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Sustainable Strategies for a

Healthy India:
Imperatives for Consolidating
the Healthcare Management

For private circulation only

June 2013

Health in India 1
Emerging trends and imperatives 3
Collaborate to Innovate 6
Creating and facilitating a collaborative environment 13
References 14
Contacts 16

Health in India –
Status and successes
India rightly brands itself as incredible. in-patient treatment, possibly making
The country’s remarkable political, quality healthcare and private sector
economic and cultural transformation facilities accessible to the poor.
over the past few decades has made
it a geopolitical force. Healthcare is However, these exciting opportunities
one of the industries that marks this often mask certain urgent predicaments.
strengthened global presence.
The healthcare sector in India is
As per industry reports, healthcare is currently at a cusp. Issues of access,
poised to grow at an estimated annual affordability, quality of care and
rate of 19 per cent to reach USD efficiency remain significant. A number
280 billion by 20201 with India being of reports have been published about
recognized as a destination for world the poor health status of India,
class healthcare. During the last decade compared to its Low and Middle
the private sector grew to become the Income Country (LMIC) peers. In terms
major provider of healthcare services. of vital statistics like infant mortality
Its share of beds increased from 49 (IMR) and maternal mortality, India has
per cent in 2002 to 63 per cent in lagged behind significantly. Even life
20102. As per NSSO 2008, the private expectancy, at 62 years, is three years
sector accounted for 60 percent of all below the LMIC average. According
in-patient admissions and 78 percent to the Global Burden of Diseases 2010
of out-patient consultations3. Private study, total Disability Adjusted Life Years
diagnostics market is growing at 20 per (DALYs) lost are 518,879,000 years for
cent and the pharmaceuticals market at the Indian population4. The economic
around 15 per cent per annum. cost of these illnesses to the country
is a staggering 600 billion dollars
The Indian government has also (approximately).
introduced several reforms. The
11th and 12th Five Year Plans and India is also facing an unprecedented
international focus on the Millennium pressure due to the poor reach of
Development Goals have led to quality healthcare to millions of its
1 Indian Healthcare :
successes, especially in the primary citizens due to issues of access and The Growth Story
health area – maternal and child health, affordability. The Indian healthcare 2 Central Bureau
and infectious diseases. The National sector has faced shortages of workforce of Health
Rural Health Mission has achieved and infrastructure. There were 1.65 Intelligence, Health
Infrastructure 2005
efficiency and health system reforms, trained allopathic doctors and nurses
and 2010
while the Rashtriya Swasthya Bima per 1000 population, compared to 3 NSSO 2008
Yojana (RSBY) - a national social health the World Health Organization (WHO) 4 Global Burden of
insurance scheme - has aimed to cover recommended guideline of 2.5 per 1000 Diseases 2010

Sustainable Strategies for a Healthy India 1

population5. Total hospital bed density 100%
in the country (0.9 per 1000 population)
37% 40% 22% 20%
was well below the global average (3.0)
and the WHO guideline of 3.56.
Total healthcare expenditure in India
was only 3.9 per cent of GDP, compared 50%
to 8.9 per cent for Brazil, 6.2 per cent 63% 60% 78% 80%
for Russia and 5.2 per cent for China7.
Out of this amount, out-of-pocket
expenditure was 61 per cent8, and only
26 per cent of Indians are covered by Beds Inpatients Outpatients Doctors
health insurance with share of private
being only 3-5 per cent9. Private Sector Public Sector

However, this is not to imply that Given this complexity of the sector and 5 WHO World Health
progress has not been made in the last the unique situation of the country Statistics 2012
6 Ibid
decade – a significant contributor to in healthcare, it is evident that a
7 World Bank Global
which has been the private healthcare single stakeholder cannot offer all the Health Expenditure
sector. solutions and address all the challenges. Database 2011
Collaboration, thus, becomes a 8 WHO World Health
Inequity in access, affordability and pre-requisite for success. Statistics 2012
9 Employees
quality of healthcare are the major State Insurance
concerns that the country is grappling Corporation; RSBY
with on one hand; and on the other website
hand it needs a strategic approach
to leverage the growth trajectory of
healthcare to its advantage.

