47 iPhone apps for smoking cessation and another one called – ‘A-CHESS’ (Alcohol Comprehensive Health Enhancement Support System) helps preventing relapse in alcoholic dependency and harnesses mobile technology to improve treatment and motivation.

C. For asthma and allergic rhinitis patients, an app called ‘m.Carat’, developed at Faculdade de Medicina da Universidade do Porto, Portugal, , helps recording their exacerbations, triggers, symptoms, medications, lung function tests and visits to the doctor or the hospital. The users of this app can also receive disease education, medication information, task notifications, and synchronize records with an online database to better control their symptoms.

D. For psychiatric patients, available smartphone apps offer benefits of ambulatory monitoring, that randomly prompts the patient to self-report psychotic symptoms multiple times throughout the day.

E. For sickle cell disease another app allows patients access to an online diary for recording pain and other symptoms.

F. For patients with dementia, ‘iWander’ app assists the affected individuals with daily living, by providing audible prompts to direct the patient home, sending notifications and GPS coordinates to caretakers, or by calling local 911 (US emergency) services.

G. For HIV (human immunodeficiency virus) and STD around 55 unique smartphone apps are available. These are used for education, prevention, testing and to provide other resources.

Self-diagnosis without a medical visit:

The above article also states that patients may even use smartphone apps to attempt self-diagnosis without a medical visit. Patients with a camera-enabled smartphone can use apps to take photographs of skin lesions and send these to a remote server for computer analysis and/or review by a board certified dermatologist. However, such apps are still not without their pitfalls, which are being addressed by the scientists, expeditiously.

Nevertheless, informed debate has already started in search of an appropriate direction for self-diagnosis with the help of robust smartphone apps, without any in-person medical visits.

Need for ‘Regulatory control’ and ‘certification’ of health apps:

I hasten to add, all such smartphone health apps should not be allowed to come to the market without stringent regulatory control and a well thought out the certification process.

As in the United States, where the health apps are being assessed by the U.S. Food and Drug Administration (US FDA), in India too the Drug Controller General of India (DCGI) or any other appropriate and designated authority should approve and certify all such smartphone health apps, before the market launch.

‘Trust deficit’ poses a critical challenge to pharma industry:

Since the health apps opportunity is new, and still in its evolutionary stage, pharma industry, in general, does not seem to have fully accepted yet, that the process of ‘Democratization of Healthcare’ has already commenced. I reckon, the progress in this direction is unstoppable now. Nevertheless, many drug companies apparently continue to prefer sticking to the same proven path that had fetched enormous success for them in the past and, of course, also its associated business models.

Besides health apps, the democratization process of healthcare includes other technological platforms too, such as, social media and video communications, which have started to bring healthcare into patients’ homes. To be successful in a situation like this, gaining ‘patient trust’ has become more important today than ever before, for all concerned.

Unfortunately, the drug companies, generally speaking, continue suffering from an increasing ‘trust deficit’ of the key stakeholders. This has been vindicated by a September 9, 2013 study of Makovsky Health, which found:

Pharma websites continued to rank low in terms of traffic, with just 9 percent of Americans visit them for health information.

WebMD is the most frequented online source for healthcare information (53 percent)

Almost a fourth of consumers (24 percent) use at least one or a combination of social media channels – including YouTube video channels, Facebook sites, blogs, and Twitter feeds with links to other resources – to seek healthcare information

The writing on the wall:

Some major global pharma players apparently have clearly seen the writing on the wall, and started collaborating with the developers of various types of digital health apps.

Quoting from the May 02, 2014 edition of ‘MobileHealthNews”, I am citing below, just as an illustration, the initiatives taken in this space by some of the drug majors:

Pfizer (2014) had backed startup Akili in the development of a mobile game to help diagnose patients with Alzheimer’s. The game could also be used in the treatment or detection of ADHD and autism, among other conditions.

Johnson & Johnson’s subsidiary, Janssen Healthcare Innovations (2013), launched the new version of its free Care4Today medication reminder app and platform – Care4Today Mobile Health Manager 2.0. It has also overhauled Care4Today medication adherence app.

Sanofi US (2013) and the Prostate Cancer Foundation announced the creation of Prost8Care, an SMS system to help prostate cancer patients and their families understand treatment processes.

AstraZeneca (2013) announced a pilot with Exco InTouch to help patients suffering from Chronic Obstructive Pulmonary Disease (COPD), with mobile and online tools.

Sanofi’s (2012) iBGStar device became the first US FDA cleared iPhone-enabled blood glucose meter.

GlaxoSmithKline (2012) offered a free asthma management app called MyAsthma, for iPhone and Android users. The app’s core offering is an Asthma Control Test (ACT), which is a simple 30-second test providing users with an index score of how well they are managing their asthma overall.

The potential in India:

In India, ‘Democratization of Healthcare’ is believed to be more broad based, with a third of all Indian mobile users expected to own a smartphone by 2017.

This is vindicated by the Press Release of Telecom Regulator TRAI, India, pharma, drug, playersy Authority of India (TRAI) of December 30, 2015. It states, the Wireless Tele-density in India is 79.39 as on October 31, 2015. The shares of urban and rural wireless subscribers were 57.61 percent and 42.39 percent, respectively, during the same period.

Conclusion:

The process of ‘Democratization of Healthcare’ is gaining momentum with the digital health app developers flooring the gas pedal. Even the global tech giant – Apple, has expressed its support and vow of taking rapid strides in this direction.

As this fascinating process unfolds, the final disease treatment decision, from various medical options available, is expected shift from doctors to patients, and may be their closest relatives. In tandem, patients would learn to take ownership of their physical and mental health conditions for disease prevention of various types, besides general fitness.

The patients, empowered with relevant digital information and knowledge, on their health status, including the pace of disease progression, would play a pivotal role not just in reducing disease burden, but also in making overall cost of individual healthcare more affordable. Additionally, access to healthcare, especially in the developing world like India and in its hinterland, will be improved significantly.

Digital apps are not just limited to patients’ use, these are being developed with equal speed for doctors, diagnostic centers, and clinical trials, just to name a few. All these would substantially reduce healthcare costs and add speed to various disease treatments.

In this golden pathway, there are some thorns too, mostly in the form of important regulatory issues, which need to be sorted out, expeditiously. Increasing ‘Trust Deficit’ of stakeholders on the drug companies is yet another hurdle, especially when the primary focus of all would shift from doctors to patients. However, it appears, the pharma players will eventually have no other choice, but to willy-nilly mold themselves accordingly, primarily for survival and thereafter progress.

As I see it today, the fast evolving trend of ‘Democratization of Healthcare’, driven by cutting-edge technology, is virtually unstoppable now. The only question is how soon will it happen?

By: Tapan J. Ray

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

Digital Therapeutics: Unfolding A Disruptive Innovation In Healthcare

Posted on November 23, 2015 by Tapan Ray

On November 9, 2015, ‘The Wall Street Journal (WSJ)’ in an interesting article reported, “Your doctor may soon prescribe you a smartphone app in addition to drugs and physical therapy.”

The hospitals in the United States (US) are developing new mobile apps to help patients manage serious medical conditions, record symptoms and communicate back to their doctors between visits, often in real time, besides helping patients adhere to their therapy, WSJ highlighted. The real beauty in these apps is, in addition to sending messages, reminders and instructions, the apps can alert providers to developing clinical problems before they become a crisis.

For example, “a new app from the University of Michigan called ‘Breast Cancer Ally’ is offered to patients to help them manage the onslaught of information and instructions they get throughout their diagnosis and treatment. It allows patients to look up and record their symptoms and provides guidance on when to consult the doctor about complications or concerns.”

Quoting experts, the article states, “this is a technology that is in everyone’s pocket and makes patients feel engaged in their own care.”

The implication of this development is profound. It appears, there could be a near term possibility of the same, for better, comprehensive health monitoring, leading to better quality of life and undergoing lesser hassles, if not hassle-free, as compared to what it is today in doing so.

Immense value in management of chronic diseases:

Besides serious ailments, these customized digital apps for smartphone, could be used to derive therapeutic impact in the early stages of chronic diseases, such as diabetes and hypertension.

As is well-known, in the early onset of most of the non-infectious chronic diseases, self-management plays a critical role to prevent the progression of the disease, saving significant treatment costs, besides other serious and expensive physiological complications in the future.

To achieve this goal, there is a critical need to appropriately educate the patients through doctors, along with the active role of pharmaceutical players. This could well be a win-win situation for the manufacturers of these products to productively engage the patients, not just for disease management, but for the commercial success of their respective brands too, with a well crafted integrated business strategy.

Digital Therapeutics:

Thus, these health apps serve the role of ‘Digital Therapies (DT)’, as well, for patients, especially at the onset of chronic ailments and to prevent any sudden crisis in serious disease conditions.

DT has, therefore, been defined as web, mobile, wearable and other digital technologies combined into an intervention to support healthy behaviors and provide therapeutic impact.

As stated earlier, DT has the potential to offer immense opportunity for patient engagement and to bring in substantial change in their health behavior with remarkable both short and long term cost-effectiveness.

The opportunities:

Offering DT to patients in India may not be very challenging either, on the contrary, it is an area of opportunity for all the interested players, especially when we go by the following facts:

According to the latest report from the Telecom Regulatory Authority of India (TRAI) mobile phone subscriber base in India recorded 6.71 percent YoY growth to 980.81 million users in Q2 2015.

There were approximately 82 million 3G subscribers in India by the end of 2014 and the number is projected to reach 284 million by end of year 2017.

SMS, email, messaging and social networking apps are the most popular ones.

The Indian Government has expressed its commitment to setting up a robust digital infrastructure and to promote adoption of mobile Internet and related products and services.

In 2014-15, the Government budgeted INR 500 crore for building infrastructure as per the National Rural Internet and Technology Mission.

Currently, as the smartphones enable individuals to access various types of information, suggestions and advice from anywhere 24×7, in the above emerging scenario, an increasing number of patients are likely to opt for digital therapeutic tools for self-management of health more effectively.

This is a win-win situation for all, including the pharma companies, though with a contemporary and honed strategic business model.

In the foreseeable future:

An October 2013 paper of IMS Institute, titled “Patient Apps for Improved Healthcare” expects that over a period of time, the health app maturity model will see apps’ progress from being recommended on an ad hoc basis by individual physicians, to systematic use in healthcare, and ultimately to an end goal of being a fully integrated component of healthcare management.

