Amity Institute Of Training & Development

Healthcare in the Pandemic War: Overwhelmed or Rising to the Challenge?

A Conversation with Sumeet Aggarwal

Sumeet Aggarwal is a governing council member of the Healthcare Federation of India (NATHEALTH) and a member of the Young President’s Organisation. He has worked in the past with organisation’s like Fortis Healthcare at the forefront of health delivery in India and Singapore, World Economic Forum, Deloitte Consulting and Monitor Group in the United States. He is currently the Managing Director of Midmark (India), partnering healthcare in meeting customers needs for more efficient and effective patient care. Sumeet has been recognized by the Asian American Business Development Centre amongst the Outstanding 50 Asian American in Business.

About: Sumeet Aggarwal is a governing council member of the Healthcare Federation of India (NATHEALTH) and a member of the Young President’s Organisation. He has worked in the past with organisation’s like Fortis Healthcare at the forefront of health delivery in India and Singapore, World Economic Forum, Deloitte Consulting and Monitor Group in the United States. He is currently the Managing Director of Midmark (India), partnering healthcare in meeting customers needs for more efficient and effective patient care. Sumeet has been recognized by the Asian American Business Development Centre amongst the Outstanding 50 Asian American in Business.

Click below to watch the recorded conversation.

 

Dr. Nitin Batra: Nothing has impacted productivity so much in the last few months as COVID has. We are looking at 26 to 27 million cases across the world, more than or nearly 900,000 deaths, which is a huge tragedy. And in India, we are facing our own onslaught of cases with a large number of active cases as well. What's your reading on these huge numbers? Has the healthcare industry risen to the challenge? What do you think?.

Mr. Sumeet:  Talking about numbers start with India, out of the 26 million or so cases which are globally there, where India is at about 4 million, it's about to touch 4 million as of today. It will be number two as a nation in the list of countries which are impacted by this pandemic. And if you look, I think, just to answer that question, that India has definitely risen to the challenge of COVID-19. If you look at our front-line workers, whether it be the doctors, whether it be nurses, paramedics staff, they have all put in their best effort to contain this pandemic. If you look from a policy standpoint, the government is also very quickly realised that this would spread and bought sometime early on by having on imposing the first lockdown and then followed by two or three more lockdowns which happened.

I also want to recognise here that a lot has been done by not only the healthcare community but if you look at the policymakers, which is the government, if you look at the supply chain which is there, whether it when it comes to delivering health care, it's important to have a good supply chain and have the ability to mobilise stuff, which includes ventilators and hospital equipment and medical furniture, and even personnel. So India has done a fantastic job.

Now, if you look at just the numbers, we are talking about 4 million cases in India and the number of deaths are standing at about 65,000 as of today. So, if you look at the rate, the death rate or mortality rate from COVID-19 stands at about 1.77% which is actually half of what it is at a global level. So if you see globally, the mortality rate would be over 3%. So again, that just showcases that India has really risen up to the challenge and if you look at the way we have ramped up there are a couple of things that has happened. If you see there was only one lab which was accredited by ICMR to take on COVID testing when we had our first lockdown and today there are over 70 Labs in the country which are able to conduct those tests. Then when we look at PPE equipment, I remember Prime Minister Modi touched upon it as well from the Red Fort on 15th August that PPE equipment in every area, if you think about it from gloves to masks to just gowns, we have so many factories that are able to produce it and when we started with the pandemic or the onslaught of it, we had very little access to PPE. So from that perspective again India has done fantastic and so has the ancillary industries which would support healthcare.

Dr. Nitin Batra: If I was to dive in on what's going well, you talked about innovation, you talked about the front line and the healthcare services, the whole healthcare services setups stepping up to the challenge, are those the two things that you would recognise as going well or is there a third?

Mr. Sumeet Aggarwal: So I think the other part of it is, the mobilisation of resources was quick, so whether it be healthcare or otherwise, it happened very quickly. And I think people during the first lockdown obviously were very much supportive of the policy around it. And then eventually, obviously things were out. And I think a lot of people are now understanding that there is a good reason why one should wear masks when in public and try to avoid social contact and maintain social distancing. So I think that has also helped quite a bit, is the awareness of this disease. Because if you think today, the digitization that has happened in India has allowed people to really embrace this change of behaviour. And I think behavioural change is very important in any kind of healthcare delivery to be successful.