Emerging trends and
The healthcare system consists of It increasingly seems that the tool to
multiple stakeholders including address the inequities of poverty is
the government, providers, payers, choice and not charity. A number of
pharmaceutical and medical devices innovations have taken this approach.
firms. Each plays a vital role in the Health care providers have tried to
health care system in India. However, increase access and quality of care for
interactions between various the poor.
stakeholders have remained limited.
Telemedicine and m-health initiatives
Healthcare in India has assumed a more have led to better reach and quality
dynamic form over the last few years in health management while being
– offering exciting opportunities for highly cost-effective. Various m-health
new reforms and improving stagnant initiatives across the world have led to
indicators addressing concerns of improvements in patient access through
access, affordability and quality across cost effective solutions – education
different population groups. and awareness, chronic disease
management and treatment support,
An ecosystem of innovations for world- remote monitoring, diagnostics support,
class healthcare delivery, driven by and disease surveillance.
private providers, is developing in India.
The country is establishing new global To leverage the healthcare growth
standards for cost, quality and delivery, story, the industry is now reshaping
through its breakthrough innovations and redefining the very concept of
in healthcare. The other end of the “healthcare”. It has moved far beyond
spectrum is witnessing a number of curative clinical practice (focused on
innovations to increase access and episodic care), to embrace prevention,
improve quality of health services for wellness and the concept of the “holistic
the poor and unreached at affordable care” through the pervasive health
costs. The last couple of years have continuum.
seen a rapid increase of private equity
and venture capital funds available for
entrepreneurs in healthcare, which
has enabled scale up of some of these
new interesting models of providing

Sustainable Strategies for a Healthy India 3

Given the demographic and Main Demographic and Epidemiological Transitions
epidemiological transitions in India,
this concept is of immense value.
• By 2020, an estimated 97 million Indians will be aged
Prevention can help maintain a healthier
60 or older, up from about 64 million in 2010.
population, thus reducing healthcare
• The number of diabetes cases expected to increase
costs for cure, easing pressure on
from nearly 60 million in 2011 to 100 million by 2030.
limited healthcare resources in India,
• India’s share of NCDs is expected to increase to 76% by
and having a healthier, more productive
population. A number of hospital chains
• Source: WHO World Development Report; National
and wellness centers are taking this
Commission on Population, CIA World Factbook.

The new age health systems thus, need

not only skilled medical doctors, but
also skilled managers. Government

Again, the broadening of the concept Medical

of health means that the healthcare Equipment/ Providers
Pharma cos
industry also expands to include a
range of stakeholders like information
technology, financers/insurers, research- Stakeholders
development, policy-makers etc.

Community/ Health
As we have observed from the Insurers
examples, there are countless new
developments cropping up regularly.
Emerging trends and innovations in the Academia
sector have the potential to change
the healthcare landscape significantly.
But these developments are often small
innovations. They need to leverage the
incomparable scale that India offers. In
other words, the healthcare ecosystem
needs excellent management and
collaborations that are strategic, cutting-
edge and forward-looking. While
interactions between and amongst
these stakeholders are taking place at
a smaller scale in a case-by-case basis,
these relationships and inter-linkages

need to be developed and sustained.
The diffusion of innovation still remains
an issue in the Indian scenario. Majority
of innovations do not percolate down
and remain limited to urban affluent
areas. Eventually, process innovation
will have to leapfrog product and
business model innovation and provide
affordable healthcare, with efficiency
and quality. These need to be the
mainstream and not exceptions.

The main imperatives of the healthcare

system are increasing access and reach
to its consumers, increasing efficiency
in service delivery to maximize profits,
and improving quality to match
global standards. Collaborations
between different stakeholders are a
pre-requisite to achieve the three aims.
A facilitative ecosystem and conducive
environment need to be created for
such collaborations to flourish.

