Health for All

>>Please do take
your seats so we can start now,
in the next five seconds. Please do take
your seats. I know that you have
more important stuff to do, once
eeverybody is seated. So here we are in
this very important session, very important
early morning session and I’m
– all of us are grateful to the
audience, all of you have taken time
away from many other important things
that are going on here to be here. So health – everybody talks about health
but does very little about anybody
else’s health. People get focused
on their own and they think that, as
long as I’m sorted out, life is OK. But that is not so. So the region where
we live, south Asia, there are some
disputes about whether we should
call it South Asia or not, as one-fifth
of the world’s population but it
disproportionate large share of the
world’s diseases. Both communicable
and Northern communicable. Non-communicable there is the history it’s
the climate, it’s the crowdedness of
our cities and lack of infrastructure,
but also now there is new phenomenon
which is a rising epidemic of
non-communicable diseases particularly type
2 diabetes. Ir’s an epidemic now. It’s almost impossible to find someone of
a certain age group who is not taking
care at least. We have a lot
to talk about. I have a great panel the me. To my left is Shobana Kamineni. Pardon me? Did someone say something? OK. I have Shobana Kamineni. She is the executive vice chair
person of Apollo Hospitals Enterprise. Those who live in India,
I think most of us have had either been
to Apollo for themselves or to
visit somebody. She’s a pioneer – Apollo
is a pioneer, her father in private
health care around India. And then I have Matthew Guilford. Matthew Guilford has an unusual job. He is cofounder after and chief executive office
Common Health, based in Asia
but he works in Bangladesh next
door as well. In Bangladesh he tells
me that he has health insurance system
which has the largest number of
people enrolled. So I think there are
lessons there that we have for India
as well because we are trying to build
something like that in India. Then we have Melvin Oscar dous dous
dous, he is the Vice-President and
general manager of Novo Nordisk. Anybody who has dealt
with diabetes of themselves or any member of the family
has seen Novo Nordisk on some level. Lately they’ve been in
news daus I think one of their new molecules
which is an oral substitute for an
advanced diabetic third line or
fourth line?>>First line now.>>Which has FDA approval and we all carry
stories about it. So his company is one
of the few at the cutting edge of
research in many pharmaceutical areas
but especially diabetes which, as
I said earlier, in the subcontinent
is a very major problem. And then we have
got Karan Singh – Shashank. And the lights there are not helping. Shashank N D founder and chief executive
officer of Practo. Practo is another
one of those unusual companies. Practo immediately a lay person would like
me would think tele medicine, which means
I can Google Web MD and treat myself
because once I know which drug to
you – everything in India is OTC, over
the counter. But he does something
more interesting and complex than that. His company brings
doctors and patients close sore you can
consult – closer so you can consult them on
Internet or on the phone, but also
go and see your doctors because India
has a terrible shortage of doctors. For even in our city, as he explains
to my, in Delhi and Bangalore, the
ratio of patient is 1 to 500 and in villages
it goes up to thousands. So how do you get those Villers or — villager
s or people who have poor access
to doctors? He tells me he has 20
million patients.>>A month, yes.>>20 million parents
a month. So more than 200 million
patients a year. So that is the kind of
need that exists there and that is why I am
particularly enthused about the new plan of
this government to massively increase
medical education in the country because we are short of doctors
in our country, especially specialists. The specialists in our
country have the longest waiting period. And then we have Karan Singh,
so Karan Singh is MD of Bain and Company. It’s a console tansy, as you would
guess, his job is to listen to everybody’s
problems and tell them what to do. He doesn’t particularly
have to do it himself but he can tell them
what to do. So it’s a powerful and sizeable
panel so I would request each one of
you to speak for a couple of minutes. I will ask you a question. Maybe I will go like this and like this and
at any point in time, feel free
to intervene when someone else is speaking
without being rude, and then I will
engage with you and then the hall
belongs to the – then the time belongs
to the audience in the hall. And finally in conclusion we will have Indu
Bhushan, who is the CEO of one of the
most health care programs anywhere
in the world right now. And he will have
some concluding remarks. So, Shobana, you first. So you are in a strange
place right now in the sense that,
on the one hand, you provide the contrast
to the health problems, which is
the best quality health care. The best quality health care at costs which
are very high for the region but very
cheap globally. So how does that
help the larger public health problem? At the same time, the new plans
that are coming up are now going to
involve the private sector like yours. So how do you see this working out
and do you have better ideas,
going ahead?>>Interesting. But just to give you a bit of a perspective,
I live in Hyderabad and the
last week I spent, you know, people calling
me – this is friends and people
I didn’t even know but who had my number
and they said, “Can I get a bed
in Apollo?” And we were full of cases
not that Apollo want to treat but
the cases we have to treat and it comes
out of this community problem. It was Dengue and chicken gunya. It was almost two epidemic proportions
and running a health company,
I have seen the spikes. So this year has
