Expert Recommendations Subsequent to Policy Meet, 26th June 2019

- A Policy Advocacy Initiative by “Voice of Healthcare” (VoH)

Foreword

- Dr. Harsh Mahajan, Co-Chairman, VoH Policy Meet

The recent initiatives of the central Government need to be lauded as there is an attempt to bring preventive, predictive and curative healthcare to the underprivileged sections of our society through the PMJAY scheme. The National Health Authority is already working to empanel both public and private hospitals across the country. However, as 500 million new patients come into the healthcare system there is an urgent need for capacity expansion by setting up new Ayushman Bharat hospitals and also by skilling lakhs of new healthcare workers. Unfortunately, the Government has not introduced any new schemes which may incentivise the public or private sector to work towards this end, and also there seems to be a certain lack of coordination between the centre and states as to how to achieve the desired results. A coordinated effort is required to be made by the government along with hospital service providers, med tech companies and financial institutions to achieve the desired goals of this highly ambitious scheme.

With this Policy Meet of Voice of Healthcare, we have attempted to put our heads together to
come out with some quality suggestions from various stakeholders of different healthcare
verticals. I hope the recommendations would help PMO, NHA, NITI AAYOG, and all other
agencies as everyone is trying to make thing happen.

- Dr. Naveen Nishchal, Chairman, Voice of Healthcare

On behalf of Voice of Healthcare (VoH), I would like to congratulate the newly formed government at the center which is recongnised for its people centric initiatives and reformations so far.

Especially when issues in healthcare are many, expectations are quite high. Indian Healthcare Delivery System is on crossroads and lot many things need to be done. Health is among the top priorities of Indian Government though the spending on health is close to just 1% of GDP. VoH has taken an initiative where we can discuss problems, challenges in healthcare industry and come up with some recommendations , some promotions, with collaborative efforts. If we talk about Indian healthcare in terms of ranking, in terms of indicators, we are much lower in the ranking- even lower that the neighboring country Bangladesh. We have prepared a recommendation for Government agencies after brain storming with prominent healthcare leaders from all strata of the sector, and we have tried to come up with good suggestions.

- Mr. Afzal Kamal, Gen. Secretary, Voice of Healthcare

Changes happening in India are reflective of India’s emergence as one of the key centers of power on global landscape. Compared to economic sector, changes in healthcare sector is dimmer but clearly perceptible. India has rapidly progressed in health status as evident from mortality reduction and life expectancy, but the progress at best is uneven and slow when compared to other countries.

India in spite of its stellar economic performance, does worse than even some of the poorest countries of the world in case of health status despite lower economic growth. Thus economic growth doesn’t automatically lead to human health improvement, but requires public policy to do so. In fact if health is not inclusive it can further exacerbate inequality and have adverse effects on human development.

This policy paper recommendation from Voice of Healthcare is a small but significant step towards an all inclusive attempt for healthcare development in India.

- Mr. Sanjay Jha, Co-founder Director Collateral Medical Devices & Moderator VoH policy meet

Forgetting about a not-so-satisfactory past, yet taking a cue from it, India need to reform the future health-care model most essentially. Owing to the country having one of the fastest ageing populations in the world, coupled with a high premature mortality from non-communicable diseases, we need to sustain past gains and meet new challenges.


Several models centered on an expanded primary health-care system have been tried and refined in the past decade with mixed results. Sustained political commitment, an effective communication strategy, a tailored health workforce policy, performance monitoring and evaluation, coordination mechanisms, and changes in administrative and financial regulations are some of the future factors that will be critical to realizing the full potential of Healthcare policies and accelerating universal health coverage in India. This recommendation paper adds to that very intention.

List of Abbreviations

VoH 
PHC 
IRDA 
CHC
DHC
MOHFW 
CDSCO
DCA
NABH 
ECHS
ESI
NITI Aayog 
NHA
PPP
MSR
GOI
QCI

Voice of Healthcare
Primary Health Center
Insurance Regulatory and Development Authority
Community Health Center
District Health Center
Ministry of Health and Family Welfare
Central Drugs Standard Control Organization
Drugs and Cosmetics Act
National Accreditation Board for Hospital and Healthcare
Ex-servicemen Contributary Health Scheme
Employee State Insurance
National Institution for Transforming India
National Health Authority
Public Private Partnership
Minimum Standards Regulation
Government of India
Quality Council Of India

Introduction to Voice of Healthcare (VoH)

“Voice of Healthcare” is a non-profit organization conceptualized with the aim of being a discerning & visionary think tank for the healthcare sector in India. Our aim is to make healthcare a priority for all by continuously collaborating with diverse stakeholder groups to shape innovative solutions through shared learnings.