Sustainable Strategies for a Healthy India 5

Collaborate to Innovate
The context of Indian healthcare in healthcare financing and making
the current times, as sketched above, healthcare accessible.
indicates a key lever – collaboration for
innovation. More often than not, stakeholders come
up with an innovation on their own
As discussed, the challenges faced without much collaboration with the
by India are unique and diverse other players across the value chain.
and tackling the entire problem of This works in scenarios where most of
access, quality and efficiency in such the cogs in the wheel are functioning
a challenging environment by a single properly. However, for India, where
stakeholder using existing solutions, is there is large room for improvement
not feasible. Stakeholders need to come at almost all stages, such a process
together to develop and implement can lead to inefficiency and unwanted
cost effective and scalable models of delays in reaching the potential
delivering healthcare. consumers. The multiple stakeholders
in the healthcare value chain need to
Effective collaboration across the value collaborate and identify innovations that
chain is essential for new technology/ would span across their domains and
drug introduction, lowering costs, add value for everyone, as the output
increasing awareness and acceptance from each stage would serve as inputs
of preventive measures, strengthening for the next stage.

Key lever for access, efficiency and

quality in healthcare

Collaboration Innovation

Need for stakeholders to use Need for product and process

each other’s strengths to innovations to provide
leverage the existing affordable and cost-effective
infrastructure and resources solutions

Collaborate to Innovate
Stakeholders need to synergize to bring
about innovative models in service delivery
and technology

Collaborations between different collaborate. Experiences from different
providers across the healthcare models, like the Colston Health Centre
continuum in Birmingham for mental illness, show
Different providers across the healthcare that employee motivation at the primary
continuum – preventive, primary, level and employee efficiency at the
secondary, tertiary and rehabilitators secondary level go up significantly with
all need to collaborate in order to form minimal investments in integration.
a seamless and efficient chain. Both
vertical and horizontal integration can Besides this, collaborations between
be implemented in streamlining business diagnostic chains, primary care facilities
processes, reaching right clients and and hospitals can be leveraged to
maximizing effectiveness. achieve these benefits.

Given the increasing competitive To better manage primary care for patients with
intensity, rising real estate costs and a mental health problems, the Colston Health Centre
tough operating environment, large in Birmingham, UK, developed a model of interaction
numbers of healthcare providers are between primary and secondary care. A consultation-
exploring new and innovative business liaison model was undertaken with the consultant
models to tap larger number of psychiatrist visiting the health centre – who would support
patient segments, lesser penetrated and give advice to the General Practitioners (GP) on how
geographies, and enhance service to manage patients with mental health issues and on
offering levels. Various unconventional potential referrals to specialist mental health care. The
formats are being tried out by some collaboration was taken further by using mobile phones
of the new entrants which have also for quick consultations, liaisons for undergraduate and
increased willingness of existing players postgraduate trainings. At a later stage, mental health
to collaborate. professionals became attached to the Colston Health
Centre to work along with the GPs to provide primary care
Investments in collaboration between and integrated therapies to patients.
primary and curative care not
only contribute to prevention of
complications in chronic diseases, but
Metropolis Health Services (a diagnostic chain) has tied
also reduce secondary and tertiary
up with the social franchising model of MerryGold Health
overcrowding by managing simpler
Network in Uttar Pradesh to provide quality diagnostic
health problems at the primary level,
facilities to patients. Patient samples are sent directly to
thereby allowing them to focus on
the Metropolis Health Services laboratories and patients
high-end treatments and in turn
can collect reports from the MerryGold hospital.
improve processes and cost efficiencies.
Referral processes also become
more efficient, timely and effective
when primary and curative providers