spiked more than the last 10
years of whatever we’ve been doing
in terms of claims. So I’m counter
intuitive, I sit on a claims side you don’t
want and on the other side we sit
on the treatment side so I’m seeing
the whole cycle of what’s happening and
I sell medicines so we’re all over
the place. So, having seen that,
it is not a problem you want to have
and I’d start first by saying whatever
we do for health care for all must
start with the measure of seeing
how we can – the environment and ->>This is what happened in Hyder bad?>>But it happens in
Delhi as well >>The Chief Minister of
Delhi is claiming that Dengue is down
90% in Delhi.>>But it’s NCR and
you will see those claims start sparking. After the rains, you will see
a huge amount of spike. This is contextual
ly it’s everybody’s problems. When you’re talking about health
care for all let this be everybody’s
problem to sort out, what is the
infrastructure in our cities? We need to start
working on some of these that
are clearly things that we can treat
and which are a problem around the
subcontinent also. Now, moving forward,
I think that Shekhar asked me
what are the models that we see and,
shek after, we kind of do it all. Our tele medicine has treated 10 million
people in rural areas. So we know how
to take it out there. We are actually
from Andamans to Africa to
everywhere. We have the largest
telemedicine network and we’re doing this every day. So we understand that. But what we need Is a model that
uses the health care facility, some
of them that are available in India
and I would like to talk about an
interesting model that we took and the
government really wants to do more
of this because, if you see the top end
spectrum in India, if you want to give
great health care, it’s going to cost
you upwards of a 10 million rupees a bed
and you cannot – when you have – when
you’re saying 10 million rupees a
bed, when you’re paying for all the ->>$150,000.>>To others it’s
cheap but for India it’s expensive. Depending on the facilities you put,
and the cost of our proton, for
instance, was – I’m trying to convert
it to dollars. Was 1,200 crows, which
is like 1.2 billion rupees?>>Yes.>>So this is the cost
that you’re spending, you know. And **Audio lost ** You have to –
and doctors charges and everything, so to
give great medicine, you really have to
be out there and spend it. So there’s a cost
to it, you know. And these are things that
you have to run as a proper business, so the
way that you do it, keep that at one end of the
spectrum and, like Shekhar said, we
do it at one-tenth, these other people
will be travelling to other parts
of the country. That is one India. There are 20
million Indian families that spend
the same amount as people in Europe
do, middle class Europe. So there is a
population that will require new
facilities.>>I think – sorry,
if I’m interrupting. This is reassure
ing but the best health care is one
you don’t have to a avail of.>>Yeah. Why we all have to invest
in it is because this is something that will
move to tier 2 to tier 3, tier 4 and at that
level we have to find what are the new models
and it’s probably not the Apollo model of
building beds at two crows a bed. So we have to find that
model and this is something that we’re all
working with and a great thing that we have done is we’ve taken
over the institute where my dad comes
from, we have taken the government hospital
and upgrade ed it and we’re doing
it at (inaudible) rates. So there are areas
in tier 2, tier 3 that we
can create more private. I can keep going
on but the message is let’s get
into some of the things that we can avoid
and the other thing is scale>>Scale is the issue.>>And technology.>>Karan, you solve
everybody’s problems. So ho how do you solve
the region’s scale problem and cost
problem?>>Let me say, it’s
great to be here and, first and foremost,
it’s fantastic that health is
a state and a government priority
with Indu Bhushan and I applaud those
who are doing things that are
a game changer for India. As we think about
the issues and the biggest
opportunities going forward, you mentioned
the tsunami of NCDs that unfortunately
we’re going to be hit by or are
getting hit by. I think it’s a huge
priority that we need to address and
the challenge is we all know the
numbers about diabetes, cardiac
care, oncology, et cetera, the challenge
is about the diagnosis rates are
about 45 to 50%. So we are a sick
population that doesn’t know how
sick we are and, given we are the
hot bed of generics in this market,
we need to be treating, we need
to be finding and treating much earlier
and much more cost effective using
lifestyle and generic drugs. And I think the point that you made is
keeping people healthy, is keeping
them out of the hospital. So there’s a
paradigm shift we need to think about
preventing and early treatment,
only then does the system become
sustainable. We need the emphasis on the primary
care, which is the early part of
treating and mass scale screening for
diabetes has to be one big priority. The second one I would say is a
paradigm shift is required in term of
creating the right incentives. What do I mean by that? Today we are a fee
for service system. I would argue that
is a perverse incentive and this
is all about curative. We would love
to think about a more of a capitated,
pay for performance, model
that allowed people – provides the
inventives to keep people healthy
and keep them out of the hospital. The hospital is the most expensive part of
the treatment. So a paradigm of how
do we think about incentives and a
pay for performance is the second thing. Third is the quality in this market,
unfortunately, is hugely disparate. When you look at the accredited
institutions, whether it’s hospitals,
whether it ‘s diagnostic labs, you’re
talking about 1% that are actually
accredited. So, in any health system
for it to be sustainable, we need
quality access and affordability
all to be taken together. So I think a minimum standard of quality