And I think by having the channels of technology, we were able to spread the message faster. And I think compliance by people has helped and I think the other part one should be aware of is that we just don't want people to be more callous around it. The prevention is the best cure, as we hear, and I think that is something which we need to follow up on. And I think a lot of people including celebrities have come and done a lot to build that awareness. The government has also very quickly launched the Aarogaya Setu app which allows for contact tracing. And I think just recently, Google and Apple have also just announced this week, that contact tracing would be something they will do together as technology companies. So I think there is that technology element which has also played a big role in preventing the spread and really rising up to the challenge.

Dr. Nitin Batra: As we were waiting for this conversation to start, we asked a poll question, Do you think India’s healthcare system has risen to the challenge? Majority of us actually said yes, and some people said no. So, for the cynics amongst us what could have been done better? What's not gone that well, as it should?

Mr. Sumeet Aggarwal: I think when you think of the pandemic and specifically COVID here, there was no playbook there, everyone around the world was taken by surprise. Yes, there were some early indication from China that there is a disease of this sort but everyone again thought that it's like Ebola or SARS or something on those lines, which allows for you to eradicate it very quickly or contain in that region. But epidemiologists very quickly realised that this is something which is not going to be contained with the travel and movement. And I think if we look at it today, even the WHO declared it only as a pandemic in late February.

So again, many governments were grappling with the situation and if you look at it with no playbook in hand, you really have to do a dip stick approach in terms of responding, and you can be. Many times, the cynics amongst us will think that we were very reactive. Yes we have to be reactive at times because without a playbook you will be reactive and if you had a playbook you could be responsive to something like this. But if you just look at the pure statistics, let me indulge you in some numbers out here. The number of people who die in India is around about 11 million annually and in that 60% by of, what they call NCDs or Non-Communicable Diseases and about 40% of are Communicable Diseases deaths.

And if you look at that, about 3.7 million, about 35% of the people who are dying of cardiac diseases, about 1 million are dying of cancer, then about 200,000 are going to be die because of liver related ailments and other 1.5 lakhs or about 0.15 million will die of road accidents. So, if you look at COVID and you look at over the last eight months, since COVID has been prevalent in India, we have only had about 65,000 deaths. I mean, if you put that in larger perspective, the number of COVID deaths is minimal. And what I fear is that we are spending disproportionate amount of resources of the Healthcare towards COVID and its containment. And my fear is that we, in these seven months have not been able to provide the care, the much-needed care that was required for the seriously ill in the other categories. And they have not been able to access hospitals at times, they have not been able to get the care that is required on a continual basis.

So I think that is where we see a disproportionate amount going and more attention going to COVID and the stigma around it is creating that. But I think that's where healthcare has to do the next phase of responding to this challenge will require us to actually look at the sick who have been ignored during these six months. 

Click below to watch the recorded conversation.

 

Dr. Nitin Batra: Based on the statistic that you just shared, which is interesting. Do you think we should not be worrying about COVID and going about business as usual because we have bigger diseases to worry about? Or is this a wakeup call for us to learn something from COVID and do something for those bigger challenges, those bigger life-threatening diseases that have been troubling us and holding our country back? Which perspective are you taking here?

Mr. Sumeet Aggarwal: I believe that this pandemic and COVID-19 is a wakeup call for the healthcare industry globally and also in India. I also think that we cannot ignore it. I think by stating the numbers, I was just saying that it's miniscule as compared to the disease burden in India. We are 17% of the world's population and we have 20% of the disease burden in India sitting out here. So it's disproportionate anyways to start with and now if you think about it, our spend in the global health care, which is about 12 trillion dollar, we are spending somewhere over 100 billion dollars in health care annually. And if you think it's only 0.8% of global healthcare spent with 20% of the disease burden and 17% of the world population. Now, even if I was to adjust that with PPP - Purchasing Power Parity, because we are talking about US dollars, even then it will remain miniscule. And I think that's what we need to fix. So if we come to where the problem is, I think it's a wakeup call to say that are we spending enough on health care. Is it an area which needs to come into focus and has the spent been adequate over the years? I definitely think not. So we really need to look at this in a more focused approach and really think of a pathway of how to get into even universal coverage which we are talking about. How do we do that. Without funding we are not going to go anywhere.

Brig. Rajesh Sharma: You mentioned in passing about many important surgeries, elective surgeries and other activities could not take place now, this has resulted in financial distress for the healthcare sector. What do you think is the kind of impact, financial distress, the healthcare sector has gone through and what can be done to support healthcare sector now at this time?