The study makes the following important observations:

The patients are unlike to ever have the tools to replace the roles of the physician

Health apps may encourage patients to take a more active interest in their overall well being and understand the consequences of poor health in later life.

By having the patients aligned with the importance of wellness programs and sickness prevention, health systems can hope to realize savings, especially from a lower burden of multiple chronic conditions.

The Governments may consider making patients aware of the need to take increasing responsibility for their own healthcare, by providing incentives to stay healthy, where health apps could play a major role.

The paper also underscores the following four key steps to move through on this process:

Recognition by payers and providers of the important role that apps can play in healthcare

Security and privacy guidelines and assurances must be in place between providers, patients and app developers

Systematic curation and evaluation of apps that can provide both physicians and patients with useful summarized content about apps that can aid decision-making regarding their appropriate use

Integration of apps with other aspects of patient care

“Underpinning all of this will be the generation of credible evidence of value derived from the use of apps that will demonstrate the nature and magnitude of behavioral changes or improved health outcomes,” the paper comments.

According to available information, currently in the United States, around 100 advanced health apps have been approved by the FDA. However, all these are not for the use of patients. Some of these are for the use of doctors. Other sets of apps are available to patients only against doctors’ prescriptions. The rest is mainly for fitness and general life style related, and are affordable only to a limited number of people.

Key benefits of ‘Digital Therapeutics’:

To summarize, the key benefits of digital therapeutics are as follows:

More cost-efficient, as compared to conventional alternatives.

Help doctors managing disease conditions through constant monitoring with digital technology

Make patients more aware and even proactive with real time information in preventing many diseases, avoiding disease aggravation and improving quality of life.

Make sharing of information between doctors and patients easier and effective.

Some concerns:

In many countries, including India, many health apps do not have appropriate health regulatory approval. Hence, a number of key concerns, in general, have been raised in this area for speedy resolution, some of which are as follows:

Product and data quality
Reliability in treatment decisions
Privacy and security for patients

Not many pharma companies are engaged in ‘Digital Therapeutics’:

In my view, there is a solid reason why many global pharma companies are still not adequately engaged with digital therapeutics.

They are generally actively involved in the high voltage advocacy by encouraging innovation, which usually does not go beyond drug discovery. This championing does not talk much either, about charting the broader area of comprehensive disease prevention, treatment and management with the application of disruptive innovation, involving other non drug related digital technologies, which are cost effective to patients.

With the low hanging fruits of drug innovation, resulting into money-churning blockbuster drugs with huge margin and almost in no time, made most of these innovator drug companies comfortable with their current business model of only drug discovery.

This business model is now exhibiting enough signs of fatigue with research pipelines gradually drying out.

Nonetheless, there are some indications now of a few pharma players’ exploring this new area of digital therapeutics, but as an extension of the current business models. It still remains a challenging decision for most of them to shift the gear, moving towards a new horizon of a winning mix of new drugs and path breaking digital therapeutics.

Conclusion:

These are still early days for the majority of the pharma players looking at commercially leveraging the potential of possible customized offerings of digital health apps as integrated digital therapeutics for patients’ self-care health benefits. What we have seen so far is the drug companies using health apps as a tool to market a drug and not much beyond that.

I discussed this issue in my article in this blog on March 30, 2015, titled, “Quantum Value Addition With Health Apps, Going Beyond Drugs”.

An April 17, 2014 article published in the ‘Forbes/Business’ epitomizes the relevance of digital therapeutics in the modern day healthcare, even in the countries like India, as follows:

“Three out of four Americans will die of a disease that could be avoided—if only they could re-route their unhealthy habits. A new category of medicine, digital therapeutics, wants to change the course of these conditions – and of history.”

By: Tapan J. Ray

Health Care: “India Has Moved From Strength To Strength!”

Posted on November 2, 2015 by Tapan Ray

The above flabbergasting assertion came recently from the Union Government of India in context of current health care system in the country.

To be specific, this proclamation of the Ministry of Health was reportedly made at its ‘point by point rebuttal’ letter to the world’s leading medical journal of high repute - ‘The Lancet’, at the end of October 2015, in response to a news report on India’s frugal public expenditure on health.

The chronicle:

On October 21, 2015 The Times Of India reported that shortly, a detail study in “The Lancet” would take Prime Minister Narendra Modi to task for failing in make public health a national priority area. It is happening despite his categorical promise of rolling out ‘Universal Health Coverage (UHC), during the last general election of India, in 2014.

The paper would be penned by some of the world’s foremost health experts and the issue is expected to be published on December 11, 2015.

In an interview with ‘The Times of India’, Richard Horton - the Editor-in- Chief of ‘The Lancet’, said that “health is an issue of national security for India, but Modi isn’t taking it seriously.”

Horton further commented, “I don’t see any new policies, any new ideas, any significant public commitment, and most importantly no financial commitment to the health sector, since he came into power in May, 2014.”

According to Norton, since Modi has come to power, health has completely lost focus of the Government. India is on the edge in this regard. If Prime Minister Modi does not tackle health, India’s economy combined with rising population is not sustainable. “The country’s healthcare system will collapse, if the government fails to invest in combating non-communicable diseases, such as, diabetes and heart problems”, he cautioned.

‘The Lancet’ to present contemporary fact-based analysis:

It is expected that the above article on India’s prevailing public health system, would be factual and analyzed based on the latest expert survey in this regard.

As I mentioned in my article of October 5, 2015 in this Blog titled, “Just 16% Of Indian Population Has Access To Free Or Partially-Free Health Care?”, the current Government has slashed union budgets for several ongoing and critical flag-ship schemes for health, such as:

Integrated Child Development Services
Mid-day meal
Aids and STD control
National Food Security Mission
National Rural Drinking Water Program

After a drastic reduction in union budgetary allocations for these crucial and very basic health schemes, there would possibly be no scope for any surprise in any quarter, if ‘The Lancet’ survey depicts a rather dismal overall public health care scenario in India.

Indian Government trashes ‘The Editor-in-Chief’s comment:

Trashing ‘The Lancet’ Editor-in-Chief’s above comments, Rakesh Kumar, Joint Secretary, Ministry of Health in a hard-hitting letter to Horton reportedly said:

“…launching an alphabet soup of program every quarter and not being able to implement them in true letter and spirit is a disservice to the people we serve.”

According to this news report, the health ministry maintained that “no existing program” of the ministry has been “curtailed, stopped or truncated due to lack of funds”. It also highlighted that funding to states had been rationalized to break from the straight jacket of ‘one size fits all’ geographies and populations.

“India has moved from strength to strength and some of recent initiatives will ensure improved outcomes for the most vulnerable,” the letter re-iterated unequivocally.

“India has moved from strength to strength” – Government retorted:

The above statement of the Union Ministry of Health that “India has moved from strength to strength” in health care, generally sounds bizarre and also absurd, to say the least. On the contrary, the available facts do not support this sweeping comment, as it were.

When compared with some much smaller neighboring nations of India and even Vietnam, it comes out clearly that they are doing far better on various critical health indicators.

This is vindicated by the ‘World Bank health indicators data’, which show that even Bangladesh, Nepal and Vietnam, with much lesser per capita GDP, are ahead of India in several key health indicators, as shown in the following table:

Some Key Indicators	India	Bangladesh	Nepal	Vietnam
GDP Per capita(PPP) (Constant at 2011 US$) 2014	5445	2981	2261	5370
Life Expectancy At Birth (Female) 2013	68	71	70	80
Survival to Age 65 (% of Cohort) 2013	63	72	69	72
Public Health Expenditure (% of GDP) 2013	1.3	1.3	2.6	2.5
Infant Female Mortality Rate (Per 1000 Live Births) 2015	38	28	27	15
Mortality Rate (Under 5 year of Live Births) 2015	48	38	36	22
Maternal Mortality Ratio (per 1000 Live Births) 2013	190	170	190	49
Rural Population With Improved Access to Sanitation Facilities (%) 2015	29	62	44	70
Vitamin A Supplementation Coverage Rate (% of Children 6-59 months) 2013	53	97	99	98
Immunization DPT (% of Children 12-23 month) 2014	83	95	92	95

(Source: Live Mint, October 28, 2015)

Similarly, another 2011 study published in the ‘The Lancet’ reported that ‘Out of Pocket’ expenditure on health in India is the highest, again even as compared to its much smaller neighbors, as follows:

Country	Out of Pocket Expenditure on Health (%)
Maldives	14
Bhutan	29
Sri Lanka	53
India	78

As I said before, these are just a few examples. In this article, I shall not dwell further on such comparisons, which are already known to many.

Instead, I would prefer to underscore, as many scholarly research papers have already done, that GDP growth of a nation cannot be driven in a sustainable manner without putting in place a robust public health care system in a country.

Reasonable public investment is necessary to improve health indicators:

If India wants to improve its key health indicators and surpass the achievements of just not smaller countries, such as, Nepal, Bangladesh, Sri Lanka, Maldives, but all other BRICS (Brazil, Russia, China and South Africa) nations, India needs to hike up its public health budget significantly, together with speedy implementation of all identified health projects.

According to the World Bank 2004 report (p56), for developing or middle-income countries with institutions of an acceptable quality, a 10 percent increase in public health expenditures as a proportion of the GDP, would be associated with a 7 percent decrease in the maternal mortality rate, a 0.69 percent decrease in child mortality rate, and a 4.14 percent decrease in low weight for children under five years of age.

Impact of health on economic growth shouldn’t be underestimated:

Between ‘public health’ and ‘other economic growth drivers’, choosing just one as priority focus area, could well be futile, in the long run. This is by no means an ‘either/or’ situation, at all. The Government should take into cognizance that there is a heavy price tag attached on an underestimation of the impact of health on economic growth, which could put its core objective of a sustainable high GDP growth in jeopardy.

I would now illustrate this point with no more than three examples, out of so many available.

According to the ‘World Health Organization (WHO)’, “Good health is linked to economic growth through higher labor productivity, demographic changes and higher educational attainment. In the same way, poor health undermines economic growth.”

India, though, seems to be chasing a high economic growth with all guns blazing, apparently does not believe in this fundamental dictum; neither does the Government accept that current public health care system is generally pathetic in the country and virtually on the verge of crumbling, if inaction continues.

To underscore the same point that impact of health on the economy should not be underestimated, I now quote from another study hereunder.

A December 2012 paper published in the “Global Management Journal” titled, “The Connection Between Health and Economic Growth: Policy Implications Re-Examined”, concluded as follows:

“Evidence presented in this paper illuminates the two-way relationship between economic growth and health. Bearing in mind the substantial influence of enhanced health to economic productivity and growth, governments need to look at health expenses as an investment rather than a cost”.