Sustainable Strategies for a Healthy India 7

Collaborations between providers Increasing access to reach the
and technology unreached, while controlling costs, is
Collaborations with technology made possible through the induction of
companies can change the way technology in healthcare. Telemedicine
providers deliver healthcare across is being used to connect remote rural
the country. Technology can not only populations to medical advice from
substantially improve efficiency in specialists, which were until now,
healthcare delivery processes, but can unavailable to them. The telemedicine
also make healthcare more pervasive based social franchising and social
and integrate it seamlessly to our marketing by World Health Partners
everyday lives. Technology, for instance connect rural patients and providers to
in diagnostics, genomics and invasive high skilled urban doctors that provide
procedures, has revolutionized clinical holistic care.
practice. Medical devices and health
technology players, like Biosense has Besides this, telemedicine technology
launched its ToucHb (a non-invasive, also allows physicians easier access
instant, portable anemia scanner) to their colleagues and patients in
through select provider clinics in India multiple locations (both domestic and
for screening anemia, especially for internationally) across health facilities,
antenatal care of pregnant women. thus offering the possibility of creating
These cost effective point-of-care a network of health service providers.
diagnostic solutions, often used by Patients, now, do not need to be
large scale providers (like the public restricted by what is the best option
health system) improve accessibility and available in India, but the best available
affordability for a large section of the in the world.
Philips’ award-winning tele-monitoring solutions enable
While product innovations have been
healthcare providers to monitor chronic disease patients
exponential in the last decade, and are
while the patient stays at home. These telehealth
only going to grow, process innovations
programs allow for early intervention in patient care, more
through technologies in healthcare
informed decision making in patient management, greater
are a recent emerging trend – making
patient self-care, and reduced risk of repeated hospital
management of healthcare more
admissions and visits.
efficient, cost effective and accessible.
Innovations in delivering what services
are available, and delivering them better
is going to be the focus of collaborative
innovations in the coming years.

Another area where technology is used
increasingly is in healthcare and hospital • Private providers like Max Super Specialty Hospital,
management to improve efficiency. Apollo Hospitals, Medanta and Escorts are collaborating
Healthcare technology companies, with public payers/insurers like the Central Government
such as GE, are offering a wide range Health Scheme (CGHS).
of clinical and financial information • AstraZeneca (a pharmaceuticals company) has partnered
technology solutions that enable with insurance and health benefits provider WellPoint
better decisions and outcomes for in the United States to gain more insight into patients.
both businesses and patients, improve Once equipped with the medical history of patients
revenue cycle, drive quality outcomes and their families, insurers can make better-informed
and accelerate image management and decisions on the coverage they provide.
wellness. With greater awareness
Collaborations between providers among consumers and patients, health
and payers/insurers seeking behaviour increases and
The coming decade is going to there is willingness and acceptance of
mark rising demands on and costs healthcare directed towards preventing
of healthcare provision, changing illness and promoting good health.
demographics with an increasing aging Wellness players involved in the
population, and an epidemiological collaboration can contribute in this
transition towards non-communicable entire process, especially in areas of
diseases. Due to this, healthcare is better nutrition, stress management,
moving towards a preventive and lifestyle diseases and mental health.
wellness approach. Addressing Insurance companies can incentivize
these demands of chronic disease wellness programmes through
management and of prevention innovative products that have reduced
and wellness promotion requires insurance premiums for clients who
collaborations amongst providers, maintain certain health standards, and
insurers, other payers (like employers) cover out-patient treatment and annual
and wellness players. health check-ups.