Mr Sumeet Aggarwal: In this time because of the stigma around COVID, a lot of people chose to remain at home and again not go to the hospital. So we saw almost a 80-90% drops in OPDs or Out Patient footfalls in hospitals in private hospitals and even in government hospitals for that matter. So if you think about it, during the first two or three lockdowns people didn't end up going to the hospital. So, obviously for admissions in an hospital, they depend on the outpatient flow as well because a lot of the outpatient consults will eventually result into an inpatient admission. So today if we look at it, the financial situation of our hospitals is definitely burdened, the cash flows are under pressure. And I have heard in industry bodies that there some hospitals are even close to just going bankrupt because they are running out of cash very quickly. And if you think about it, a hospital has a lot of cost. The cost structures are very-very heavy and it requires people to really work on thin margins.

So while many people and the cynics will think that private hospitals are money making machines, I just wanted to let you know that there's a lot of overhead costs and there's a lot of operational costs which make it very difficult for a hospital to even make it in margin. And that's what is happening. Now there is, as time has passed we have seen more and more footfalls happening in the OPDs and people are a little bit more willing to go for elective procedures within the hospital. So that has helped.

But I think if we look at a country like United States and we look at Europe, a lot has been done by the government in terms of funding the healthcare by doing some emergency funding and unfortunately in India we have not seen that happen. So the backbone of Indian Healthcare is the private sector. If you think about it, 4% of GDP gets spent on health care in India, 3% of it comes from the private sector or private health sector contributes that 3%. And that's something which is getting compromised right now. And the government could step in and boost this spending on health services and making sure that private hospitals are able to deliver care. And also in the government hospitals, I think it has to take a holistic approach and really help both the private and the government sectors.

The other part, which is a little bit being difficult is that in certain cases, state governments have put a rate card on private sector hospitals to provide care for COVID and other ailments as well. So they have not consulted the private sector and really put a rate card which is at a fraction of what their cost of delivering care in these settings is. So obviously, if you are accessing high quality care, there's a cost to it. And unfortunately, I believe that the health care sector has been a soft target in that because as health is a social subject and it is an essential for human life so is food, for example. And I want to ask if you look at the food industry during the pandemic, obviously that was also important for sustaining human life but was there any Cost Caps or capping in terms of pricing going on in the food industry. Did Parle-G have to put the price of biscuits at 2 rupees for their 10 rupees biscuit because that's exactly what happened in healthcare in the private sector. So that's the conundrum that we face right now.

Brig. Rajesh Sharma: Talking about some challenges that we have all faced in terms of diagnosis, testing, paucity of skilled workforce, infrastructure, among many other things. What are the innovative solutions that are on the horizon in India that we could look forward to?

Mr. Sumeet Aggarwal: This was a wakeup call. But what is amazing about India is that it always rises to the challenge. So whatever problems are thrown to us, we somehow figure it out. And I think that has happened in many industries and I love the example of the telecom industry, which has actually today connected so many Indians and done a grassroot level change in India. But when I look at what should be there when it comes to paucity of labs and diagnostic equipment and other things, again resources are mobilised very quickly. So as I said from one lab to more than 70 Labs today are able to do the test. Again, factories are producing PPE, we were able to very quickly look at innovative ways of manufacturing ventilators and even providing for them from various parts of the world.

But I think if we were to look into the future, I think technology will play a very big role because surveillance systems, disease surveillance systems are going to become very-very important in near future. So how do we leverage technology in a way where we are able to get to learn about spread of diseases which are happening? So at a community level, what are some of the interventions that we can make and then at a city level or a town level. So can wearable devices create a cloud system or cloud gathering of data, which will allow for crunching in the backend and say that Mumbai has had flash floods, for example. And we are seeing people's blood pressure rising, and we really need to look into this and kind of intervene out. So this is just an example.

But there are so many things that can be done in terms of technology and again, technology can be leveraged for skills because again India has a huge shortfall of doctors. We today require 200,000 more doctors, 400,000 more nurses and 800,000 more paramedic staff, but how do you ration them? The only solution, because we are only able to produce 50,000 doctors a year which are joining the workforce in India, the only way to do effective outcomes and care is to use technology through which doctor patient can interact. And that is something which will allow for the care to be delivered without having doctors all over in the remotest parts of India, which is very difficult. So, I think again technology has to play a role in this, in a big way.

Brig Sharma: As we continue to confront the COVID crisis, healthcare providers are being forced to rethink facility design and how care is delivered. How does a healthcare provider harmonise the space, technology and workflow for better outcomes and this is one area I think you are in a particularly good position to answer this question?