My third example would be another paper published in ‘OECD Observer’ titled, “Health and the economy: A vital relationship”, written by Julio Frenk, Mexican Minister of Health and Chair of the 2004 meeting of OECD Health Ministers. This paper too reiterates that the impact of health on the economy should not be underestimated. Thus, our challenge today is to harmonize health and economic policies to improve health outcomes.

Julio Frenk further emphasized, “The effects of health on development are clear. Countries with weak health and education conditions find it harder to achieve sustained growth. Indeed, economic evidence confirms that a 10% improvement in life expectancy at birth is associated with a rise in economic growth of some 0.3-0.4 percentage points a year.”

Here comes the critical importance of improving ‘Human Development Index (HDI)’ ranking of India to achieve a high and sustainable GDP growth, as the nation moves on.

Improve ‘Ease of doing business’ and ‘Human development’ indices together:

According to ‘World Bank’s Doing Business Report 2016’, India has moved up four rungs in the global rankings for ‘ease of doing business’. The country now ranks 130 among 189 countries, against its last year’s ranking of 134. This is a significant achievement, which has been widely publicized by the Government and very rightly so.

Whereas, according to the latest (2014) ‘Human Development Index (HDI) report, published annually by the ‘United Nations Development Program (UNDP)’, India ranks 135 out of 187 countries across the world. The next HDI report is expected to be launched in November 2015.

HDI is a statistical tool used to measure a country’s overall achievement in its social and economic dimensions. It captures a composite statistic of life expectancy, education, and per capita income indicators, which are used to rank countries into four tiers of human development.

Increase in life expectancy is a composite outcome of long-term effectiveness of a robust public health care system in the country.

Interestingly, the present Government does not talk much about HDI. Its primary focus seems to be now on ‘ease of doing business’, though for a sustainable high economic growth of a nation both should be speeded up and right in tandem.

Conclusion:

Reducing Union Budget allocation on health substantially and passing the responsibility of the same to the States with no assigned accountability for implementation on the ground, may not work in India.

Even if the comments of Richard Horton, the Editor-in-Chief of ‘The Lancet’ on this score, are brushed aside with contempt, his factual observations should be noted as valid suggestions. Accordingly, much required action steps need to be factored in by the Government in its 20116-17 Union Budget planning process.

Before concluding, I would very humbly, respectfully and with all humility submit that the Union Government should always be open to outside experts’ comments and suggestions, especially on public health in the country, to initiate a constructive debate. Any voice of discord or dissent, either on Governments’s action or inaction or both, may not necessarily be construed as an act against the national interest.

In this context, I am curious to know, what happened when on October 19, 2015, the Union Cabinet Minister for Women and Child Welfare – Mrs. Maneka Gandhi, who oversees a scheme to feed more than 100 million poor people, reportedly expressed her anguish and concerns in public. She openly said that slashing of her Ministry’s budget by half to US$1.6 billion, has hit her plans to strengthen the fight against ‘Child Malnutrition’ and makes it difficult to pay wages of 2.7 million of health workers.

Leave aside ‘The Lancet’ squabble for a moment. Does the above public anguish of a senior Union Cabinet Minister, in any way, depict that “India has moved from strength to strength” in health care?

By: Tapan J. Ray

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

Is Drug Price Control The Key Growth Barrier For Indian Pharma Industry?

Posted on October 19, 2015 by Tapan Ray

The corollary of the above headline could well be: “Are drug price hikes the key growth driver for the Indian Pharmaceutical Market (IPM)?”

Whenever the first question, as appears in the headline of this article: “Is drug price control a key barrier to growth of the IPM?”, is asked to the pharma players, irrespective of whether they are domestic companies or multinationals (MNCs), the answer in unison would quite expectedly be a full-throated ‘yes’. Various articles published in the media, including some editorials too, also seem to be on the same page, with this specific view.

Likewise, if the corollary of the above question: “Are drug price hikes the key growth driver for the IPM?”, is put before this same target audience, most of them, if not all, would expectedly reply that ‘in the drug price control regime, this question does not arise at all, as IPM has been primarily a volume driven growth story.’ This answer gives a feel that the the entire or a major part of the IPM is under Government ‘price control’, which in fact is far from reality

Recently, a pharma industry association sponsored ‘Research Study’, conducted by an international market research organization also became quite vocal with similar conclusion on drug price control in India. This study, released on July 2015, categorically highlights ‘price control is neither an effective nor sustainable strategy for improving access to medicines for Indian patients’. The report also underscores: “The consumption of price-controlled drugs in rural areas has decreased by 7 percent over the past two years, while that of non-price controlled products has risen by 5 percent.”

I argued on the fragility of the above report in this Blog on September 7, 2015, in an article titled, “Drug Price Control in India: A Fresh Advocacy With Blunt Edges”.

Nonetheless, in this article, going beyond the above study, I shall try to put across my own perspective on both the questions raised above, primarily based on the last 12 months retail data of well-respected AIOCD Pharmasofttech AWACS Pvt. Ltd.

Pharma product categories from ‘Price Control’ perspective:

To put this discussion in right perspective, following AIOCD-AWACS’ monthly pharma retail audit reports, I shall divide the pharma products in India into three broad categories, as follows:

Products included under Drug Price Control Order 2013 (DPCO 2013), which are featuring in the National List of Essential Medicines 2011 (NLEM 2011)

Products not featuring in NLEM 2011, but included in Price Control under Para 19 of DPCO 2013

Products outside the ambit of any drug price control and can be priced by the respective drug manufacturers, whatever they deem appropriate

The span of price controlled medicines would currently be around 18 percent of the IPM. Consequently, the drugs falling under free-pricing category would be the balance 82 percent of the total market. Hence, the maximum chunk of the IPM constitutes of those drugs for which there is virtually no price control existing in India.

According to the following table, since, at least the last one-year period, the common key growth driver for all category of drugs, irrespective of whether these are under ‘price control’ or ‘outside price control, is price increase in varying percentages:

Value vs Volume Growth (October 2014 to September 2015):

Month	DPCO Product Gr%		Non-DPCO Products Gr%		Non-NLEM Para 19 Gr%		IPM
2015	Value	Volume	Value	Volume	Value	Volume	Value	Volume
September	2.8	1.2	10.9	1.1	11.5	9.0	9.9	1.4
August	3.3	(2.7)	14.5	2.4	15.2	13.7	13.0	1.6
July	5.1	(0.6)	14.2	4.1	11.8	9.9	12.9	3.3
June	5.6	(0.1)	16.2	6.2	14.6	11.7	14.8	5.0
May	5.3	(0.3)	12.1	3.4	7.2	4.3	11.0	2.6
April	11.1	5.3	18.4	9.6	11.9	9.6	17.2	8.7
March	17.6	9.5	21.7	13.0	15.6	13.2	20.9	12.2
Feb	13.9	7.6	20.0	10.1	14.4	9.9	18.9	9.6
Jan	6.9	1.8	14.0	3.7	NA	NA	12.7	3.3
2014
December	8.0	0.7	14.8	3.2	NA	NA	13.6	2.7
November	3.1	(3.4)	12.6	0.3	NA	NA	10.9	(0.4)
October	(2.4)	(5.7)	6.8	(1.7)	NA	NA	5.2	(2.6)

Source: Monthly Retail Audit of AIOCD Pharmasofttech AWACS Pvt. Ltd

Does ‘free drug-pricing’ help improving consumption?

I would not reckon so, though the pharma industry association sponsored above study virtually suggests that ‘free pricing’ of drugs would help improve medicine consumption in India, leading to high volume growth.

As stated earlier, the above report of IMS Health highlights, “The consumption of price-controlled drugs in rural areas has decreased by 7 percent over the past two years, while that of non-price controlled products has risen by 5 percent.”

On this finding, very humbly, I would raise a counter question. If only free pricing of drugs could help increasing volume growth through higher consumption, why would then the ‘price-controlled non-NLEM drugs under para 19’, as shown in the above table, have generally recorded higher volume growth than even those drugs, which are outside any ‘price control’? Or in other words, why is the consumption of these types of ‘price controlled’ drugs increasing so significantly, outstripping the same even for drugs with free pricing?

The right answers to these questions lie somewhere else, which I would touch upon now.

Are many NLEM 2011 drugs no longer in supply?

DPCO 2013 came into effect from from May 15, 2013. Much before that, NLEM 2011 was put in place with a promise that all the drugs featuring in that list would come under ‘price control’, as directed earlier by the Supreme Court of India. Even at that time, it was widely reported by the media that most of the drugs featuring in the NLEM 2011 are either old or may not be in supply when DPCO 2013 would be made effective. The reports also explained its reasons.

To give an example, a November 6, 2013 media report stated: “While the government is still in the process of fully implementing the new prices fixed for 348 essential medicines, it has realized that most of these are no longer in supply. This is because companies have already started manufacturing many of these drugs with either special delivery mechanism (an improved and fast acting version of the basic formulation) or in combination with other ingredients, circumventing price control.”

Just to give a feel of these changes, the current NLEM 2011 does not cover many Fixed-Dose Combinations (FDC) of drugs. This is important, as close to 60 percent of the total IPM constitutes of FDCs. Currently, FDCs of lots of drugs for tuberculosis, diabetes and hypertension and many other chronic and acute disease conditions, which are not featuring in the NLEM 201, are very frequently being prescribed in the country. Thus, the decision of keeping most of the popular FDCs outside the ambit of NLEM 2011 is rather strange.

Moreover, a 500 mg paracetamol tablet is under price control being in the NLEM 2011, but its 650 mg strength is not. There are many such examples.

These glaring loopholes in the NLEM 2011 pave the way for switching over to non-NLEM formulations of the same molecules, evading DPCO 2013. Many experts articulated, this process began just after the announcement of NLEM 2011 and a lot of ground was covered in this direction before DPCO 2013 was made effective.

Intense sales promotion and marketing of the same molecule/molecules in different Avatars, in a planned manner, have already started making NLEM 2011 much less effective than what was contemplated earlier.

Some examples:

As I said before, there would be umpteen number of instances of pharmaceutical companies planning to dodge the DPCO 2013 well in advance, commencing immediately after NLEM 2011 was announced. Nevertheless, I would give the following two examples as was reported by media, quoting FDA, Maharashtra:

1. GlaxoSmithKline (GSK) Consumer Healthcare having launched its new ‘Crocin Advance’ 500 mg with a higher price of Rs 30 for a strip of 15 tablets, planned to gradually withdraw its conventional price controlled Crocin 500 mg brand costing around Rs 14 for a strip of 15 tablets to patients. GSK Consumer Healthcare claimed that Crocin Advance is a new drug and therefore should be outside price control.