VoH intends to be the voice of healthcare industry at national and international platforms, to facilitate exchange of ideas, learning and best practices in the healthcare sector.

We are bringing under our fold organizations ranging from private and public hospitals to pharmaceutical companies to healthcare consultants, med tech firms, NGOs, govt. bodies, medico legal experts, healthcare IT companies and upcoming start-up firms.

At Voice of Healthcare, we hope to introduce positive changes through policy advocacy; knowledge sharing; skills development; and liaising with the government, social entrepreneurs and private entities. Our team strongly believes that a consultative and concerted approach can go a long way in finding practical solutions to the many issues plaguing Indian healthcare systems.

Brief on the Policy Advocacy Meet held on 26th June, 2019

In pursuance of the above objectives, VoH, organized a ‘Policy Advocacy Meet’ with prominent personalities of healthcare industry on Wednesday, 26th June at New Delhi.

The key objective of this round table discussion was to bring together subject matter experts and prominent voices in the healthcare Verticals to deliberate on various issues that they are facing, and provide their valuable recommendations/inputs/feedback to newly formed Government of Informed for needful intervention.

The dignitaries who attended the meet were- Mr Rishi Suri- Director Deloitte India, Dr Arjun Dang- Associate Lab Director of Dr Dangs Lab, Mr Atantra Dasgupta- Director, South West Asia Head For Samsung HME, Dr Ravi Gaur- COO Oncquest Labs, Mr Rajiv Nath- MD HMD And Forum Coordinator Aimed, Mr DC Jain- CMD Akums Pharmaceuticals, Dr Vidur Mahajan- Head of Research at CARING and Associate Director at Mahajan Imaging, Mr Vikram Anand- Director Capbuild Clinical Skills, Mr Vishal Gandhi-Managing Partner And CEO, Biorx Ventures Advisors, Mr Anjan Bose- Founding Secy General NATHEALTH, Mr Pradeep Lal Mehta- President of Association Of Hospitals Of Eastern India, Ms Ruma Banerjee- VP Projects & Business Operations of Neotia Healthcare, Mr Abhitabh Gupta- CEO Paramount TPA, Mr Gaurav Malhotra – MD Medicover Healthcare Pvt Ltd , Mr Vikram Goel- Co-founder Incredible devices, Anwesha Pandey- Director NATHEALTH, and Mr Navin Sharma- Director Government Affairs at Baxter

We also received many suggestions from the larger VoH community through emails and messages. This community comprises of doctors, academicians, healthcare consultants, public health specialists, medical technology experts, health insurance providers etc.

We hope to have brought together practical and innovative ideas/concepts for the improvement of Indian Healthcare sector. Soon the valuable suggestions and revolutionary ideas to transform healthcare scenario will be tabled with appropriate Government authorities like NHA, NITI AAYOG, Ministry of Health and Family Welfare, IRDA, CDSCO, QCI etc at the center as well as state level. VoH hopes the government will give it due importance and include the concerns in the collaborative and constructive framework.

Key Recommendations from the Policy Advocacy Meet Key

PM JAY- AyushMan Bharat Segment

  • Ayushman Bharat has successfully covered millions of Indians by providing them free insurance in secondary and tertiary care since inception for IPD services. The scheme, however, failed to focus on primary healthcare which was to be provided by health and wellness centers. Present government aims to establish over 1.5 lakh such health & wellness centres across the country, still exact figure of operational centres is unknown. Though only setting up such centers won’t solve the crisis, a constant flow of funds would ascertain their sustainability in the long-term.
  • A lot of private practitioners practice in remote areas, it would be good to convert their personal centres into Health & wellness centre by empanelling those who meet or fulfill a minimum recommended criteria or benchmark. The cost factor involved in opening a new wellness center and converting the practice of existing doctors can be compared to reach at a decision. OPD of Ayushman Bharat empanelled hospital should also be free to cover out of pocket expanses of poor.
  • Earliest possible finalization for diagnostic packages (rates as well as a bundle of tests to be done) for these 1.5 lakh wellness centers along with the earliest possible decision on medical devices and modalities like an x-ray for Wellness centers to be closed.
  • Upward price revision for PM JAY- Present rates are based on (20% lower than) CGHS 2014 rates, which itself need an upward revision. The offered rates are not aligned with the present inflation rates and hence none of the private players are happy with it. It is getting difficult for private hospitals to sustain themselves.
  • Even the non-poor and urban poor need to be insured, given the rapid shift in the country’s disease burden towards non-communicable diseases such as cancer. Due to the low penetration of health insurance in the country, out-of-pocket spending on healthcare services is very high. One major reason why health insurance has still not penetrated most of India is that it is optional. The weaker section has been covered Ayushman Bharat and the government has taken significant efforts to implement it, but it needs to make health insurance coverage mandatory for all citizens in a phased manner, starting with the organized sector.
  • Keep provisions to make it non-mandatory, non-binding for unwilling hospitals those who don’t want to be empaneled with PMJAY. Allow some kind of %age allocation of general beds for PMJAY patients as the hospital has to accommodate other general bed category patients like ECHS, ESI etc.
  • Quantify quality on certain predefined parameter on then on the basis if that hospital can be rated and accordingly package can be decided and beneficiary can be offered a choice. we can have 2 models of ratings- basic models with AYUSHMAN BHARAT and supra top-up model at different pricing.