Mr. Sumeet Aggarwal: Yeah, I think, again with this crisis of COVID, we have realised that there is a way where we have to segregate some of the patients which are high risk in the COVID category and highly infectious and continue the services of the hospital in a place where we are able to assure that there is no infection possible. So, I think when we look at, when we look at these spaces, it is essential to look at ways in which we have a step-up procedure. So, in COVID facilities, it is important that we look at isolation obviously, for those who are not that sick and then step them up if they require ventilation or not and there has to be separate entry procedure and exit procedure for that and a lot of hospitals have already done that in India. But we have to look at again bringing the cost down for certain pieces of furniture or of certain things which are there in isolation facility because those patients do not require that much medical, I would say, supervision, so, we can look at ways in which we can have lower cost solutions for them, whether it when it comes to furniture or other things, but when we look at the space which is required for ICU care, there are certain protocols that need to be followed. So, obviously that will add to the cost. But there is also again, something called the RTLS which is the Real Time Location Services, which is something which our company Midmark does in the United States, we don't have that solution here in India, but that allows to track personnel within the hospital space and see what is their compliance. Where have they moved within the hospital? Where have they washed their hands? How many times have the nurses wash their hands how many times a doctor has spent time in a room or moved around in a facility? So, this is something which helps in bringing better efficiency into the healthcare system because there's a lot of wastage which goes on in healthcare to be very honest, out of the $12 trillion spend globally, I think about $3 trillion is wasted, which can be prevented with better tracking systems and better billing systems and that is something which we are making a difference in, at Midmark by bringing in better speeds management. And I think that is something which will continue to bring the cost down. And I think we have to bring that into India and implement it.

Brig. Rajesh Sharma: Price control is a reality in India. There's no doubt on that. Does this really signal the end of private investment and innovation in India?

Mr. Sumeet Aggarwal: I think, you know, what is private sector in any country thrive on? A private sector will always thrive on returns right return on investment and if you look at the hurdle rate in India and the kind of interest rates that are there, it's around 8%. And if you're lucky, you are at 8%, otherwise business loans standard about 11% and if you add the weighted average cost of capital, which is !^&, it's much higher and for a private sector to be successful. You really need to pass that hurdle rate, right and that's something which is in the north of 15%. So if you're getting that kind of return or a return on invested capital of over 10%, obviously, private investments will go down and the way today, healthcare is structured in India, it's becoming more and more difficult to extract that kind of return because of increased cost pressures and if we look at private equity investments, while there has been a lot of activity in this space in the healthcare arena for a while, I think they'll start rethinking because with the ROIC's and the VAT numbers where they are, it's going to be very difficult. And if you look at innovation the cost is always on innovation, because a lot of the returns are then redeployed into getting better equipment or spending on R&D, whether it be in a company like mine or whether it be in any other multinational? And f you're not going to get that return, you're not going to be able to allocate money into R&D and others innovation measures which are required because disease patterns are changing, and we require more and more innovation. Actually, the minimum spend on R&D in healthcare has to be around 3%. But it should be much higher than that and that is getting compromised, if we do not see a return and they will retreat Yes, the private sector will retreat innovation will be stemmed. And already am seeing a lot of pressure from multinationals not able to get the price that they need out of India, so they are actually looking to exit from the Indian markets.

Dr. Nitin Batra: As we were talking about price, we launched a poll with our audience here to get their perspective, the question was, do you think the price of healthcare in India is unreasonably high? We have our responses in, about roughly about 66-70% of us saying they are unreasonably high. There is a sense that the margin is too high. There is a sense that the cost on the family wallet keeps going up unreasonably year after year. What would your response be for that kind of sense that some of us may have?

Mr. Sumeet Aggarwal: This is interesting because I know that there's a lot of cacophony around health care costs and then it is also a lot of mistrust between which has been created between the healthcare system and the patient and that has led to also many times violence, right. And I think the Supreme Court just passed a rule now that, if you're going to be violent to anyone in the healthcare system while they're delivering care, they can you can be put behind bars. I mean, I am just talking about the amount of mistrust that they are, you end up losing your temper, once you start taking things in your own hand, patients have done that. But nonetheless, I think when we start thinking about healthcare costs, Now, again, I'll indulge you in some numbers of years, if we go back to early 2000s, right, and if you look at the cost of a CABG, or a open heart surgery of sorts, the cost would have been in the private health care system say around 300,000 rupees or three lakh rupees, right, is what they would have quoted you at that time. And you would be surprised that today also, if you were to get that quote from a private health system, it would be about 300,000 to 400,000 rupees, right? If you were to look at inflation from then and now, you know, how much inflation has been in India, is that 300 times procedures should have been maybe costing more than a million rupees. But actually, it's only moved up maybe 20 to 25%. Right. And otherwise it should have been maybe 300%. But what has led to that cost containment is the fact that there has been a lot of efficiency that has been brought into the healthcare system. We have been able to cut contain costs; we have been able to increase the number of procedures which has again made it possible to pass those efficiencies to the patient. But the mistrust continues, and It is very sad to see that because actually, if you were to go in and dig into the cost structures, you will realize that the price of health care delivery hasn't changed.