According to IMS Health data, ‘Crocin Advance’ achieved the fifth largest brand status among top Paracetamol branded generics, clocking a sales turnover of Rs 10.3 Crore during the last 12 months from its launch ending in February 2014. The issue was reportedly resolved at a later date with assertive intervention of National Pharmaceutical Pricing Authority (NPPA).

2. Some pharmaceutical companies reportedly started selling the anti-lipid drug Atorvastatin in dosage forms of 20 mg and 40 mg, which are outside price control, instead of its price controlled 10 mg dosage form.

Why DPCO 2013 drugs showing low volume growth?

From the above examples, if I put two and two together, the reason for DPCO 2013 drugs showing low volume growth becomes much clearer.

Such alleged manipulations are grossly illegal, as specified in the DPCO 2013 itself. Thus, resorting to illegal acts of making similar drugs available to patients at a much higher price by tweaking formulations, should just not attract specified punitive measures, but may also be construed as acting against health interest of Indian patients…findings of the above ‘research report’, notwithstanding, even if it is accepted on its face value.

In my view, because of such alleged manipulations, and many NLEM 2011 drugs being either old or not in supply, we find in the above table that the volume growth of ‘Price Controlled NLEM drugs’ is much less than ‘Price Controlled non-NLEM Para 19’ drugs. Interestingly, even ‘Out of Price Control’ drugs show lesser volume growth than ‘Price Controlled non-NLEM Para 19 drugs’.

Government decides to revise NLEM 2011:

The wave of general concerns expressed on the relevance of NLEM 2011 reached the law makers of the country too. Questions were also asked in the Parliament on this subject.

Driven by the stark reality and the hard facts, the Union Government decided to revise NLEM 2011.

For this purpose, a ‘Core Committee of Experts’ under the Chairmanship of Dr. V.M Katoch, Secretary, Department of Health Research & Director General, Indian Council of Medical Research (ICMR), was formed in May 2014.

The minutes of the first and second meetings of the ‘Core Committee of Experts’, held on June 24, 2014 and July 2, 2014, respectively, were also made public.

On May 5, 2015, the Union Minister for Chemicals and Fertilizers Ananth Kumar said in a written reply to the ‘Lok Sabha’ that “The revised NLEM would form the basis of number of medicines which would come under price control.” This revision is taking place in the context of contemporary knowledge of use of therapeutic products, the Minister added.

Would pharma sector grow faster sans ‘price control’?

If ‘drug price control’ is abolished in India, would pharma companies grow at a much faster rate in volume with commensurate increase in consumption, than what they have recorded during ‘limited price control’ regime in the country? This, in my view, is a matter of conjecture and could be a subject of wide speculation. I am saying this primarily due to the fact that India has emerged as one of the fastest growing global pharmaceutical market during uninterrupted ‘drug price control regime’ spanning over the last 45 years.

Nevertheless, going by the retail audit data from the above table, it may not be necessarily so. The data shows that volume growth of ‘out of price control’ drugs is not the highest, by any measure. On the contrary, it is much less than ‘price controlled drugs under para 19 of DPCO 2013′, which are mainly prescribed for non-infectious chronic diseases on a large scale.

I am referring to AIOCD-AWACS data for just the last 12 months, because of space constraint, but have gone through the same for the entire DPCO 2015 period, till September’15. The reason for my zeroing in on DPCO 2015 is for the three simple reasons:

- The span of price control in this regime is the least, even lesser than DPCO 1995, which was 20 percent.

- It is much more liberal in its methodology of ‘Ceiling Price (CP)’ calculation, over any other previous DPCOs

- It has also a provision, for the first time ever, of automatic price increases every year for price controlled drugs, based on WPI.

A safeguard for patients?

Medicines enjoy the legal status of ‘essential commodities’ in India. Thus, many believe that ‘drug price control’ is a ‘pricing safeguard’ for Indian patients, especially for essential medicines and ‘out of expenses’ for drugs being as high as over 60 percent.

In the prevailing health care environment of India, the situation otherwise could even be possibly nightmarish. The key reason for the same has been attributed to ‘market failure’ by the Government, for most of the pharmaceutical products, where competition does not work. I discussed this issue in my article titled, “Does ‘Free-Market Economy’ Work For Branded Generic Drugs In India?” of April 27, 2015, in this Blog.

In India, ‘drug price control’ has successfully passed the intense scrutiny of the Supreme Court, along with its endorsement and approval. Any attempt of its retraction by any Government, without facing a tough challenge before the Apex Court, seems near impossible.

Conclusion:

The fundamental reasons for overall low volume growth, or in other words, price-increase driven value growth of the IPM, I reckon, lie somewhere else, which could be a subject matter of a different debate altogether.

As I said in the past, IPM grew at an impressive speed consistently for decades, despite ‘drug price control’, and grumbling of the industry for the same. This high growth came from volume increase, price increase and new product introductions, the volume growth being the highest.

Most of the top 10 Indian pharma players, came into existence and grew so fast during the ‘drug price control’ regime. The home-grown promoter of the numero-uno of the IPM league table, is now the second richest person of India. These are all generic pharma companies.

Generally speaking, Indian pharma shares even today attract more investors consistently than any other sector for such a long time. Granted that these companies are drug exporters too, but they all gained their critical mass in partly ‘price controlled’ Indian market. The criticality of the need for consistent growth in the domestic market, by the way, still remains absolutely relevant to all the pharma players in India, even today, despite…whatever.

Growth oriented overall Indian pharma scenario remaining quite the same, ‘drug price control’ with a current span of just around 18 percent of the IPM, can’t possibly be a growth barrier. Otherwise, how does one explain the highest volume growth of ‘price controlled non-NLEM drugs’, which is even more than ‘out of price-control drugs’?

Be that as it may, in my view, implementation of public funded ‘Universal Health Care (UHC)’ by the Indian Government, in any form or calling it by any other name, can possibly replace DPCO. Similar measures have been adopted by all the member countries of the ‘Organization for Economic Co-operation and Development (OECD)’ in this area, though following different paths, but nevertheless to attain the same goal.

Lamentably enough, the incumbent Government too has not ‘walked the talk’ on its number of assurances related to this core issue of health care in India.

Still, the hope lingers!

By: Tapan J. Ray

Just 16% Of Indian Population Has Access To Free Or Partially-Free Health Care?

Posted on October 5, 2015 by Tapan Ray

Is health care currently a low priority area for the Government of India? Probably yes, and thus it is worth trying to fathom it out.

Besides planned frugal spending on overall public health in 2015-16, even as compared to the past trend, two other health related budgetary decisions of the Government are indeed baffling, at the very least.

As many of you, I too know that the incumbent Government in its first full-year budget of 2015-16 has sharply reduced the budgetary allocation on many important health related other projects, such as:

- Union budget allocation for the National Rural Drinking Water Program (NRDWP) that aims at providing safe drinking water to 20,000 villages and hamlets across India, has been drastically reduced this year. Curiously, this decision has been taken at a time, when India loses 200 million person days and Rs 36,600 crore every year due to water-related diseases.

- The Integrated Child Development Services (ICDS) scheme, which provides food, preschool education, and primary health care to children under 6 years of age and their mothers, has also been hit by a 54.19 percent budget cut this year. This decision too of cutting public expenditure on food, nutrition and health care for children to more than half, defies any logic, especially when 40 percent of growth stunted children in the world are reportedly from India, exceeding the number of even sub-Saharan Africa.

I hasten to add that the Union budget 2015-16 has indicated, as the states’ share in the net proceeds of the union tax revenues has increased, as per recommendations of the 14th Finance Commission, these central Government programs will now be run with a changed funding pattern between the Union and states. However, according to financial experts in these areas, regardless of devolution, the total money available to run these critical projects is sharply decreasing.

That said, on the other pages of the same Union Budget, public funding in the current fiscal year for bridges and roads has more than doubled. The budgetary allocation for these two areas now stands more than even education.

I deliberated on similar subject of access to health care in my blog of March 16, 2015, titled, “With Frugal Public Resource Allocation Quo Vadis Healthcare in India?”

Health care sector is important for job creation too:

According to the World Health Organization (WHO), health care sector is one of the largest job creators, not just in India, but globally. Thus, Indian health care industry being one of the fastest growing industrial turf in the country with a reasonable base, deserves a sharper focus of the Government.

Additionally, the socio-economic benefits that this sector provides in creating a sustainable, healthy and highly productive work force, has been well documented and can’t just be wished away, in any case.

The neglect is intriguing:

Currently, total healthcare spend of India is no more than 4.2 percent of the GDP with public spending being just 1.2 percent of it. Other BRICS nations are way ahead of India, in this area too. To set a direction on country’s public healthcare spend, breaking the jinx of a long period of time, the draft National Health Policy 2015 of the Government aimed at initial increase in health expenditure to 2 percent of the GDP.

As a result of the legacy of neglect over a long period of time, which continues albeit more blatantly even today, only 16 percent of the Indian population declares today that they have access to free or partially-free health care. I shall dwell on this area subsequently in this article.

Keeping these in perspective, it was intriguing, when the union budgetary allocation for health care in 2015-16 was kept at Rs. 297 billion or U$4.81 billion for its main health department, almost the same outlay as in the previous budget.

When compared against public fund allocations, such as, US$ 93 billion for highway projects or US$ 7.53 billion for 100 smart cities in the country, one will get a realistic perspective of this meager health budget allocation, in terms of effectively addressing the health care needs of around 1.25 billion people of India. Over 70 percent of this population live in the hinterland.

Agreed that the Government focus on these ‘infrastructure projects’ are not unimportant by any means. Nevertheless, the above comparison only highlights how much priority the Government assigns to the health care sector of India and for the health of its citizens. This issue assumes even greater significance in combating several challenging health situations, such as, ongoing fight against increasing incidence of life-long chronic ailments and deadly life-threatening diseases like, cancer, fueling already high rate of morbidity and mortality in the high country.

A quick glimpse on a few outcomes of neglect:

The Working Paper No. 1184 dated January 8, 2015, titled “Improving Health Outcomes And Health Care In India” of the Organization for Economic Co-operation and Development (OECD), highlights some interesting points, as follows:

Chronic diseases are the biggest causes of death and disability accounting for 50 percent of deaths, with cardiovascular diseases and diabetes, respiratory conditions and cancers figuring most prominently.