is essential because there’s no
point spending a lot of money when
we’re not clear about what is the
outcome of that today. So I think quality
has to be expanded>>Will you tell us
something about maybe the most interesting case
you’ve dealt with?>>I think there is a
tremendous opportunity when it comes to
health tech. So we are doing a
tremendous amount of work with the leading
health tech companies and I think, if you look
at the next 500 million that are going to come online,
our penetration of using health tech
is actually very low. This should sky rocket. And the issues around access
and afford ability are – there
are some very interesting solutions
that health tech allows us to address. Especially the issue of the lack of con concentration of
infrastructure, hard and soft infrastructure
in the smaller towns which is where
there’s a huge population. So we’re doing a lot of work when it comes
to how do you expand health tech
to the needily population — needy
population and it will be good, Shekhar,
to get some discussion going
on – in that same need y population,
its middle class that is the most
vulnerable today. The insurance penetration
rates there are about 10%. So we’re very well taken care of in the VPL,
the top end has great care, there
is a very vulnerable middle class where
I think we need innovation on
insurance and on delivery.>>The self-employed I
think have the toughest time. Matthew, you have a lot
of practical experience of this and you’re
dealing with all strata of populations. In diverse countries – bash desh
and Malaysia — Bangladesh and
Malaysia are very different in therm
terms of their social base. Tell us of the experiences you have
had and you have had these two layout
some problems and possible solutions>>Great. Thank you very
must have. When we started the journey in Dhaka
when I moved to Bangladesh five
years ago, when I think about health
for all it comes back to. This I am sure
many of you have seen a sachet
of shampoo and I think when we think
about who we serve in health for all
the question is how can we connect health
care, design health products
for a woman who is buying shampoo
in a sachet. When we talk about the city
of common health, we want health to
be as common as going to your corner
store and getting access. One of the things that we quickly discovered
as far as barriers for this segment in
Bangladesh was how do people pay for
health care. And I think if you look
globally, out of pocket spent on health
care is roughly 18% of health spend,
in South Asia it’s about 65. In Bangladesh we did a survey and asked
1100 people do you have health insurance. And three people out of
1100 had health insurance. So that kind
of calibrates where we were starting. I think when we think about the
answers and the solutions, it is
absolutely about tech and these new
models for lowering costs, increasing
efficiency. I think it’s also about
distribution and one of the things that
we looked at is how can we reach into
communities and villages? Very quickly we found we were, for example,
billing through telco air time,
so through a partnership with
the largest Telecom business in Bangladesh
and we found people didn’t have
enough air time balance to pay for
their subscription. I don’t know if this
is still the case in India, but
scratch cards. This is the way that
people in many parts of the world used to
buy and top up their phones. So we launched
scratch cards. This is about 60
cent and had about $500 of inpatient
insurance and discounts at labs,
pharmacies and diagnostic centres. As we think about getting to this health
for all tier, it is the technology
and the business model but what can
we learn from other industries as far
as distribution reach>>What does it take to convince poor people
that insurance is fair, that insurance
will not make a distinction between
those those at the upper end and the
end in which you’re engaging with them
and what do you do to make sure insurance
is fair?>>Yeah, there was
a quote from a guy from Ogilvy who said
health insurance is the hardest product
in the world to sell. It’s tough to sell health insurance. We see a couple
of barriers. Especially for
populations that are low income, there’s a high discount rate
on the future. So you’re basically
asking someone to pay now for something that,
as we say in Bangladesh, that
hopefully they won’t need to use and
they have to invest in it now. So that relevance is a challenge. I think the other piece that we see is trust. Please.>>I cannot ->>Please feel
free to ask questions.>>Having run an
insurance company, what prevents adverse
selection? If this is a monthly
think and you’re paying 500 rupees, if I’m sick
I will take the text month so I
can postpone my surgery and
avail of it. So how do you do it
averse selection?>>I think we learn that
one the hard way. So when when we first
launched, the intention was to cover any
inpatient procedure because we want it to be simple. And the rule was any
hospital stay of three nights or more anywhere
in bash desh and we — bang Der and we — Bangladesh
and we pay a flat rate payout. We know what C-section rates are in and
we got killed by elective C-sections. So people were buying the product
in one month, going to claim 100 times
what the premium was the next month. So we’ve had to adjust the product. I think the other piece to this is we
don’t sell it just as insurance. And so it’s the
bundle piece. So in fact what we do is
we’ve shifted towards marketing it as it’s
access to a doctor with insurance. And so we have a pool
of people that are buying the product
because of the telemedicine piece
that are not necessarily claiming. But I think to your point it’s
chicken and egg. Because the typical
potential insurance players
in many places where we work will
say you have anti-selection. So now what we have to do is put in more
rules and then you put in more rules
and people start to lose trust in the