Now, what has changed, I also want to acknowledge that there is the diagnostics have improved significantly right over the last two decades. So now your doctor will ask for more tests, right? And sometimes that's taken as a negative because we will say, they're just prescribing more and more tests and now there is a cost to it because the technology has changed. I just had a back injury recently; I am giving my own example. They asked me to do a Lumbar Spine MRI, I did that I got some disc bulges which were there. But then my radiologist said “that you know, what I want you to also get a Cervical Spine MRI done because I want to rule out something I see something, I just want to rule out”. Now there's a cost to that right. And it's not cheap and MRI is not cheap and it's up to me now, right? Because the diagnostics have improved so much. The call is on me that you know, you want to get a peace of mind you want to get another test done and just say that, you know, can I actually eliminate the cost on the healthcare system by knowing early on and preventing disease which will take course later on, is something there but I could look at it another way and say that, you know, am I being asked, I am over prescribed on the diagnostics part and it is costly. So then comes the mistress or look at it in a positive way, and say, you know, the diagnostics has improved, and this could help me in the long run. So, that's the kind of debate that has to be there, but overall, I can assure you that from a cost structure perspective, hospitals have looked at it in bringing about efficiency and have tried to pass it on to the patient. And yes, the other cost structure which is being changing is the skills, right, so doctors and nurses and what we pay them obviously is increasing, the payments are increasing, but that's also required because we are just keeping them at par with inflation, and that is necessary in any job that you do. So that's my take. I don't know if I fully answered the question.

Dr. Nitin Batra: I just wanted to shift the conversation a little bit and start thinking about the future. So if you can help us dive into the future, the structure of healthcare today in India, as I understand it, is that it's largely services driven. We have 132 billion in services, we have pharma sitting at 55 billion devices sitting at 11 billion diagnostics, a smaller proportion, three to 4 billion even though they've been in the news recently. And then we have the primary healthcare setting at about 13 billion so it for our participants, I lay the structure out, you know, where are you going? You're going to the hospital. That's the largest part You're getting diagnostics done. That's a small miniscule part. And then you are, you know, buying medicines to help with your cure, that's the reasonable probably half the size of the healthcare industry. What do you see as the change in the structure over the next five to 10 years? Or what do you see the overall trends that are the tailwinds that are going to drive healthcare sector one or the other?

Mr. Sumeet Aggarwal: So, I think the government has realized that health is important for having a productive nation, a healthy nation is important and that is something which they are working on. And they have recently committed that they are going to increase the spend on health from 1% of GDP, which is the public expenditure of health to 2.5%. And I think what you touched on Nitin is he crux of how a healthcare system can be successful and that is primary healthcare. Primary healthcare in any successful health system has to be robust. If that is robust, It is not about health care, it is about health actually. And our objective has to be to keep people out of the hospital. So we don't want people to end up in secondary or tertiary care, we want them to be sorted out at the primary care level. So something which the Delhi Government did for example, is the Mohalla clinics which was started by Arvind Kejriwal. Very good way the interventions are required, right at that level, because your burden and the price of healthcare increases as soon as admission in the hospital happens, right. And that's where we want to drive our attention towards is that we don't want people ending up in the hospital. We want to keep them out. But how do we do that? Now I was very fortunate to have my early experiences at Kaiser Permanente, which is one of the large US Healthcare systems and they run their hospital system on something called Population Health Management, right, which is in public health it’s studied widely. Population Health Management is to see that how we create interventions to a large set of a population to keep them out of the healthcare system, right. And Kaiser has done that beautifully because they had, I think about 40 hospitals and 10 million members or people who were in Kaiser, now Kaiser is in a unique situation that they have both the insurance and they have the hospitals. So it is in their you know, best interest to keep the insurance and hospital admissions balanced, obviously because there's a cost to keeping anyone in the hospital and it is paid by their own insurance which they offer to the members. So but 10 million members are managed through 14 hospitals, how beautiful is that? Right? So can we leverage something like that? How have they done that? They have done that through technologies. They encourage all their members to have primary health care checks on a yearly basis. And they are able to just pick up the segments which are the highest risk. So, the any given population will have about 10% of the population, which is at high risk because of maybe smoking because of just their lifestyle because of previous history of theirs. So, how do I actually come and counsel them and keep them out of the hospital and educate them and create awareness? I think those are the things that Kaiser has done a fantastic job in focusing on and I think that is something which India is just starting on, through something like the Mohalla clinics and the primary health care has to become robust. Now. The other thing which I have a suggestion is that in India, our health insurance, which is offered never covers primary health care, right. It only covers secondary and tertiary health care. So when you're in the hospital is only when your insurance gets activated. So there is a disconnect, there's a big disconnect from primary health care. And that is why you know it because there is no incentive for the insurer to keep you out of the hospital here, right when that incentive is built, or if they are taking charge of primary health care where they have to reimburse for primary health care, they themselves will become very intelligent to keep people out of the secondary and tertiary system. And that's something which I think India needs to change about how health care insurance is provided by the private sector and even by, say schemes like Ayushman Bharat, which the government has just started because they also only cover secondary and tertiary health care, why aren't they playing an important role in primary health care? I fail to understand.