Preventive interventions such as improving access to a clean water supply, reducing the spread of HIV/AIDS through better sexual education, and vaccination campaigns for other diseases will each deliver more significant returns in life years.

Vaccination rates for diphtheria, tetanus and pertussis, for measles and for hepatitis B are all much lower than in OECD and peer countries.

Minimal access to free or partially-free health care.

It is an irony that ‘life expectancy’ in India still remains well below the countries at a similar level of development.

Abysmal overall hygienic conditions:

The OECD survey brings to the fore abysmal hygienic conditions still prevailing in India. It can only be improved through active intervention of the Government with necessary budgetary allocations, sans photo ops for some celebrities and most politicians. Sincere support and participation of the civil society and intelligentsia, in general, are also equally important.

The paper underscores, among others, the following extremely unhygienic conditions still prevailing both in urban and rural India:

Most households in rural India do not defecate in a toilet or latrine, which leads to infant and child diseases (such as diarrhea) and can account for much of the variation in average child height. Even today the sight of poor children defecating openly in the streets, that too in a city like Mumbai, is also not very uncommon.

The burning of solid fuels in particular (undertaken by more than 80 percent of the population in cooking) is a major risk factor behind ischemic heart disease, lower-respiratory tract infections and chronic obstructive pulmonary diseases and could also increase cataracts and stroke.

Exposure to air pollution is a significant problem.

Many of the poor continue to smoke heavily.

11 of the lowest income quintile did not undertake sufficient physical activity, compared with 16 percent in the highest income quintile.

India provides minimal access to free or partially-free health care:

As I mentioned above, India provides minimal access to free or partially-free healthcare to its citizens, as compared to all the BRICS nations, many other countries in South East Asia and even in Africa.

The above OECD paper states that with poor health intertwined with poverty, the greatest gains lie with policies that address the social conditions which enable combating communicable and non-communicable diseases.

Among BRICS countries, India provides least access to ‘Free or Partially-Free Health Care’ Services to its general population. This is despite being the largest democracy in the world, which is now striving hard to emerge as an economic and military superpowers.

The following study shows that only 16 percent of the Indian population declares having access to free or partially-free health care from the government:

BRICS Countries	% surveyed said ‘Yes’ to the question: “Does your household have access to free or partially free health care from the State”
India	16
Brazil	24
China	73
Russia	96
South Africa	62

Source: Credit Suisse Research Institute, Emerging Consumer Survey Databook 2014.

As the OECD paper states, in this study approximately 1500 respondents were surveyed in each country, with India and China both having larger sample size of 2500. The male-to-female split between respondents was roughly 50:50 in all cases with rural-to-urban split varying by country.

Poor satisfaction level with existing health care services:

This is very important; as public facilities are the predominant source of qualified health professionals in rural areas where much of the Indian poor reside. In addition, significant population growth is occurring in urban slums, where urban public health care facilities are struggling to provide basic services. In a situation like this, slum dwellers face challenging economic barriers to accessing expensive private health care services (MoHFW, 2012).

The OECD survey indicates that 41 percent of those in rural areas and 45 percent in urban areas were not satisfied with treatment by their doctors or facility.

The reason attributed to this dissatisfaction are as follows:

Distance was cited by 21 percent of people in rural areas and 14 percent in urban areas.

Public health care centers remain closed more than half the time and lack basic medical supplies, such as stethoscopes and blood pressure scales.

Non-availability of required services was cited by 30 percent of people in rural areas and 26 percent in urban areas.

This is quite credible, as according to the Government’s own estimates:

- 10 percent of primary health care centers are without a doctor

- 37 percent are without a laboratory technician

- 25 percent without a pharmacist (MoHFW, 2012)

The above picture is quite consistent with large scale surveys in poor communities of India, by OECD.

Health care business for up market is booming:

Growing inequitable distribution of healthcare products and services is now wide open and blatant, more than ever before. There is no signal yet that the Government would soon consider health care sector as its one of the key focus areas, along with education, just as infrastructure, such as, building roads, highways, e-highways, flyovers, bridges and smart cities.

For up-market patients, the private sector is creating world class facilities in India. We can see today a good number of ‘five-star’ hospitals, with more number of newer ones coming up offering jaw-dropping facilities, quite akin to, may be even surpassing what are being offered for patients’ luxurious comfort in the developed world. Although these facilities cost a fortune, one would usually need to be in a queue to get admitted there for any medical or surgical treatment.

Most of these hospitals are now in high demand for ‘medical tourism’. According to available reports India currently caters to health care needs of over 200,000 foreign patients. ‘Medical tourism’ business reportedly fetched around US$ 2 billion to India in 2012.

On the flip side of it, as we all read in the recent media reports, some of these hospitals in Delhi refused admission even to seriously ill dengue patients, as they can’t afford such facilities. A few of these patients ultimately succumbed to the disease and the parents of one such poor child, who died without any hospital treatment in that process, committed suicide unable to withstand the irreparable and tragic loss.

Giving ‘Infrastructure Status’ to health care sector:

When creating basic infrastructure is the priority area of the present Government for financial resource allocation, why not give ‘infrastructure status’ to the health care sector now? This is not just for the heck of it, but purely based on merit and earlier detail evaluation by a Government Committee of experts.

To address the critical health care needs for the vast Indian population with appropriate infrastructure, quality products, services and manpower, providing ‘infrastructure status’ to the health care sector could facilitate the whole process. Additionally, it can transform the Indian healthcare sector as one of the biggest job-generating industry too.

This has been a key demand of the industry until recently, though not so much being talked about it today. A few years back, the previous Government was reportedly mulling to assign full fledged infrastructure status to the healthcare sector, as it merits inclusion in the category of ‘infrastructure’, satisfying all the nine criteria set by the erstwhile Rangarajan Committee.

I find in my archive, the Confederation of Indian Industry (CII) also demanded ‘infrastructure status’ for the health care sector in its pre-union budget memorandum for 2010-11. In that proposal CII had estimated that health care industry in India requires an investment of around US$80 billion, whereas in the current fiscal year the public expenditure on health still languishes at U$4.81 billion.

This specific issue seems to have taken a back seat today, for reasons not known to me. However, it is interesting to note that not just the Government apathy, no such demand is being made today by the large multi-industry trade associations of India, as vociferously as we witness, for example, in the case of ‘The Goods and Service Tax (GST) Bill’.

Health care debate is not to the fore today:

Critical health care issues of the country don’t seem to be in the fore front today for comprehensive debates even for the Indian main stream media, to influence the government.

We have been experiencing for quite while that Indian media, including social media, in general, usually goes ballistic 24×7 mostly with selective sensational topics. These may include, among others…glitzy events on Government’s high profile advocacy initiatives to attract more Foreign Direct Investment (FDI) from large overseas companies…Or back home some unfortunate and tragic Dengue fever related deaths due to negligence just in Delhi, though the same and equally grave incidences taking place in the other states of India, are hardly getting any coverage…Or on some high profile alleged murder pot-boilers announcing media verdict conclusively, even before completion of police investigation and charge-sheet being filed in a court of law.

These are probably neither bad, nor unimportant, nor avoidable, nor can come within the ambit of any media criticism. I am also not trying to do that, either.

As the saying goes, variety is the spice of life. We, therefore, generally want to get a feel of it everyday early in the morning, mostly glancing through the newspaper headlines, or in the late evening watching impatient anchor with strong personal opinion trying hard to dominate over all other participants in high-decibel ‘TV debates’, as these are called by the respective channels.

In an era of sensationalized and eye-ball grabbing ‘Breaking News’ of all kinds, flashing everywhere almost every now and then, critical health care issues seem to have become a mundane subject to the newsmakers for any meaningful debate to influence the Government. Serious debates on critical health care issues presumably would not generate all important Television Rating Points (TRPs) to the TV channel owners. Though I have no idea, the TRP of such debates probably has been estimated to be even lesser as compared to the cacophony aired by the TV channels on the cost to exchequer for the MPs subsidized meals in the Indian Parliament…with intermittent high pitch ‘war cry’ of the dominating anchor… ‘the nation wants to know this’.

Conclusion:

Be that as it may, health care environment impacts all of us, quite appreciably. There is not even an iota of doubt on it. However, we can feel it mostly when the reality hits us or our families hard…very hard, as serious and cruel ailments strike suddenly, or as we face avoidable disease related deaths of our near and dear ones, or when illness makes a loving one virtually incapacitated, even after facing financial bankruptcy.

Health care is a serious matter for all of us, just as it is a serious and critical business for every nation and every Government. This criticality factor is independent of whatever level of economic development the country is aspiring for. Thus, the indifference of the Indian Government, if I may say so, despite promising so much on health care earlier this year, is intriguing, and more so, when just 16 percent of the total population has access to free or partially-free health care in our India of the 21^st century.

By: Tapan J. Ray

India: Tops The GDP Growth, Remains At The Bottom On Health Care

Posted on July 13, 2015 by Tapan Ray

On February 9, 2015, the Wall Street Journal (WSJ) reported, “India’s statistics ministry surprised economists when it unveiled the new numbers for the growth of India’s gross domestic product. It ratcheted up India’s GDP growth figures using a new methodology that pegs expansion in Asia’s third-largest economy at 7.5 percent last quarter and 8.2 percent the quarter before that. Economists and the ministry, using the old methodology, had originally said growth was closer to 5.5 percent during those quarters. This recalculation indicates that India has already dethroned China as the world’s fastest-growing big economy, though China’s economy is still four times the size of India’s.”

For Indians in particular, this has indeed been a significant ‘feel good factor’.

However, keeping this ascending GDP growth rate in perspective, when we study the current health care related data of India as compared to BRICS nations (Brazil, Russia, India, China, South Africa) or even OECD (Organization for Economic Co-operation and Development) countries, India features at the rock bottom.

In this article, I shall quickly compare some critical health care parameters of India, against the same for other BRICS countries.

At the rock-bottom on healthcare:

This becomes absolutely clear when we look at the recent data on ‘Health Status’ of BRICS Nations, as follows:

Health Status of BRICS Nations (2013*)

	Life Expectancy at Birth	Infant Mortality per 1,000 Live Births	Child Mortality under 5 per 1,000 Live Births	Maternal mortality ratio (per 100 000 live births)
Russia Federation	71	9	10	24
Brazil	74	12	14	69
South Africa	59	33	44	140
China	75	11	13	32
India	66	41	53	190

* Life expectancy at birth data is of 2012; maternal mortality ratio is of 2010; all the others are of 2013. Source: Health and Health Care in BRICS Nations by Victor G. Rodwin, Wagner School of Public Service, New York University,

The legacy factor:

This has not happened overnight, public health care has been getting neglected in India over a long period of time. However, the process of slowing down in this area has become more pronounced in the recent years, as we shall discuss below.