MedTech Segment

  • Price benefit through incentivization should be given to the quality certified device manufacturers those who have been certified from QCI, based on quality parameters.
  • There should be some kind of scaled up pattern for import duty and taxation of medical devices based upon the indigenous manufacturing capability. Those devices for which the infrastructure is there in place and being made in India, the import duty should be highest to discourage import and kill the interest of the local manufacturers.
  • A product which is not made in the country or having no history of making in India should not be charged import duty at all. And some kind of slab in between as well. So there should be 3 slabs/scaling system. So that when a device manufacturer makes a device for the first time in India and notifies the same, the import duty should be immediately raised from lower bracket to the mid or highest bracket to support such manufacturer.
  •  For healthy competition import duties should not be exponentially high to the tones of 30-40% and can be somewhere about 20% to keep the local manufacturer at the toes and keep the good competition intact.
  • There should be clear cut rules of reuse/reprocessing of medical devices. The manner of reuse should be elaborated.
  • Activate & energize GOI’s HTAB (Healthcare Technology Assessment Board) fully with inclusive participation of diverse segments
  • Non-authentic certification of medical devices is a big hindrance. We need a system in place where we don’t allow non-authentic certification bodies to issue certificate. Only accredited certification bodies should be allowed to issue certificates- to clinics, hospitals, diagnostics and medical devices. Just consumer awareness is not going to help. Stringent practice needs to be put in place.
  • We need to have a separate law for medical devices rather than regulating them under DCA. Drugs and devices are two distinct entities. Devices are not Drugs but Engineering Products and Patient Safety by Risk Mitigation needs Risk Proportional Control & Penalties. They can’t look at a similar platform as drugs. CDCSCO has to evaluate drugs and device manufacturers with different prisms.
  • Need to control Labelled MRP of Medical Devices by Tax Based Disincentive- For Non-Notified Devices to discourage use of high MRP as disincentive, Capping Trade Margin For Devices Notified as unscheduled formulation to discourage use of high MRP as inducement tactic and Price Cap For Devices Notified as Scheduled Formulation and where price disparity is very high, then in some rare cases, Price Caps are needed
  • Incentivize Q1 and Preferential Pricing in Public Healthcare as preferring L1 is undermining Quality. We need to promote Q1 & R1 e.g. (QCI Certification – ICMED) and Rating based system on performance- To ensure Patient Safety & Make in India and motivate better quality Products from indigenous manufacturers.
  • NITI Aayog is going to roll out a medical device bill soon, we have to strengthen and push it for faster implementation.

Healthcare Investors Segment

  • The healthcare sector also faces the challenge of funding huge capital investments to set up hospitals, while the returns are low. Access to timely credit with priority status and creating a specific fund for healthcare infrastructure and innovation would ease the availability of capital for the sector. These funds would encourage entrepreneurship and newer business models to improve access, availability, and quality of healthcare, especially in tier 3 and 4 cities and rural areas. The government can consider providing the seed capital for such funds.
  • There is no proper financial incentive or any kind of scheme from Government side which can actually attract an investor. On top of that the healthcare sector is marred with LICENSE RAJ. To open and run a tertiary care center in India About 110-120 odd licenses are required. EASE OF DOING BUSINESS is worst in healthcare which needs to be streamlined.