Dr. Nitin Batra: So, you see a huge disconnect with the size of primary health care. You know, we have some statistics, that we have gathered as part of this exercise where we look at India as to India right, there is 37% of rural population. Only 37% of rural population have access to any health facilities. Only 2% of doctors in rural India. So that's 700 million of our fellow citizens. That's one doctor in every 40,000 people. So I wouldn’t say primary health care system is broken. I think it's not. So is that one trend you see or a necessity you see, picking up?

Mr. Sumeet Aggarwal: It is definitely a necessity and needs to be addressed at war footing . We cannot afford to not have primary health care at the grass root level or the last mile level because this is really, really going to change how India will be in the next decades right India is a young, we always say that India is a young nation we have the largest number of youngsters here, but think about it in 10 years, they are also going to get older, the disease will change and you know, there's a huge onslaught of new things are coming in from a disease standpoint but the calling is now, we really need to step up and we need to focus on spending more on health care and health I should say not even health care I should reframe the word is health, and we need to look at ways in which we can bring about change and also contain costs, I think that's something which has to go hand in hand for a country like India. But right now, it's a minuscule spend 1% is not adequate at all. And I think, just to give you another statistic on preventive healthcare, which is primarily driven on the outpatient or from the primary healthcare standpoint on preventive health care is an outcome of primary health care checks. Only 9.8% is spent annually on preventive healthcare. So, if you look at the most successful systems will spend 25-30% of the resources on primary health care and on preventive healthcare and that’s something where India is lacking again big time.

Dr. Nitin Batra: Great so the other trend or necessity you're pointing out is health, which is so far the structure is healthcare dependent once I'm sick, how do I get well. But how do I avoid getting sick and for that, you know the approach you're recommending is a community approach is that what I get right.

Mr. Sumeet Aggarwal: That’s absolutely right, community is essential and then from a community standpoint, it then goes to a town city level and then may be at the district level but the first level intervention and accountability lies in a community. I mean look at what COVID has done, this is just amazing right now in my building for example where I live here in Mumbai, it's a community decision how many people can visit you. How many people will be led into our building, should there be a paper deliver, should there be, you know, milk delivery happen or certain things like there are, so the community has taken accountability of healthcare. Look at how powerful that is because everyone is following those norms and the community level you know, policy making has helped.

Everyone get better outcomes in terms of not having the infection spread right. So this is what I'm talking about this is where it happens the change happens and the behaviour change happens at that level, we have to drive all the way to that community. And, you know, a classic example is what Dharavi did I mean some amazing recognition has come from the WHO and on how we have contained the spread because awareness was increased the testing was increased. So if we look at Dharavi from a standpoint of Mumbai it would be wrong because that's a micro set of Mumbai. It has its own challenges its own problems its own density So we need to tackle this at that community level, not at Mumbai level and Mumbai cannot be tackled at Maharashtra level. So that's, that's why community is so important.

Brig Rajesh Sharma: We touched on the topic of insurance and we touched on the topic of primary healthcare. Now I want to combine a question of Ayushmann Bharat which as for the benefit of viewers I'll just say that it's a National Health Protection Scheme and it cover about 10 crore poor families, each family gets a cover of five Lac rupees per year in secondary and tertiary. Now so on one side we have the government stepping in with insurance cover which of course increase and in this case the private sector hospitals can also be approached by a patient that they doesn't have to go to government sector hospital only and the other aspect is the low penetration of insurance which is only hospitalisation cover and no OPD cover. Now what do you think is going to be impact of the Ayushmann Bharat scheme, how do think that Universal insurance health cover will it ever be coming to India, may we have your thoughts on that.