The following table based on relatively recent data on ‘Health Expenditure’ in BRICS Nations, well captures the abject lack of focus in this area, which is so vital for sustainable economic progress of India:

Health Expenditure in BRICS Nations (2012*)

	GDP Per capita (PPP)	Public Expenses on Health (% GDP)	Private Expenses on Health (%GDP)	Total Expenses on Health (%GDP)	Out-of pocket Health Expenses (% of Total Healthcare Expenditure) 1
Russia Federation	24,805	3.8	2.4	6.3	33.52
Brazil	16,096	4.3	5.0	9.3	31.08
South Africa	13,046	4.2	4.6	8.8	7.21
China	12,880	3.0	2.4	5.4	34.67
India	5,855	1.3	2.7	4.0	58.05

* GDP per capita in PPP is of 2014; Human Development Index is of 2013; the rest of the data is of 2012. 1. Calculated based on private expenditure on health (% of GDP), total expenditure on health (% of GDP), out-of-pocket health expenditure (% of private health care expenditure). Source: Health and Health Care in BRICS Nations by Victor G. Rodwin, Wagner School of Public Service, New York University.

Lowest Human Development Index:

Human Development Index (HDI) is broadly defined as a composite statistic of life expectancy, education, and per capita income indicators, which is used to rank countries into four tiers of human development. Net outcomes of both education and health care play critical roles in the statistical calculations of HDI.

Among the BRICS nations, India registers the lowest HDI at 0.586, as compared to 0.658 of South Africa, 0.719 of China, 0.744 of Brazil and 0.778 of Russia.

Source: Health and Health Care in BRICS Nations by Victor G. Rodwin, Wagner School of Public Service, New York University.

High economic costs of neglect to health care:

An April 30, 2015 article of Reuters stated that over 60 percent of deaths in India are due to non-communicable diseases (NCDs) such as cancer, diabetes, chronic respiratory and cardiovascular diseases, which are responsible for about 70 percent of spending on healthcare. They also make serious adverse impact on the economic health of the country, with NCDs and mental illness expected to cost India US$ 4.58 trillion between 2012 and 2030.

This, by all means, creates a high priority situation, which needs to be addressed with commensurate well thought-out policy measures backed by adequate budgetary support.

The condition assumes even greater significance, as healthy and well-productive workforces contribute immensely to high and sustainable economic growth aspiration of a nation, always.

Healthcare budget gets further axed:

To meet the expectations of many, when the incumbent government is trying to floor the gas pedal for accelerated economic growth of the country, requisite budgetary allocation for quality and affordable healthcare in India, continues to lag behind.

On the contrary, in December 2014, just prior to the Union Budget Proposal 2015-16, the new Government reportedly ordered more than Rs 6,000 Crore or US$948 million cut (20 percent) from its own healthcare budget allocation of around US $5 billion for the financial year ending March 31, 2015, due to financial constraints.

In 2014-15, the finance ministry also ordered a spending cut of around 30 percent to US$ 205.4 million on India’s HIV/AIDS program.

Then came the Union Budget proposal 2015-16. Interestingly, even after several well publicized announcements by the Government on the ‘National Health Assurance Mission’, with generous promises on rejuvenation of public health care services sooner, the budget ignored all these – lock, stock, and barrel.

For 2015-16, the health care budget allocation was kept at Rs. 33,152 Crore, a tad more than Rs. 30,645 Crore of 2014-15. There has been no indication either for any comprehensive and integrated focus on healthcare, adequately backed by commensurate budgetary allocation, any time soon.

Could crimp efforts to control the spread of diseases:

Just around this time, a report from Reuters, quoting one of the health ministry officials, stated that this budget cut could crimp efforts to control the spread of diseases.

Interestingly, more newborns die in India than in poorer neighbors such as Bangladesh, and preventable illnesses such as diarrhea kill more than a million children every year.

This issue becomes even more glaring, when India contributing to 21 percent of the global disease burden, accounts for just a fraction of global spending on health.

What the Government promised, but did not deliver:

Before the Union Budget proposal of 2015-16, another article of Reuters dated October 30, 2014, quoting an Government announcement, reported that under the National Health Assurance Mission, Narendra Modi government would provide all citizens with free drugs and diagnostic treatment, in addition to insurance cover to treat serious ailments.

The proposed plan was to be rolled out in phases from April 2015 and was to cover the entire population by March 2019. The project would reportedly cost an estimated US$11.4 billion annually, when the entire population of the country comes under it.

National Health Assurance Mission was reportedly to focus, among others, on the following:

Improving preventive healthcare services by ensuring adequate availability of medical practitioners in rural areas.

Creating new infrastructure under existing welfare programs.

Providing tertiary care services through an insurance-based model with the government offering more than 50 drugs free to all the citizens.

Offering in the package, along with the drugs, about 12-15 diagnostic treatments.

Encouraging the State Governments to enter into outsourcing agreements for the provision of treatment.

All admirers of the new dispensation felt greatly obliged for this announcement. It was to some extent fulfillment of a long awaited expectation for a just and efficient healthcare system in India.

Adding strength to the Government’s promise, it was also reported that the World Bank along with UK’s health cost-effectiveness agency NICE are assisting India in this regard, providing technical assistance and advice on treatments the government should offer in its health care package.

However, at the end of the day nothing got translated into reality, at least not just yet.

Patients are compelled to turn to expensive private sector providers:

At around 1.3 percent of GDP, India’s public health expenditure is already among the lowest in the world, even as compared to 1.4 percent of Bangladesh, 1.6 percent of Sri Lanka and 2.9 percent of Thailand.

It is noteworthy that the public sector is the main source of health funding in nearly all OECD countries. However, in India, only 33 percent of health spending was funded by public sources in 2012, a much lower share than the average of 72 percent in OECD countries.

Moreover, health accounted for only 4.8 percent of total government spending in 2012, significantly lower than the 14.4 percent across OECD countries.

A January 2015 paper titled, “Improving Health Outcomes And Health Care In India”, published by the OECD reconfirms that with India’s low life expectancy largely reflecting deaths from preventable diseases, the most significant gains in health would come from population-wide preventive measures.

The paper highlights that except a small number of states, overall access to public health care services in India is rather poor even today, resulting in many people turning to more expensive private-sector providers, who mainly serve those who can pay.

A quick comparison between public and private health care expenditure:

For a quick comparison between public and private health care expenditure, I shall refer to a very recent Government survey report.

This survey titled, “Key Indicators of Social Consumption in India Health” was conducted by the National Sample Survey Office (NSSO) under the Ministry of Statistics and Program Implementation of the Government of India from January to June 2014 period and was published in June 2015.

The following table prepared from the above NSSO survey, is an example that would highlight the extent of difference in the average medical expenditure per hospitalization between a public and a private sector hospital.

Average Medical Expenditure Per Hospitalization/Case in Public And Private Hospitals

Broad ailment category	Public (Rs.)	Private (Rs.)
Infections	3007	8134
Cancers	24526	78050
Cardio-vascular	11549	43262
Respiratory	4811	18705
Gastro-intestinal	5281	23933
Genito-urinary	9295	29608
Obstetric and neonatal	2651	21626
Psychiatric & neurological	7482	34561
Blood diseases (including anemia)	4752	17607
Endocrine, metabolic & nutrition	4625	19206

Need to garner resources to implement ‘National Health Assurance Mission’:

The High Level Expert Group (HLEG), constituted by the erstwhile Planning Commission in January 2011, under the chairmanship of Dr K. Srinath Reddy, produced a comprehensive report on ‘Universal Health Care (UHC) in India’ in November 2011.

On health financing, HLEG made 10 recommendations, where from I would quote just two as follows:

Government (Central government and states combined) should increase public expenditures on health from the current level of 1.3 percent of GDP to at least 2.5 percent in the first 5 years and to at least 3 percent of GDP by the next 5-year period.

Use general taxation as the principal source of health care financing – complemented by additional mandatory deductions for health care from salaried individuals and taxpayers, either as a proportion of taxable income or as a proportion of salary.

I reckon, to meet the budgetary needs for ‘National Health Assurance Mission’ both direct and indirect taxes require to be levied if possible, at least in the next budget, along with adequate incentives to the State Governments to do the same.

Conclusion:

Over a period of time, economic aspirations of India have grown by manifold and very rightly so. To achieve these aspirations, alongside, at least two critical social needs such as ‘Education’ and ‘Health Care’ must be focused on simultaneously. I underscore ‘simultaneously’. There does not seem to be any alternative either, if we want to ensure that Indian aspirations do not remain just a pipe dream, for long.

It does not give any pride to many when one witnesses India topping the league table of GDP Growth percentage, while continuing to remain at the rock bottom so far as the health care is concerned.

Education and health care are universally considered as the bulwark for sustainable progress and growth of any nation. Even all BRICS countries have realized and implemented that, being well ahead of India in those fronts, unquestionably.

Let’s believe and hope, India would not continue to neglect these two critical growth catalysts of any nation, for long, while trying to build a robust economy. Otherwise, pushing hard only for economic growth as a percentage of GDP, could well be akin to chasing a rainbow, if not creating an unsustainable bubble with disastrous consequences, in the long run.

By: Tapan J. Ray

Would Affordable ‘Modicare’ Remain Just A Pipe Dream In India?

Posted on April 6, 2015 by Tapan Ray

When ‘Universal Health Care/Coverage (UHC)’, considering a critical socio-economic national responsibility’, has been implemented by the Governments in a large number of countries across the world, why has it still not been effectively addressed by the successive Governments in India, garnering adequate resources, at least, for its phased roll-out in the country?

According to published reports, not just all the developed countries of the world, a good number of developing nations too, including some in Africa, have various kinds of UHC mechanism already in place.

Even within the BRIC countries, India is still a laggard in this area.

Health related major national initiatives of this kind and scale, not only effectively addresses the issue of access to affordable healthcare for all, ensuring high quality of public health environment for a healthy society, but also helps improving economic productivity maintaining a healthy work force.

It goes without saying, UHC helps reducing ‘out of pocket expenses’ towards health, significantly.

OECD Health Statistics 2014: How does India compare?