Investment in preventive care by The Finance Bill 2012 in India has

insurers is cost-effective and yields high extended tax deduction under section
returns by preventing critical illness 80D for expenditure on health insurance
episodes among the insured population, premiums for preventive health.
and thereby, reducing pay-outs. These regulations by the government
Insurers and payers can also undertake go a long way in boosting focus on
awareness generating initiatives about prevention, rather than curative care,
prevention, disease management and as well as towards creating a facilitative

Sustainable Strategies for a Healthy India 9

environment for insurers to collaborate
with preventive/primary care providers. Health Stream provides learning products customized
for healthcare organizations to meet a broad range of
Collaborations for nurturing and their training, certification, and development needs. It
retaining talent offers a variety of specialty courses for retail customers
In a resource constrained setting including CME, CNE apart from several healthcare
like India, the challenge is not just compliance trainings. It has a total customer base of over
talent management and retention, 2,500 healthcare organizations (50% of all US Hospitals)
but also fundamental training and throughout all 50 U.S. states, and has contracted
capacity development. As we have approximately 2.45 million healthcare professionals from
seen in the first section of this report, different healthcare organizations.
there is a huge shortage of qualified
healthcare personnel in this country. Health Stream has partnered with Harvard Business
Medical and nursing colleges need Publishing, to offer ‘Harvard ManageMentor’- to
to strengthen, improve and increase enhance leadership and management skills in healthcare
training infrastructure to bridge the organizations.
shortage of skilled human resource. This
requires support from the government while containing costs and increasing
to form facilitative norms, accreditation access and profitability, has brought
criteria and grants and possible entry of about a shift focus from just medical
investors to encourage private players in expertise to principles of business
delivering quality medical education. and management. Apart from clinical
specialization, corporate hospitals are
Besides medical and paramedical focusing on internal business functions
education, modern healthcare needs such as inventory, asset, financial and
management training. Rising costs, human resource management as well
expanding demand, and increasing sales and marketing and customer
customer expectations characterize relationship management (CRM). It is
healthcare today and are redefining the expected that this trend will continue
roles of patients, providers and payers. and create a demand for a specialized
This is especially true as health facilities resource base of healthcare managers.
across the chain (primary, secondary,
tertiary) are increasingly being run Collaboration of educational institutions
by corporates and funded through with providers, especially hospital
private equity – which demands chains and other modern modes of
better management practices and delivery are needed for continuing
accountability mechanisms. The need medical education so that healthcare
for efficiently managed health systems, professionals keep themselves updated

with the latest developments in this
constantly changing sector. Besides this, Apps like Bant, developed by the University Health
updating teaching methods and syllabi Network in Toronto, allow Type 1 diabetes patients
to be relevant to the current sectorial monitor their blood sugar levels to help manage their
developments is essential. condition.

Collaborations for an empowered “Sleep as Android” is an app for insomnia patients to track
patient their sleep cycle and analyze insomnia conditions to help
Increasing use of technology is also improve sleep patterns.
resulting in evolution of interactive
patient care by educating and UChek by Biosense is a urine analyzer that uses the
empowering patients to be active iOS platform and iPhone camera to automatically read
participants in their care management. commercially available urine dipsticks to diagnose upto 25
Models such as interactive technology medical conditions.
platform, online patient self-help
groups, and increased involvement of continuum, and the government have
patients in care pathways – right from also been undertaken.
before admission to post discharge,
mobile health, social media platforms The involvement of the government
and patient remote monitoring among in a cross-sectorial convergence
others are increasingly being accepted. cannot be emphasized enough.
These models play a dual role – provide Although India has experimented in
patients with multitude benefits limited scale with multi-stakeholder
including convenience and choosing collaborations for healthcare, other
a healthcare delivery model/ provider countries like Indonesia, Mexico,
based on informed access, and help and Bangladesh have had successful
healthcare providers increase service experiences. Facilitative regulations by
levels and at the same time reduce costs the government (such as the preventive
owing to higher efficiencies. healthcare in the Finance Bill 2012 in
India mentioned above), allocation of
Multi-stakeholder collaborations adequate resources (such as allocations
While there are models of two or three and preferences for Public-Private-
categories of stakeholders coming Partnerships in the 12th Five Year Plan),
together for specific goals of healthcare empowering key stakeholder groups
(as seen in the above sections), multi- for policy action, and political will are
stakeholder collaborations involving crucial for creating and managing large
players across the value chain and care scale collaborations.