Mr. Sumeet Aggarwal: :I'll just start with allocation to healthcare public allocation to the healthcare in India so the health ministry has an allocation of 64,000 crores and 1/10th of that which is 6400 crores is spent on Ayushman Bharat, that’s the funding Ayushman Bharat has during this financial year. Now if you look at that and you said 10 crores families, which is great and if I multiply just saying that it is 5 individuals in that family on an average that comes out to be about 500 million people or 50 crore people and if you look at 50 crore people I say that they get sick 5% of the population requires hospitalisation of this 500 million. The math around it comes out about Rs. 2500 per person is what the allocation for just the sick is for Ayushman Bharat Rs.2500 right and Rs.2500 today is the cost of maybe in a year two times a family of five can dine at Pizza Hut or something on those lines is what I'm trying to get there but how is a hospital in the private sector even a Government hospital able to provide care for ₹2500 and I'm only taking 5% of the people fall sick out of the 50 crore or 500 million people. So this is where I see that there is a big gap in the funding again. Now defence is important, it's great, we are spending on defence about 2% of our GDP which is again on public health expenditure recently we have bought Rafale jets at 59,000 crores which is equivalent 36 Rafale jets were 59,000 crores allocation to the health ministry 64,000 crores so you can think yes we have to protect our borders we have to also protect our citizens, I just want to bring a comparison out there, but Ayushman Bharat is a good step I'm saying it’s something it's in its second year or about 2 and half years I think it's the right step I feel that the way we need to take it is bring some owners why do insurance companies have a co-pay, we cannot dove out free stuff, we should also make everyone accountable whether we take 2% or 3% of the hospital bill we need to bring that accountability in Ayushman Bharat where people are also held accountable for their own health and they are responsible to pay, one) a certain amount of the bill, second) Ayushman Bharat should cover primary healthcare is my take because without primary healthcare we know that it has it brings more people into the healthcare system in the secondary and tertiary levels and I think a universal healthcare path is being started out for sure the government has announced the National Health Digital mission which was just announced by the Prime Minister. Again, very miniscule allocation of 400 crores has been made for that I think to digitise health records for every citizen in the country a much higher allocation is required but I think the will is there by the Government. They have just embarked on this it's been only 2.5 years but I see the forward path, we just need to increase the funding, we need the willingness is there the other part which I want to also bring about is that skilling is very important we are lacking we can create as much infrastructure as we want we can put as much money as we want into healthcare but without having people which are the doctors the nurses and the paramedic staff we're not going to achieve anything and today we have brain drain out of India for people going abroad because they get better opportunities because possibly they're not getting paid enough or they seek better opportunities over there. A critical shortage of manpower 200,000 doctors, 400,000 nurses, 800,000 paramedics are required as of today and we have built capacity in the medical Education Trust by 50,000 graduates coming out every year from the medical arena or MBBS degree but that’s still is not going to cut it for us. So, these are some of the things which I think we need to work on.

Dr. Nitin Batra: What's your sense about the alternative treatments, whether it's Ayurvedic hospitals, Naturopathy are these going to take off and contribute to health in the country. What do you think?

Mr. Sumeet Aggarwal: : I think that these treatments are definitely something which one cannot look at, I mean allopathic cannot be looked in isolation because Naturopathy and other alternative therapies are essential and many countries actually many people come to India seeking that. Ayurveda is very popular for people travelling so medical tourism if you see is there a lot of people seeking care into India because one it is cheap but also the fact that there is a holistic approach to healthcare we have in India, so they look at many alternative therapies like Ayurveda, anything between that bit of Ayush is looked at and I myself today you know to be very honest after my back issue I have taken Naturopathy kind of things where I'm not actually taking any medication but I'm letting myself heal naturally and it's working wonders. Many times allopathy is a quick fix but if you have the time and the ability to wait it out sometimes naturopathy works and some of these alternative treatments are just proven wonders so and in India you can tell that many of the companies which are doing work in this space have done well whether it be Patanjali or Dabur or others which are trying to foray into the space so the belief systems of Indians lies in these therapies and it has proven to be good and I see a lot of private equity activity in that so I'm sure there are some good prospects coming along.

Dr. Nitin Batra: How do we ensure safety and support of healthcare workers and you as a leader of cutting edge healthcare service provider for the healthcare industry, how you ensuring safety in your frontline?