product and then you have more anti-selection
and then you put in more rules and you get into
this downward spiral where suddenly you
don’t have a book. So this is a longer
discussion.>>Yeah. I don’t want to side track.>>You said about
Bangladesh – when the situation is too adverse, you
do lead lean on god. I think a lot
of the hinter heartland is
doing that. So gods are kept busy in
the heartland.>>Shashank, you deal
with many of the issues that the three
speakers so far have mentioned. The next speaker will have some solutions. But after problems going out
of control, so tell us about your
experiences because you are connecting so
many people and so many people are
very diverse backgrounds and very
diverse economic ability to doctors.>>Thank you, and it’s a pressure
to be here. We – I think the advantage
of sitting in our shoes is the access
to data. We have about 200 million
users each year coming in, accessing
information, accessing service
on our platform and we get access
to a lot of user behaviour and data. In the last 10 years with all this
data and other data available it’s
very clear that India has high quality
health care. That’s the reason,
you know, we all here use the Indian
health care facilities and we
have a lot of people outside coming in. Unfortunately we’re not able to use the
same health care for everyone in India. So clearly inaccessibility and
an affordability problem. Through the data that we have, we have
30,000-plus doctors and we noticed issues
for years now. And what very
interestingly is coming out of this data is that
the doctorings are all grouped in
the metros, where the patient-doctor
ratio is quite low, which basically
meanis it’s much better than what
the WHO describes. In the rural areas
it’s much higher. That means we have
overcapacity in the urban centres and
we have seen data which shows that
over 70% of doctors have 30% of their
time or more available. And then we have another India where there
is a lack of doctor, lack of quality doctors
and lack of access. Clearly, the answer
to digital health and how digital
health through telemedicine can
solve this problem. What we are also
seeing is a very interesting point
that I shared on this panel already,
is that in developed countries
the number of doctor consultations
per year is 10 to 12 but in India it’s
two to three. So more number of doctor
consultations leading to a health
ier society>>Can I request you
specify that?>>An average individual
in a developed nation does about
10 to 12 doctor consultations in
a year and when it comes to India and
we have the data for our users it’s
about two to three.>>I think in India
someone did 10 to 12 if someone is
generally healthy and declared a
hypochondriac.>>I think it’s a lot of
insurance coverage, I will come to
that point. We’ve also seen Indian users
over the last month years increase their
frequency of use from three to four,
so it’s on the increase. So what we need
to do is be able to get doctor
access to Indian consumers and Brigade
bring – bring the awareness that
early access to a doctor brings early
detection. So there’s less
self-diagnosis and this is very critical. We’re also notiesing that doctor behaviour
is changing and doctors are more and
more comfortable consulting irrespective
of time and location. So they are ready
to consult on phones and so
are consumers where there’s an increase
in the number of voices happening>>Can I interrupt you? Now in a country
where actually there’s nothing as
prescription medicine because everything is available over the
counter, there is a hazard in doctors
advising from a distance. It’s the same
as me going to Web MD or something
and saying I need this drug and going
to a neighbourhood chemist or an
online farm. Is – pharmacy. How do you agres that?>>With every innovation
comes the risks. One is self-regulation
where we have quality teams that
do it but I think it’s actually the
government’s role to actually put
the right soft regulations in here. And, second, I think the way to
actually get tele medicines propagation
going in my opinion is to
make it part of insurance. And insurance
companies can actually leverage
telemedicine to reduce the costs and
do the screening that we spoke of. So one is to allow insurance companies
to be more innovative and include
telemedicine as a means of health
care delivery. I would regard have
a patient, doctor, doctor and get
medicines in a regulated manner instead
of diagnosing himself. So there is a
lot to be got out of the telemedicine.>>I think the power of
data and health care is huge. I think one is how do
you use data in a more connected manner? What I mean by that is
using the data from primary, secondary. Today, there is siloed data that
each one has. That connectively, the
power of that will improve the outcomes. I think there’s a massive
opportunity to publish outcomes. So when he talked
about poor quality, I think
with the system we have today and the
connectivity we need to be able
to understand consecutively
in a much more understandable manner. So we can leverage quality
in quite a substantial manner.>>Sges >>These are
very interesting concepts and if you want
to scale up, you need these, for somebody
who has been – who has spent a few years
of life, a few decades of life I’d
say that there is something odd about
a doctor who treats you have
a distance because today even if you
have to a specialist usually the guy
doesn’t feel your abdominal, your
pulse, the doctor looks at the scan
and prescribes something and while
the prescription is on the patient
is googling for side effects. So that is a quality to doctor-patient
relationship which is disappearing because
the doctor is busy. Is telemedicine
convincing enough for patients? You could answer that question.>>I guess what I would
say is it depends on what you’re competing
with. Right? So if you look at rural
Bangladesh where the option is a pharmacist
who has no training and that’s how people