Total health spending of India with only around 4.0 percent of GDP in 2012 was less than half the OECD average of 9.3 percent.

Public health spending usually tends to rise with the economic growth of a nation. However, despite high GDP growth in the past two decades, India ranks well below the OECD average in terms of per capita health expenditure, with spending of only US$ 157 in 2012 (calculated based on purchasing power parity), compared with an OECD average of US$ 3484.

It is indeed an irony that with highest billionaire wealth concentration, India still tops malnutrition chart in South Asia. (I discussed this subject in my blog post of January 26, 2015.)

Public sector usually becomes the main source of health funding:

In nearly all OECD countries, the public sector is the main source of health funding. However, in India, only 33 percent of health spending was funded by public sources in 2012, a much lower share than the average of 72 percent in OECD countries.

In India, health accounted for only 4.8 percent of total government spending in 2012, significantly lower than the 14.4 percent across OECD countries. Out-of pocket costs accounted for 60 percent of health spending in India in 2012, higher than in any other OECD country.

This trend has not improved much even today.

UHC deserves public funding:

In almost all OECD countries, including many developing nations, as well, UHC remains a key area of public health funding.

Interestingly, very often UHC is projected as an idealistic social goal that is within reach of only the prosperous countries of the world. This is indeed a myth, as UHC is in place also in countries like, Bangladesh, Sri Lanka and even Rwanda in Africa, besides South-East Asian countries, such as, Japan, South Korea, Taiwan, Thailand, Singapore and China.

The strong relationship between health and economic performance of a country has now been well established globally.

Many case studies covering both the developed and developing nations, clearly point out that a country’s desirable focus on UHC does not just increase the life expectancy of its people, in general, but also facilitates economic growth in a sustainable way, which India is so keenly working towards.

Expectations for UHC received further boost from the new Government:

Just before the Union Budget Proposal 2015-16, in November 2014, national media reported: “ ‘Modicare’ to introduce free medicines, health insurance for citizens”.

It highlighted that in a major health sector reform, the new Government would ensure that every resident in India has access to affordable healthcare with provisions for free essential medicines while bringing over a dozen of diseases, including cancer and heart ailments, under the ambit of the proposed National Health Assurance Mission.

Another pre-budget media report on December 30, 2014, flashed: “The National Health Assurance Mission (NHAM) set to roll, once PM Modi gives go-ahead”.

It articulated, NHAM that has been in the works since 2011 when the erstwhile Planning Commission’s expert group submitted its report on UHC, is likely to take final shape in 2015. PM Narendra Modi is, however, still to see the presentation.

NHP 2015, bolstered hope for early adoption:

On December 31, 2014, when the present Government was in the midst of a series of major policy announcements for the country, The National Health Policy 2015 (Draft) was also released, further bolstering the hope for early adoption of UHC.

I discussed a related issue in my blog post of March 16, 2015 titled, “With Frugal Public Resource Allocation Quo Vadis Healthcare in India?”

Affordable ‘Modicare’ overshadows even ‘Obamacare’?

Universal Health Care (UHC), as narrated in the National Health Policy (NHP) 2015 (NHP 2015 Draft) of Narendra Modi Government, making health a ‘Fundamental Right’ for Indian Citizens, is indeed profound in its both content and intent.

In this article, I would term the new health policy as ‘Modicare’, just as many others did. If implemented in letter and in spirit, as it has been proposed, NHP 2015 has the potential to overshadow even ‘Obamacare’ of the United States…hands down.

A change in the fundamental narrative:

UHC, as detailed in NHP 2015, changes the fundamental narrative of the country’s approach to extend healthcare services to all Indians, irrespective of caste, creed, income level, age or any other pre-determined and conceivable parameters.

However, for this purpose, Modi Government would need to double the public healthcare expenditure from its current level of less than 1 percent to 2.5 of the GDP. It was also indicated that the required fund would be raised by levying healthcare tax to citizens, directly or indirectly.

Government to assume a key role in healthcare:

Currently, private players are playing dominating role with around 70-80 percent share (around US$ 40 Billion) of total healthcare services domain in the country. In other words, public healthcare services cater to no more than 20 percent of the total market, and mostly are of dubious quality standards.

It is interesting to note, NHP 2015 places the Government as the major provider of quality healthcare services for all. However, an individual would have the right to opt for private facilities, of course by paying significantly more.

The business scenario could change dramatically for private sector:

In NHP 2015, the Government becomes the major provider of UHC services. The private sector healthcare players would then probably require going back to the drawing boards to reorganize their business models.

They may well choose to embrace Public Private Partnership (PP) initiatives related to UHC or decide to turn into to niche players in the high-price private healthcare space or something else, as they would deem appropriate. But surely, they would have to take a step or two back from the current dominant role, where there is virtually no competition from the public sector, even in the mass healthcare market.

NHP 2015, underscores the need for affordable drug prices. Thus, the private players could also face tough pricing pressure, as well, while negotiating for large Government procurement.

Both the above issues, when put together and in perspective, would probably not make the private healthcare players terribly enthused or feel at ease. In that scenario, the Government has its task well cut out, mainly for navigating through tough resistance coming from both the national and international lobby groups, in the process of implementation of ‘Modicare’ in India, of course, if it fructifies any time soon or at all.

No control on quality even in private healthcare services:

In India, besides medicines, there is no quality control on any healthcare services, be it public or private.

As public healthcare services are hardly available to a vast majority of Indian population, common people remain virtually at the mercy of pricing diktats of the private healthcare providers, while availing the same. They usually do not have any inkling for high cost of such services, which generally follow the simple ‘demand and supply’ market economy model.

With the implementation of NHP 2015, the Government being the single largest buyer and provider of both healthcare products and services, would presumably negotiate hard both on quality and prices with the respective suppliers, benefitting the patients immensely.

Moreover, since Indian citizens would be paying for healthcare on an ongoing basis through direct and indirect taxes, NHP 2015 proposes free medicines and diagnostics facilities to all, as and when UHC would roll out.

Quietly comes the dampener:

When the Union Budget 2015-16 raised the national allocation for health only by 2 percent over the previous year, it literally extinguished the hope for healthcare reform in India, any time soon, even in a phased manner.

Central budgetary allocation for this initiative is very important, as UHC has been planned to be funded both by the Union and State Governments in 75:25 ratio.

In this intriguing phase, Reuters came out with the ‘Breaking News’.

On March 27, 2015, it reported, though the health ministry developed NHP 2015 on UHC in coordination with the prime minister’s office last year, along with an expert panel, including an expert from the World Bank, Prime Minister Narendra Modi has asked for a drastic cutback of the ambitious healthcare plan after cost estimates came in at US$18.5 billion over five years. Consequently, this would delay a promise on healthcare made in his well-publicized election manifesto, indefinitely.

Prime minister Modi’s manifesto, ahead of 2014 parliamentary election that brought him to power, accorded “high priority” to the health sector and promised a ‘Universal Health Assurance’ plan. The manifesto also said, previous public health schemes that have been mired in payment delays, had failed to meet the growing healthcare needs of the public, the above report highlighted.

Initially, the new Union Health Ministry reportedly proposed rolling out the system from April 2015, and in October 2014 projected its cost as US$25.5 billion over four years.

By the time the project was presented to Modi in January 2015, the costs were already brought down to US$18.5 billion over five years. Even that revised estimate was considered too much and the program was not approved by the Prime Minister, without assigning any timeframe even for a relook.

The delay in ‘Modicare’ is intriguing:

Inordinate delay in the commencement of implementation process of ‘Modicare’ or UHC in India is rather intriguing, primarily due to the following two basic reasons, besides some others:

- NHP 2015 proposes to fund the scheme through indirect and direct taxation on people, who would be covered by this new health policy.

- Experts, such as, Nobel Laureate Dr. Amartya Sen, in scholarly writings, have established with strong evidences, both from the developed and developing nations, that the national focus on UHC goes well beyond just increase in the life expectancy of the population. Besides many other tangible benefits, UHC helps facilitate sustainable economic growth of a nation significantly, which India is now so keenly working on.

Conclusion:

Over the past couple of decades, despite impressive GDP growth of the country, successive Governments in India have not shown desirable inclination to invest in a comprehensive public healthcare project, like UHC.

As a result, the nation still suffers from public health maladies, such as, grossly inadequate number of doctors, nurses, other paramedics, number of hospital beds and other related infrastructure to cater to even the basic healthcare needs of all Indians.

Ironically, at the same time, either the government fails to spend the paltry budgeted amount because of poor governance, or even that small amount faces a year end drastic budgetary cut from the Ministry of Finance to manage the fiscal deficit target of the year, as happened even in 2014-15.

Considering the series of events that followed the announcement of the draft NHP 2015, it appears, the prospects for affordable ‘Modicare’ in India is rather bleak, as it stands today.

There is also a possibility that in the implementation process of ‘Modicare’ the Government may encounter tough resistance from interested lobby groups, purely for business considerations, as deliberated above.

The real reason for delay of ‘Modicare’ has not come from the horse’s mouth, just yet. Nonetheless, it is certainly one of those much hyped and publicized public promises of the Government that remained unfulfilled, at least in the financial year of 2015-16.

Although one should not try to see ghosts where there isn’t any, the moot question that still keeps haunting today: ‘Would much publicized and well sought-after ‘Modicare’ continue to remain just a ‘Pipe Dream’ in India?’

By: Tapan J. Ray

Quantum Value Addition With Health Apps, Going Beyond Drugs

Posted on March 30, 2015 by Tapan Ray

Besides all important brand attributes and how well those are communicated to the doctors, the ‘game winning’ differentiating factors in the prescription drug business, as it appears today, would revolve around overall quality of patient-centric approach and offerings of pharma companies, craftily tagged with the associated products.

To hasten business growth, being more and more patient-centric, in increasingly competitive, demanding and complex environment, pharma players would require to leverage the cutting-edge technology to its fullest for significant value addition in their respective sales and marketing models too.

Keeping pace with today’s ‘technology revolution’, rapid advent of various game-changing and user-friendly digital health applications for consumers are showing immense potential for a refreshing catalytic change in the overall landscape for patient-centric healthcare services as a key differentiating tool from the pharma players’ perspective.

The capability and capacity of ‘out of box’ thinking, professional expertise to choose and customize the right technological tools, making them key components of pharma sales and marketing models and above all, their effective implementation on the ground, would eventually differentiate men from the boys in the ball game of competitive excellence in the Indian pharma industry.

This emerging opportunity brings to the fore immense potential to revolutionize the treatment process of many serious chronic ailments with significant value creation, even in India, generating a unique synergy between the drugs and customized disease related digital tools.