Health Informatics segment

  • National Health Stack needs a substantial push from Govt. Big-ticket largeimpact areas of future like AI, ML, IOT etc. are the future of healthcare. Using these technologies on a larger scale covering entire India to create a disease database is indeed beneficial. Registry of Implantable devices also falls in the same perspective. It’s required to keep and maintain a record of the implant- which implant has been put into which patient so that we can keep a track of it.
  • Disease Mapping and all the services we have to approve on USE CASE basis on a small unit and then to proceed on to larger scale. We have faced multiple failures when we try to do something on larger scale without running a pilot project – where we study the nuances of implementing the program. You first have to show a model where a disease mapping is done at a multilateral approach right at the level of wellness center, PHC, CHC going up to district level, involving technology, digital media, and all other innovations.
  • The authenticity and credibility of data that is coming to the key accreditation bodies like NABH is questionable. The process of getting data, its authenticity, processing and acting upon- everything is questionable. With no robust data, how can regulatory bodies claim that a particular formula is working or not, a particular hospital is efficiently working at a given price point or not, etc. Data has to be measured for any model to come up and sustain and to claim Government for any kind of revamp or relook.
  • New challenges posed by non-communicable diseases are posing an additional burden on the healthcare delivery system, which is still geared more towards the communicable, maternal, neonatal and nutritional health conditions. Adapting to the fast-changing disease transition requires significant additional policy reform and financial resources within the health sector.

Health Education and Health Skill Development Segment

  • NITI Aayog has released a state-wise Health Index to instill a spirit of competitive federalism between states on healthcare. Among the key indicators which were accessed to judge every state staff crunches was a crucial hurdle in healthcare delivery. In most states, the gap between required and available specialists stands between 80 – 99 percent. Vacancies of staff nurses in primary health centers (PHCs) and community healthcare centres (CHCs) were highest in Jharkhand with 75 percent, followed by Sikkim with 62 percent; Bihar with 50 percent; Rajasthan with 47 percent; Haryana with 43 percent; and Delhi with 41 percent. This indicates that India has a shortage of an estimated 600,000 doctors and two million nurses. A lack of skilled labour in administering antibiotics is preventing patients from accessing lifesaving drugs and contributing to a crisis of antibiotic resistance in the country. lack of skilled labour is pronounced in the healthcare sector, with around 25%of India’s healthcare workforce lacking the necessary qualification. This staff crunch across the country needs to be addressed at the earliest to ensure an effective healthcare delivery system. Can providing insurance through Ayushman Bharat work if there is a lack of quality service being provided ?
  • The government needs to take strategic steps to increase the skilled medical workforce by empowering medical colleges. This can be done by investing more funds in the present infrastructure of medical colleges to create a workforce that can execute healthcare services in an efficient manner.
  • The government needs to prioritize areas with a critical shortage of doctors along with regulations that enable private participation in medical education. To fulfill the dream of ‘Swastha Bharat’ (Healthy India), efforts to bridge the supply gap must be at the top of India’s National Health Agenda.
  •  Technology should be harnessed to scale and accelerate the development of skills at lower costs, for example, through online continuing medical education (CME), virtual training and distance learning.
  • The existing doctor population can be scaled to an extent by reducing demand focusing on primary care can help reduce hospitalization rates. We are facing an acute shortage of specialists, such as cardiologists, neurologists among others at all levels from primary to tertiary. So, along with bridging this gap, augmenting specialists, nurses and allied health roles can decrease the burden on doctors. And telemedicine and remote monitoring tools can also be used to widen the reach of existing doctors and increase their productivity.
  •  Better governance is required to improve the quality of healthcare personnel. Uniform governance standards in teaching, training and licensing of professionals must be applied. Mandatory accreditation of teaching institutes is necessary for better quality.
  • The government’s National Innovation Council, which is mandated to provide a platform for collaboration amongst healthcare domain experts, stakeholders, and key 1 participants, should encourage a culture of innovation in India and help develop policy on innovations that will focus on an Indian model for inclusive growth.

Regulatory Bodies Segment

  • Other than the inadequacy of funds, inconsistency in fund utilization and disbursement of money to the state has also contributed to inequity between states in terms of service delivery and quality. On average, there are more unutilized funds at the end of the year in the states that needed them most. A 2017 study by National Institute of Public Finance and Policy (NIPFP) and WHO India on utilisation, fund flows and public financial management found that, at the state level, a file with a request for release of funds has to cross a minimum of 32 desks while going up the administrative hierarchy, and 25 desks on the way down. Hence it is strongly recommended streamlining the processes to ease the rigidities in the system. Adding to the issue is the fact that many states simply do not spend their healthcare funds on health, many diverting them to different sectors.
  • Regulating body to streamline Home Healthcare segment is the call of the day. Needs early ironing out of legal angles. Limited ability to scale up the infrastructure to meet the relentlessly increasing demand mandates that India looks for novel ways to address this issue as sheer hospitalization based care for targeted > 50 crores BPL population to be covered under PMJAY will fall short on delivery. Therefore, Government should consider homecare as an option. Novel home therapies like CAPD for ESRD patients, Chemotherapy at home etc. can address the challenges of infrastructure, medical and clinical manpower shortage and thus spare beds and equipment for the more-needy or patients requiring emergency care.