are getting care, I think we find
that for a lot of people, even rural
people with low education levels
they realise it’s a heck of a lot better. There’s’s use cases where people
actually want some distance. So my friend
Ivy who does a lot of work around
women’s health, if you’re a woman who
wants to talk about family planning, do
you want to go to the doctor with
your husband or is that advice you would
like to get in a confidential way? I am curious with Practo what type of
use cases you see in this as well?>>50% of our users are women but the
Internet generally has 30% as women. So the three main cases is one, women’s
health, two, psychiatry, health
and three is sexual health. These are taboos
in a country like India and people
are deprived of solutions or advice. So telemedicine can be a great leverage
for this.>>Do you have any
input on this before we come to Melvin?>>No, I completely a
gree with the point of view. I think when
it comes to a specialist, maybe
the consults for an emergency, or at
night or you really can’t get a doctor
at that time, telemedicine is
absolutely essential. So we have to mix
these and to me my biggest worry
of these online pharmacies is that
they’re coming from a perspective of how
many drugs can I sell so then there’s
no perspective on habit forming and
I’m very worried, and I ‘m sure Melvin
will talk about the antibiotics
prescription, what happens if this
whole population becomes resistant? So that resistance is something we’re
not taking seriously enough? I would add that element in too.>>Melvin, you are being blamed now.>>I am saying please take care.>>I am just giving
you awe hard time.>>Yeah, yeah, of course
Melvin, your company works in chronic
life threatening disease, life
threatening or debilitate ing disease
and something like that which will
debilitate you, and also if you’re
not well to do, clean you out because
even though insulin has become
cheap now it’s cheaper but it’s
still quite costly. And even most of the
diabetic medicine is costly. And then you
be “evil”, not my words, multinational
s, you are to blame for many of
the problems in our health care. So just hold court for a couple of minutes.>>Glad to be part of
this panel but usually pharmaceutical companies
are the famous beating boys. You start working from a
place where you see what is your role, what
problems do you solve? I think if you look at
diabetes and Shekhar reported very
nicely because the biggest problem
that we see is an average person comes
very, very late into a clinic. That means – and lost close to six to eight
years before you have identified you
have the disease. So we say diabetes
is an emergency in slow motion. So by the time you reach the doctor’s clinic,
the patient already has two or
three complication s and that’s when
the pharmaceutical company comes in
because you are trying to give a
medication which probably would
have sort of exaggerated the disease
so far, that you are doing a mostly
salving job. Many of you in this
room would have heard, we are
of course within diabetes care we
are a company which is involved in protein
developments. What we see is
– it’s not that insulin-like product
can solve the issue buzz we – but
we believe working in partnerships is
a key to making or finding a solution
to the problem. So how do we get the
diagnosis rates up? How do we make
sure that this doctor-patient ratio
can bridge those gaps? And I think most
of the work that we do in India
is also revolving around these issues. Trying to build a bridge for
accessibility, trying to build a bridge for
affordability. And also trying to bridge
towards making sure that we have
some sort of way how to make our products
available. It is not easy because India
is such a vast country. A product like
us – I mean, the number one product
in the pharmaceutical industry for that matter, it takes time
and a little bit of distribution
knowledge like what Matthew put in,
is to make sure to get this product to the
remotist part of the country and that
itself is a job>>You’re talking
of insulin?>>Insulin. And, for us, it’s not
that once you keep that insulin in the remotist
part of the world this the patient is going to
buy it, the patient has to travel back to the
city to get themselves diagnosed. I think as an
organisation we are trying to solve
this issue. We are trying to find out
is there a possibility to find ways to make sure
that this happens? Actually we came up on
a very interesting project, Karan also is
involved in it, we’re actually looking at
the nursing homes. We believe am some point
in time, we will reach the nursing homes and
we believe if there is a possibility that
the primary and to some extent the
secondary care of a patient happens at
this place, there is probably a much
better way to manage people. Like Shobana put in a lot of people occupy
beds and if you ask me most of the
time people with complications reach
a place where possibly there is
very little hope. I am not saying doomsday
but basically what’re doing is
a salvage ing job rather than preventive
care. So what I’m saying is,
yes, we should collaborate, look
at pharmaceutical companies as people
who can really honestly start working
towards finding a solution when it
comes to the three big mantras that
is government is talking about –
how do we solve access, how do we
solve afford ability and how do we solve
availability? We are up there, we have
a few projects. We strongly believe
there is value in creating those bridges
and making sure things happen>>Do you have a view on
price controls that this government has brought in
in the last five of six years?>>I think good
to some extent. Like I said,
pharmaceutical companies generally try to adapt. We also believe that the
sections of society needs to have some sort
of care, which is possibly available at the
primary level itself. I can give examples
about ourselves. We actually have a
product at every point price and we believe ->>You have insulin for the poor, insulin