In this evolving ball game; wearable, decent looking and user-friendly ‘Health Apps’, installable in smartphones having Internet and Bluetooth connectivity along with touch screens; signal a great potential for augmentation of the overall disease treatment process.

Consequently, it would kick-start a healthy competition within the pharma companies to continuously raising the bar of unique value offerings to patients, more than ever before.

A close experience:

Purely prompted by my keen interest in technology for a long while,the ‘Health App’ that I have bought and installed in my iPhone and wearing for sometime, is basically a multifunctional and multi-dimensional fitness tracker.

From the decent looking digital ‘Wrist Band’ that comes with it, the Health App tracks on a daily basis, kilometers that I have walked (from pre-calibrated steps), calories that I have consumed with intake of different food types and burnt up through physical workouts, total duration of time that I have slept in a day, quality of my sleep (sound and light sleep) with duration, number of times that I woke up at night, precise daily intake with quantity of nutrition, such as, fluid, carbohydrate, protein, fiber, different types of fat, salt etc., pulse rate, breathing and mood, besides many others.

Current users:

Besides some global pharma companies that I shall deliberate below, the current users of ‘Health Apps’ are mostly those people who are increasingly becoming fitness and diet conscious (at any age) and also want to take proactive measures for prevention of many chronic ailments.

A study:

According to a report co-authored by an official of IMS Institute of Healthcare Informatics, a study based on nearly 43,700 purported Health or Medical Apps available on Apple’s iTunes App Store, found that 69 percent of those Apps targeted the consumers and patients, while 31 percent were built for use by clinicians. Most of the ‘Consumer Healthcare Apps’ were simple in design and do little more than provide information.

The study observes, a large number of Health Apps are being designed to track simpler data on health and fitness. However, the more sophisticated Apps are capable to perform advanced functions, such as, real-time monitoring and high-resolution imaging.

Possibility for much wider use in healthcare:

Although, many of these Apps have been devised as personal fitness and health trackers directly by the consumers, the information and hard data thus captured can possibly be shared with the medical practitioners by the patients, as and when required. This data could serve as valuable patient life-style information inputs for the doctors, while managing their serious chronic illnesses.

Health Apps could also help the users reduce, at least, the primary care costs through preventive self-monitoring measures and take control of their own basic health.

In tandem, I reckon, there is a good possibility for a much wider use of such Health Apps in India by the pharma companies, along with many drugs, especially those, which are used for chronic ailments.

For example, real-time data tracking on:

-Exercise, diet and Body Mass Index (BMI) for patients on anti-diabetic and anti-hypertensive drugs

- Quality of sleep for patients with sleep disorders and are on related medicines

- Mood for patients taking anti-depressant medications

The data captured by the Health Apps in all such related areas could be useful for both the doctors and the patients in the process of effective disease management along with the drugs.

Going beyond drugs:

Based on this emerging trend, it is envisaged that in not too distant future, it won’t be very uncommon for patients, suffering from especially serious chronic diseases, to get prescriptions for both the drug and an the related customized Health App, for better quality of life through effective disease control.

Similarly, some hospital discharge orders may possibly include downloading of related mobile Health App on patients’ smartphones, primarily to provide an ongoing link between the doctor and the patient for better patient care and more effective follow-up visits.

Pharma players showing interest in Health App market:

It is, therefore, no surprise that pharma players have started showing keen interest in Health App market. In fact, this emerging market is now dominated by the big pharma players, with Bayer having 11.2 percent market share, followed closely by Merck, Novartis, Pfizer, and Boehringer Ingelheim.

The top 20 Health App makers are as follows:

No	Company	No. Of Health Apps
1.	Bayer	139
2.	Merck	111
3.	Novartis	108
4.	Pfizer	62
5.	Boehringer Ingelheim	51
6.	Janssen	45
7.	AstraZeneca	44
8.	GlaxoSmithKline (GSK)	41
9.	Roche	41
10.	Johnson &Johnson (J&J)	39
11.	Novo Nordisk	32
12.	Siemens	29
13.	Amgen	28
14.	Medtronic	27
15.	Abbott	24
16.	Biogen Idec	20
17.	Merial	20
18.	Sanofi	20
19.	Genentech	19
20.	Allergan	17

(Source: Pocket.md as of 12/2/2013)

A novel business expansion opportunity:

Pharma players in India may consider to actively focus on, with requisite resource deployment, to collaboratively develop and market smartphones based digital Health Apps, for quantum value addition in their brand promotion.

Moving towards this direction, pharma sales and marketing strategy for a chronic disease treatment should consider making Health Apps an integral part of doctors’ prescription along with the related drugs of the company.

Some examples:

To give an idea of the evolving trend, I am citing below a few examples, out of lot many, in this emerging area:

- Betaseron (interferon beta-1b) of Bayer: This drug is indicated for the treatment of relapsing forms of multiple sclerosis to reduce the frequency of clinical exacerbations. The company launched its first iPhone App, named ‘myBETAapp’ with ‘Personalized Tools’ to assist people on Betaseron (interferon beta-1b) in managing their Multiple Sclerosis (MS) treatment.

myBETAapp provides patients with injection reminders, injection site rotation assistance and injection history. Through Internet, myBETAapp also gives patients access to the BETAPLUS Web page on Betaseron.com, including links to educational tools, peer support and contacts listed on the site. With active phone service, patients enrolled in the BETAPLUS program can dial directly to speak to BETA Nurses, who are specially trained in MS.

- Tobi Podhaler (tobramycin inhalation powder) of Novartis: This drug is indicated for the treatment of Cystic Fibrosis.

Podhaler Pro App is an iPhone based navigation tool for patients and also the doctors during treatment with Tobi Podhaler. This Health App is a customizable digital pocket companion that helps, besides many others, with timely reminders to keep track of treatments, real patient stories and access to a live PodCare nurse to answer questions about taking treatment.

- Pradaxa (dabigatran etexilate)of Boehringer Ingelheim: This drug is indicated for ‘Reduction of Risk of Stroke and Systemic Embolism in Non-Valvular Atrial Fibrillation; Treatment of Deep Venous Thrombosis and Pulmonary Embolism and Reduction in the Risk of Recurrence of Deep Venous Thrombosis and Pulmonary Embolism’. It comes with a Health App, available in online ‘Apple Stores’. This is a tool providing healthcare professionals with information about stroke risk in Von-valvular Atrial Fibrillation.

Pradaxa Health App contains a ‘Stroke Risk Calculator’, ‘Bleeding Risk Calculator’, Renal function and dosing and administration information.

Pradaxa Health App also has a great resource section, split into ‘Patient and Health Care Professionals’ sections, which can be sent to patients via email.

- Xarelto (rivaroxaban) of Janssen Pharmaceuticals: This drug is indicated for ‘Reducing Stroke Risk in Patients With Non-valvular Atrial Fibrillation (AF); Treating Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) and Reducing the Risk of Recurrence; DVT Prophylaxis After Knee or Hip Replacement Surgery’. It also comes with a Health App, called Xarelto Patient Center and available in online ‘Apple Stores’.

Xarelto Patient Center App features include, personalize questions that help patients speak with their doctors about treatment with Xarelto, Appointment reminder, Xarelto ‘Savings Programs’, Registration to receive more information, Videos that share more information on Xarelto and hear from others who have been treated with the drug, After receiving a prescription the patient can enroll in the ‘XARELTO CarePath’ patient support and savings program.

Thus, especially for high-risk ailments, such iOS Apps directed at patients with information on the drug, including interactions with other medicines, dietary requirements, fitness/health trackers, besides many others, can add additional value both to the prescribers and the patients in the process of effective disease management.

Tightening the loose knots:

A 2014 report titled, ‘r2g mobile Health Economics’ by ‘Research2Guidance’ states, even though they try hard, most of the pharma companies fail to have a significant impact on the mHealth App market. Some pharma companies have published more than 100 Apps available for iOS and Android, but have generated only limited downloads and usage.

It states, pharma companies have created only little reach within the smartphone/tablet App user base. In fact, the leading pharma companies have been able to generate 6.6m downloads since 2008 and have less than 1m active users.

Analysis and comparison of the App activities of the top 12 Pharma companies in the report, gives reasons why pharma companies have not succeeded in becoming leading mHealth Apps providers, as follows:

- The App portfolios are not globally available: Almost half of the pharma companies’ Apps target only local markets. This means that their apps are available only in 3 or less countries.

- The App portfolio is built around the core products of the pharma companies and not around the actual market demand: For example, if a company specializes in the treatment of hematological diseases, the App portfolio reflects that. Apps in this case would provide references to the latest research, support diagnosis and facilitate information exchange with/between the experts. There exists an App market for such products, but there are other segments e.g. health tracking, weight loss, fitness or diabetes condition management, which attract more users.

- No cross-referencing or common and recognizable design: So far, pharma companies have not used the full potential of cross-referencing between their Apps. They also do not use common style guides for their App portfolio. Both of these could improve their App visibility as well as strengthen their corporate identity in the App market.

From this research analysis, it is quite evident that there is a need to tighten the loose knots in the Health Apps space by the pharma players. All improvement areas, as indicated above, should be addressed, sooner, especially, the need to targeting patients globally and inclusion of segments such as health/fitness tracking, weight loss, together with patient management focus areas of chronic illness conditions, such as, diabetes or hypertension, which have been attracting more users.

A comprehensive look and well thought-out action would help realizing true potential of the Health Apps market in India.

Conclusion:

Based on the emerging trend, it appears, those days are not quite far off, when it will become quite common for the doctors and also for the hospitals to co-prescribe with the drugs, user-friendly, disease related smartphone based Health Apps for the patients. This practice would provide an ongoing link between the doctors and the patient, leading to not just better quality of treatment, but a comprehensive overall healthcare in that specific disease condition.

However, currently there does exist a down side to this approach, which can’t be totally ignored either. The reason being, such Health Apps are not quite affordable to many, just yet, especially in a country like India. This affordability barrier could probably be overcome, if Indian IT software and hardware development companies consider this area lucrative from an emerging business opportunity perspective, as the country moves on with its ‘Make in India’ campaign.

If it makes sense…probably it does, it needs to be tried out sooner, in a much larger scale, for a win-win outcome. To begin with, the interested pharma players can tailor these well differentiated value offerings, at least to suit those, who can afford such augmented treatment process for a better quality of life, going much beyond drugs.

By: Tapan J. Ray

PILMAN

A Tapan Ray Website

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