Annexure

Some voices from the Voice of Healthcare Community

“Anti private healthcare feeling is rising within the country, be it society at large, be it political class, be it administrators, be it in judiciary, so we have to tread very cautiously. It’s not that private healthcare is without its own weak point and fallacies, somehow the society has to recognize that quality healthcare is provided by the private players in the country for which the price they need to pay is already very cheap in the world.”
Dr Harsh Mahajan, Founder and Chief Radiologist, Mahajan Imaging

“I am very much hopeful with the government upcoming plan of having 1.5 lakhs wellness center where they are going to put diagnostic facility basically at PHC, CHC and DHC level. We have validated a lots of technology about what investigations have to be done. But when it came to the deliberation, there were lots of disagreement and none of them were able to come up with proper agreement what should comprise of the basic health check package at the PHC level.”

-Dr.Ravi Gaur, COO, Oncquest Laboratories

There is some trust deficit somewhere. There still seems to be some question mark about how much profit is being made by the private players. Some concrete steps need to be taken to convince Government – may be data sharing, balance sheet whatever. People have done it earlier as well. Something which can balance trust upon each other for PPP model to work.

-Anjan Bose, Founder secretary general, Healthcare Federation of India

“As they (government)have incentivized quality with healthcare providers by 50% price benefit to certified hospital . We have similarly sought price benefit to be given to the quality certified manufacturers those who have been certified from QCI.”

-Rajiv Nath, MD, Hindustan Medical Devices & Syringes Pvt Ltd & Forum Co- ordinator – AIMED

“Recently we have seen government doing lots of work and some of them are very well thought of, others not very well executed, and the role that I see here is how we help the government. It is very easy to find fault in the Government but really very hard to help them.”

-Sanjay Jha, Co-Founder Director, Collateral Medical devices

 “But since a year we have observed that future investment in healthcare has stopped. Leave aside AYUSHMAN BHARAT, all the Government rates are based on CGHS which itself has not been updated since 2014 whereas in comparison prices of manpower, machinery, infrastructure, reagent cost etc has risen manifolds. The gap is huge and at times in appears impossible to bridge it”.

-Pradeep Lal Mehta, President, Association of Hospitals of Eastern India

“On top of every other challenge that a Healthcare investor has to face, what we have is LICENSE RAJ in healthcare. To open and run a tertiary care center in India About 110-120 odd licenses are required. A sword constantly dangle upon our heads that anytime anyone can come and close our hospital for any reason. EASE OF DOING BUSINESS is worst in healthcare which needs to be streamlined.”

– Gaurav Malhotra, MD, Medicover Healthcare Pvt Ltd

 “ I question the authenticity and credibility of data that is coming to the key accreditation bodies like NABH- its nothing but crap. The process of getting data, its authenticity, processing and acting upon- everything is questionable. With no robust data how can you claim that a particular point is working or not , a particular hospital is efficiently working at a given price point or not. Data has to be measured for any model to come up and sustain and to claim Government for any kind of revamp or relook.

-Vikram Anand, Founder & Director ,Capbuild Clinical Skills Pvt Ltd

 “Ayushman Bharat is a big step up to those patients who otherwise were going to a quack. Atleast now a common man is going to hospital.”

– Rishi Suri, Director , Deloitte India

 “We have to wait and see how AYUSHMAN BHARAT can improve the building of healthcare as a sector in general so that the access to capital becomes cheaper and easier. Healthcare as a sector should also be able to get an infrastructure status. You have a priority sector lending elsewhere. So if lending cost is lower, you can generate some capex.”

-Vishal Gandhi, Managing Partner & CEO , Biorx Venture Advisors

“I am moved by the Government proposal and plan to somehow unify all the data sets.. Its time that the government should put a system into place towards developing our own National Health Stack as patient outcomes can be drastically improved.”

-Vidur Mahajan, Head of Research at CARING and Associate Director at Mahajan Imaging

 “If import duty of an equipment/device is raised without comparing technology, then ultimately the quality suffers. First improve the quality then jump into the bandwagon as the China did. Let’s build and infra and environment to match that quality.”

– Mr Atantra Dasgupta- Director, South West Asia Head For Samsung HME.