for the middle class and insulin
for the rich?>>I wouldn’t say that. I would say you would
have the latest innovations coming at a
price but you have the products which is your
own legacy, good, strong products which already
work and we strongly believe we should not
take it out because there is always this one
that comes from the price control – is
it viable or not? But I think for a company
like us it is very important to address this
issue of viability and for us to keep those
products and let me tell you those are 70%
of our business. And that we still make
sure that we have to ->>So I think
one of us have reported and so have we,
the report they’re is sitting there for us, you have a new drug now. It’s new diabetic drug
which I am reading a lot of good stuff about. But, as I understand, it
will still take a fair bit of time before Indian
patients can get it. So is there an issue
with the gap that exists between
FDA approval or international approval
of a new drug and then its
introduction in India? It is healthy? Can something be done about it. Because if it’s not
(inaudible) get it from outside and the rest will suffer. In any case, your
business will suffer.>>Shekhar, very
good point. Actually (inaudible) That we have
seen globally. We would have launched those
products in India within a year of
FDA launch and that is primarily because
we used India as a clinical trial
hub, not because it is cheap tore do
clinical trials here but you get a diverse
data points which possibly the
Indian pool can contribute to. Current ly no-one believes in the fact
that India has to be 10% of the clinical
trial and that becomes a very strong
candidate for us to launch the drug
very early. If you’re talking about
the new oral protein, I know we
are just about in the process of launching
this product in the US and I am
sure sure if you have the right mechanics
and the right price point and strategy
we might have it as early as possible
and we have the most ->>But how does the Indian regulatory
system work?>>If you try early to
start working on the clinical trials
you have a better chance of having
the product early>>Have you been
getting out trials already?>>Yes, even on oral – we have already
have large ->>An oral what?>>It’s an oral
protein, which we are going to
launch globalry. We already have a number
of data points in India.>>I can keep chatting to you but let’s learn
to the audience . Please raise your
hand and request a question, but
not a comment. If it’s a comment, keep
it very short.>>I set up India’s
first rural hospital network. My question is the
discussion has been around largely
doctors and hospitals. What is the role of the
community health workers, particularly in
primary care, that we are missing in this
conversation?>>Matthew, will
you take this?>>Sure. I can start but I am sure
others will have views as well. So I think our experience
has been that they can play lots of roles. For us, part of it is
distribution, so we have done partnerships in
Bangladesh with NGOs to sell these community
health cards along side other
products. There is a huge potential as
we look as NCDs and we look at screening
and adherence around screening
for NCDs. There is also a capacity issue
and we need to confront this issue
around saying what is this level of
capability of those community health workers
and how do we upskill people because
I would say our experience has been
it’s pretty uneven as far as what they’re
able to, do especially compared
to what you would get in tertiary
or secondary care setting.>>If I could respond –
we did a couple of things in three
states in India. We actually run the CSCs, you know what they
have the community service centres
in villages. So we trained nearly 40,000
health workers and upskilled them
and here is where this point of care
devices will start making a big
difference. Can you imagine that now
you can do the cervical cancer check
with an iPhone? There’s a device to it. We’re doing point of care of
H B1 tests and EMIR is a big one. Basically we have get ->>How do you point
of care – someone comes and takes
the blood sample?>>They do a prick,
it’s not a blood sample, it’s only a
blood sample that you are able to do, you said
the touch and feel so the health workers are
trained to do this and communicate on the
telemedicine. So with the specialist.>>I think this is so
fascinating that we can do on. But there are other
questions. Please keep your
questions short because we have to leave
time for Indu.>>Good morning. I run an early stage
fund and we have made investments in
health care. My question is
more on holistic medicine. We talk about homoeopathy but maybe from the
point of the rest where does that stand?>>Thank you for bringing it up.>>Does anybody want
to take it up?>>We’ve really
tried, I can tell you – I>>I think she
accepts the complement>>We have tried to do
stuff with it but the regulations.>>I think this
government is investing a lot of money in
alternative medicine but homoeopathy has not great
press globally right now>>And they can’t write
the prescriptions.>>Question in the back
and then we will come to the front row and then,
if there’s time, I don’t think we will have time
for one more, but let’s see.>>Hi, I’m co founder of
a medical device company based out of Bangalore,
one of the big issues we face a lot with hospitals
which you are saying why all drug companies
are tech companies go to US first and then come to
India because hospital ask us for US approval. They said if you don’t
have this, you can’t even get inside the
hospital and when we spend this money
and see a Lucative market outside it’s
more obvious for us to go first there
and then to come back. How to deal with
this situation?>>Karan, are you
addressing anyone in particular?>>Karan?>>I think there’s a
massive mass market opportunity here. I think if you talked
about affordability – what you’re talking about
with your product, your devices will if you can