Mr. Sumeet Aggarwal: :So for us safety for any institution whether in the healthcare industry or otherwise any industry there this is very important and I think what we did early on is build awareness and also a response mechanism which allowed for us to see that what is when I say surveillance we did our own little surveillance system where we are checking our workers as and when they enter our premises and we're trying to look at technologies which will help to do a mass screening because right now obviously it's time consuming and that takes certain things then we are looking at ways in which we can constantly sanitize our factories and office spaces so that we can keep the safety of the people intact. Obviously PPE plays a big role but I think we have also asked that people voluntarily tell us that there is something which they're not feeling well or they have come in contact with someone and one thing is not to make them feel like there is anything that they will be penalised because people feel like or there's a stigma around it, we need to remove that and that's the approach that we have taken. So if you're supportive we give them more time off, actually in our factory cases have been where people have fallen sick and they say that we want to come back to work and we say you just take your time, just be at home, isolate yourself if need be, take the medicines, or vitamins and minerals and whatever. But we give them time off we do not hold them accountable during that time to come to work or even inform us so those are things which have worked out well. I think because everyone requires that emotive support and I think that's if you were able to provide that I think that's half the battle won right. I mean that was what has helped us in a big way, and we do not say that you need to take time off from your accumulated leaves and what not and there's a lot of counselling that happens. So that's something which has worked out well and I think that's the future for any company to be or anywhere for it to be successful is that emotive intelligence I think that EI will play a big role in this.

Dr. Nitin Batra: : What are the suggestions for young entrepreneurs that wish to enter healthcare so if there are one or two or three areas where, I'm a young person, I have limited resources but I have boundless energy, enthusiasm and a will to contribute back to my society what should be those platforms that young entrepreneur should think about.

Mr. Sumeet Aggarwal: :For that I always think about value-based healthcare. So value based healthcare define beautifully by Harvard Professor Michael Porter is outcomes plus quality divided by cost. So my suggestion to any entrepreneur ,young entrepreneur is to really look at this equation take it to heart, outcomes + quality divided by costs, now that can be not only in healthcare you can take it to any industry so our objective as an entrepreneur should be to continue to bring the cost down because it is inversely proportional which will boost value so value is inversely proportional to cost and it is directly proportional to quality and outcomes. So if you keep on looking at ways in which I can bring out better quality of care or better access to care and continuously bring out better outcomes when delivering care or doing anything which is related to the healthcare supply chain for that matter or the care supply chain or the care continuum I should say that will be so whether it be Netmeds for example which is just I think Reliance is going to acquire because it provides better access, it brings more convenience and if it is really about outcomes if we are thinking of quality let's say in both cases quality and outcomes if you look at AI role in radiology for example analysing radiology images it does a better job, it's proven to do a better job than many radiologists, because they could be fatigue and what not but there's a 99% accuracy in analysing radiology images by artificial intelligence the computer can do that and similarly WATSON initiative by IBM so these are some of the things which are happening which is really reducing costs and boosting that healthcare value equation and I would urge every entrepreneur to look at it and see where they can contribute on this.

Dr. Nitin Batra: Great model there so that leads me to just summarise we talked about how the Indian healthcare industry standing up to the challenge you spoke about what's going well you spoke about what are the trends in the future and you listed out your urgent needs for the healthcare market which need to be done at war footing specially the resurgence or the rise back of the GP that friendly neighbourhood GP that sees you first that's what you're emphasising you're talking about alternative therapies being in the future as well for us and your message for entrepreneurs is think hard about outcome think hard about quality and think hard about lower costs if you want to contribute in this sector. Great any final thoughts that you'd like leave to our participants with?

Mr. Sumeet Aggarwal: :: I think the only final thought that I want to leave everyone is that let's take owners of our own health. I think if we are able to do that there is a lot that we can put or blame or put our finger towards and say the government didn’t do this, the private sector is not doing that or whatever that all starts with us and we can also blame the community for that matter because it's a collectively we can it's easy to blame but are we ourselves putting owners on our own health is something which should be lies and this is something which can be a big change and can really really unburden the healthcare system and this can be done through awareness which can come yourself about the things that you can do to your own health and hold others accountable for that matter and I think that is something which is necessary right that community intervention which we were just discussing is something which we can think about there will be always temptations, we have temptation from the food industry, we have temptation from the gaming industry we have to sit around from Netflix to be in front of our and be couch potatoes but I think it all starts with us and it all starts with taking that on us and holding ourselves accountable and our near and dear accountable for health.

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Credits:

Moderated by Dr Nitin Batra | Brig Rajesh Sharma
Transcription by Alka Nathan | Geeta Bhatt | Anju Arora
Edited by Rohin Bishnoi

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