Sustainable Strategies for a Healthy India 11

Collaborations between the government, healthcare
technology firms and implementers have helped
strengthen community-based efforts to improve maternal
and child health. Dimagi and D-Tree International are
leading CommCare- a mobile based case management
solution for community health workers in 25 countries.

In India, ASHA (government workers) have been trained

on using the CommCare application to monitor danger
signs, use as a job aide and to capture patient data.
The application is also used to monitor the activities of
the ASHAs and for health surveillance. The use of the
application has improved quality and consistency of care
and has helped in engaging and educating the population.
In Zambia, CommCare has led to standardized
interventions in clinical care and community health by
linking patient data entry systems at health facilities with
community health workers using CommCare on their
phones. This helps clinic outcomes to be handled in a
timely manner and the referrals made by the community
health workers can be tracked at the clinic by using the
mobile application.

Creating and facilitating a
collaborative environment


Equitable Increased
Talent Access Coverage


Affordable Improved
Financing Care health
Pharmaceuticals outcomes

Medical Devices

Enablers for driving sustainable strategies

The striking feature of the sector is like the ones listed in the previous
that it has the potential to grow at section need a conducive environment.
an exponential rate in the foreseeable The ecosystem has to be facilitative
future and to present new opportunities of such partnerships. All stakeholders,
within itself, which will emerge as including industry, government, and
growth drivers. In order to realize the investors need to step up to make
immense potential for each to invest coordinated and concerted efforts
in and grow with the sector, there is a towards creating such an environment.
need for a cohesive and collaborative
approach, where all stakeholders Some of the key questions that need to
work synergistically and leverage the be resolved to achieve these desirable
opportunities to create a lasting impact. collaborations are:
• What role can the government play
Collaborative innovations not only and what are the policy action points
increase value for all players, it also needed to create such collaborations?
reduces cost for the end user and • While collaborations between
improves health outcomes. But government and industry is
sustained and meaningful collaborations common through public-private

Sustainable Strategies for a Healthy India 13

partnerships, how can they be made • What specific action points can
truly collaborative rather than just private players enact upon in the
“outsourcing and insourcing”? coming years to facilitate and sustain
• How can regulation be made collaborations?
meaningful - without restricting
talent and innovations - to counter The All India Management Association
malpractice, unethical measures and (AIMA)’s seminar on “Sustainable
patient-rights violations? Strategies for a Healthy India:
• How can technology and patient data Imperatives for Consolidating the
bases be used for improving patient Healthcare Management Ecosystem”
experiences/outcomes, improving aims to facilitate a discussion
revenue cycles and broadening/ among key stakeholders from the
deepening reach of healthcare, health management continuum
without being misused for denying towards developing a facilitative and
insurance or for irrational care? sustainable environment for meaningful
• What can investors do to promote collaborations.
collaborations and a progressive
and innovative development of the
healthcare sector?

1. Indian Healthcare: The Growth Story
2. Indian Health: The Path from Crisis to Progress, Richard Horton and Pam Das,
Lancet 2011
3. Cardiovascular Diseases in India: Challenges and Way Ahead; Deloitte Paper,
4. India’s Health Care Hurdles, ISB Insight, Vol 9, Issue 2
5. Guest Editorial Introduction to the Special Section on Pervasive Healthcare, Ilkka
Korhonen and Jakob Bardram; IEEE Transactions on Information Technology in
Biomedicine, Vol. 8, No. 3; September 2004
6. Welcome to Welness, Sonal Vij, Express Healthcare, September 2009
7. Five Health Information Technology Trends for 2012, Physicians Practice
8. India Pre-Visited: New Frontiers in Healthcare Innovation, Indo-Swedish Health
Week 2010, Information package for the Leading Health Care Program

Sustainable Strategies for a Healthy India 15

Charu Sehgal
Senior Director & Lead
Life Sciences and
Healthcare Consulting

Sustainable Strategies for a Healthy India 17
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