make it affording, this is the country where they
need to be using and leveraging and testing
the mass market, the affordability products. And I think there is
a high end market for sure which is
the CE mark and the FDA approved. There is another segment with good enough
quality there is an opportunity not only
in India but in multiple other markets. So I think Indu will talk about
this but India will be a huge part
of any system and if you have an affording
product, why not.>>Question there?>>Hi, I vrkds y, I’m the CEO
of a health tech company in Bangladesh. You were worried that the whole
nation doesn’t become resistant
to antibiotic. How is India addressing
that issue of controlling the
prescription? For example, we are trying
in Bangladesh to limit the expiry
date of a prescription
to 30 days. Is there something happening
in India that we can learn for shared
knowledge?>>They’re working
on it. I think maybe – if you want
to – but I the tell you it’s a
work in progress. There’s an E pharmacy
regulation which is coming into place. We will have to see. As of now, there
is a huge – every state has its own
drug controllers from the centre. This has been put into
place for many, many years. And most states
it works quite well in terms of
prescription and you cannot dispense without
a proper valid prescription.>>I just want to add there that the E
pharmacy bill is going to be coming
out which ensures that every medicine
dispensed has to come through a
legitimate prescription that has to
be uploaded. I think that is a great new policy. That is still in the
draft stage and we hope it will come
through soon. There is still a need for
better regulation when it comes to medicine
dispensing. It comes to online
consultation, it comes to how do we use
technology in the more responsible manner? And I think there’s still
a big vacuum there, very grey area,
especially telemedicine India
is extremely grey. And the faster we put good
regulation in place I think thing
will speed up. Another problem health has
is it’s a state matter and each state
deals with its differently making
it extremely challenging for
innovation.>>I will give the last
question and then, Indu, your turn.>>In the world over
people are talk about population health and trying
to get into preventive medicine. I am involved in population health
in the US in terms of managing the risks
of the patients and trying to minimise
the risks. I would love to hear
from the panel how India and also from
Mr Indu Bhushan>>Does anyone want
to respond to this?>>We did a great study
with Microsoft and this has been published
all over the world. We used longitudinal data
and latitude nal of 50,000 techups over
the last 10 years in Popovic using that
— Apollo using that data and we brought
out a health risk assessment,
a predictive that Microsoft is now
so excited about is has been published,
was recently put in San Francisco
in their conference and they’re so excited
about what can happen. And Indian s have a predisposition to
a higher systolic rather than the rest
of the world. So these are studies
that are actually coming about when
you look at population health
but you would also bring out disease
patterns of different states
from north-east to, you know, the ones
that are vulnerable to different
antibiotics.>>Can I pick up on what
Karan was talking about, in terms
of trying to incentivise people
not get sick, like what you said.>>OK. Indu, I think you should
take the floor now. And I know we are left
it exactly so minutes and this is WEF time. So these 10 minutes
are yours. I will sacrifice my closing remarks. You should all be deprived of my
closing remarks!>>Thank you, Shekhar,
but I will very generously give you
back five minutes, and thank you
for giving this opportunity. I just wanted to make three points. One was that in India I think for the first
time last 70 years we are seeing
highest level of political commitment
for the health sector. I have not seen that or actually none of
you would have seen that in many years,
many decades, and the Prime Minister
himself is keen that we improve
the health of our population and the
time – the amount of time he devotes
to the health sector. We recent ly were
marking our first year of operations
and he spent two hours with us
and before that in UN he spoke about
health and he was part of the – like
he was part of the panel supporting UFC. So we are at a time when India
is serious about health sector, I
think for the first time probably. That was the first point. The second point is that, irrespective of what
we do right now, there’s a momentum
and the demand for health care services
is going to rise and I have a
feeling rise exponentially because
for many factors but I will just pick
out four factors. Two factors outside
the health sector something is happening
and two factors within. Outside the health
sector, one thing that is happen
ing is ageing of the population. Even if our age specific rates for
cancer and cardio vascular diseases
remain the same, by the factor there’s
a momentum going and people are ageing,
we will have more cases of cancer,
more cases of disease and CDs and
from 1990 to now, the number of cancer
cases have double, not because
incidence has increased but because the
population has aged. So we will see greater demand for these
services because of ageing of population
and the second thing which is happening
outside the health sector sin
creasing – is increasing incomes
and ps airations and people want
to get more health care in general because
now all over the world we have
seen that health care is a luxury
good when incomes increase by 1% demand
for health care increases by
more than 1%. So since we are growing by six,
seven, eight per cent, we are going
to be seeing increase in health
care demand. So that is going
to happen. But within the health care,
what we’re doing is going to have a great
impact on the demand for services. One is very ironically we are
extending our prevention and one
would argue that prevention is going
to reduce the amount of health care. Actually the reverse will happen. When you focus on prevention you
are focusing on screening. So all the cases
of cancers and cardio vascular
diseases and diabetes which are
going unnoticed now, you will see
a tsunami of those people – cases coming
out and they will go for treatment. So that is one issue. The second is those
500 million people who didn’t
have the paying capacity and never
thought of going to services, now
have the paying capacity, they have
that rupee in their pockets to
go and see services so we will be seeing
that increase in demand. So the next 10
years if you are in the health
sector on the suppliers side, it’s
a great sector to be in because you
will see exponential increase in demand
for services. Now the challenge for
us and the third point for policy makers
is how to make those services available
at affordable cost. Because of what
we will be seeing is that
services are not available for the
current demand and we see if you go to
AIMS, the kind of lines you see there
are like something to be believed. How to provide quality
services at affordable cost is a challenge that
we will be seeing and how to go through
with that or how to ensure these services
is something that we will tackle. Many of the things that we discussed
today that innovation, sector
technology, will have to be part of
the solution but also major part of
the solution will have to come from
government. Right now, government spends
about 1.2% of GDP on health which
is among the low nest the world. I am not talking about the neighbourhood
South Asia. I think out of 191 countries,
we rank about 180th in terms of
the amount we spend. So our policy health
policy of 2017 says that we will
increase the spending to 2.5%
of GDP and so it’s easier said than
done because, once you have to increase
the amount budget for health, you have
to decrease it somewhere else. So it’s not some game. If we can increase
this budget for health and more
than double it in coming three, four,
five, six years, obviously that is
going to help, but at the same time
we have to seek support of the private
sector as well, which has been part
of solutions, part of the puzzle for
the health sector for a long time. 70% treatments are done in private sector. And so we will be looking at collective
bargaining and as the issue
came up, if we can provide volume to
private sector and in return they can
reduce prices that would be something
that we would be looking at. But innovations, technology will
have to be part of solution and, lastly,
improve the efficiencies and
redistribution because right now
if you see while we have – we need to
increase the number of doctors and services
but if you look at where they’re
located there’s a huge skewed
distribution right now that most of the
services and doctors being available only
in large cities and if this distribution
of demand and that has followed
demand because demand is in the large
cities, so once we have distributed
demands and created demands in
rural areas in tier 2, tier 3 cities
I am hoping that supply will also
follow and we will see that distribution
which is much more efficient
and equitable.>>If I may ask you a
question – you talked about private sector. Very positively. But that’s the suspicion
you are hit with. You are not including
the greedy private sector
– not my words! I’m supposed to provoke. So how can the state leave the
poor their their health care for the
private sector, whose motive is profit? How do you answer that and how
do you bring in safeguards?>>You know, it’s funny. Maybe I was telling
you this – that if you look at – and
this is our data. Poor people largely
go to the public sector because
they can’t afford private sector and
people like you and probably me we go
to private sector because we don’t
trust the public sector or – we trust
them in terms of skills but we don’t
trust in terms of the hygiene>>We wait for the best doctors from government
hospitals to be tempted out by
hospitals like hers so we can go to them.>>So now what we are saying is
those of these best private hospitals
should be open to poor people as well
but you’ve raised a good point, that
are our regulations good enough? Can we insure – ensure that this problem
we have in the private sector can
be resolved and we can ensure quality
services? We are working on that through
many means a lot going to that. Frankly, if 70% of
treatments are being provided by private sector,
and most of the tertiary level treatment
is available in the private sector
and keeping the poor people out of
this will not be fair and we need
to connect them, we need to open doors
of these facilities to them. At the same time
we need to ensure, of course,
with the private sector, that they
provide the quality services and they
don’t charge them too much. And for charging
we can – we actually have – we
have rates and that has been the bone of
contention between us and the private
sector that we are not paying
them enough. So obviously they’re
saying that they’re losing money while
working with us. So hopefully we can
find a sweet spot where they are not
losing money but they’re not also
not charging too much. At the same time,
we have this compact that they
provide them quality care not poor care.>>So I think as we search for the
sweet spot, the time is up but I can tell
you one of the most important data
sources that you can look at is a dashboard
of his office. So if you can have the
benefit of his hospitality or his
colleagues you can see the dashboard for me,
it’s eye opening. I just gives you – it’s
just a snap shot of whatever is happening to
India’s health on a very large basis. So thank you very
much all of you. You’ve all been
marvellous. I wish this was a longer
session but I am sure there will be other
ones soon enough.>>Thank you.

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