Technology Race – What is India’s Status in Healthcare System Technologies? Part VII

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(Brig (retd) GB Reddi)

“Healthcare System” comprises Hospitals, Doctors, Nursing Staff, Technicians, Advanced Medical Devices, Medicines etc.  The scope of this paper provides a broad perspective of the current status of Healthcare System (Basic Facts), Role of Medical Technology, Trends in HealthCare, Healthcare Sector Growth Projections, Medical Indigenous Technology state of Key Medical Devices like MRI and CT Scan etc., and  Pharmaceutical sector opportunities.

Basic Facts: Key Highlights include: Population as per Worldometer as on 06 December –  141.35 crores; Health State subject;  Only Delhi, Meghalaya and Pondicherry are allocating 8%; Union Budget 2022-23, Rs. 86,200.65 crore allocated;  2.1% of GDP in 2021-22 against 1.8% in 2020-21; Healthcare industry is $372 billion by FY22; Hospital Industry is 80%  – $132.84 bn FY22; Planning to introduce a credit incentive programme worth Rs. 500 billion (US$ 6.8 billion) to boost the healthcare infrastructure; as of 2021, employs a total of 4.7 million people; Allopathic doctors increased to 13.4 lakhs in November 2021, from 9.4 lakhs in 2014; and, Doctor-Patient Ratio Of 1:854 Better Than WHO’s 1:1000.

Total number of Districts as of August 2022 are 766 districts up from the 627 in December 2014; inhabited villages 597,483 with 82,149 villages having population size of less than 200, with population more than 2,000 but less than 10,000 residing in 115,029 villages; and Panchayats to include: 630 Zilla Panchayats; 6614 Block Panchayats; and 253163 Gram Panchayats.

Medical Infrastructure to include: public hospitals – 25,778 with 713,986 beds, 35,700 ICUs, and 17,850 ventilators; private hospitals – 43,486 with 1.18 million beds, 59,264 ICUs, and 29,631 ventilators; as on 23.09.2022, 313 Government M.B.B.S Colleges with an intake of 46,380 students, 283 Private M.B.B.S. Colleges with an intake of 41,740 students. Apart from that there are 361 Government PG (MD/ MS/Dip.) Medical Colleges with a capacity or 24,245 PG students and 360 Private PG Medical Colleges with a capacity of 16,281 PG students. With regard to Super Specialty Courses (DM/MCH), there are 235 Govt. Medical Colleges with an intake capacity of 3,622 and 89 Private Medical Colleges with an intake capacity of 878.

Public health facilities norms to include: Sub Centre (SC) – 1 per 5,000 population in general areas and 1 per 3,000 population in difficult/tribal and hilly areas; Primary Health Centre (PHC) – 1 per 30,000 population in general areas and 1 per 20,000 population in difficult/tribal and hilly areas; Community Health Centre (CHC – 1 per 1,20,000 population in general areas and 1 per 80,000 population in difficult/tribal and hilly areas. As per the Rural Health Statistics (RHS) 31.3.2020, the status of public health facilities functioning includes: 1,57,921 SCs – shortfall of 46,140 (24%); 30,813 PHCs – shortfall of 9231 (29%);  5,649 CHCs – shortfall of 3002 (38%); 1193 Sub-divisional Hospitals (SDHs); and 810 Districts Hospitals (DH).

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Role of Medical Technology: Medical devices, particularly medical technology and their costs, play a role not only in screening, diagnosing and treating patients but also in restoring patients to normal lives and in regularly monitoring health indicators to prevent diseases. With technological advancements, the role of medical devices is now expanding to improve quality of care across each stage of the healthcare continuum:  Screening and diagnosis;  Treatment/Care;  Restoration; and monitoring. The list of monitoring devices includes: Cardiac Monitoring Devices, Neuro Monitoring Devices, Respiratory Monitoring Device, Multi-Parameter Monitoring Devices, Hemodynamic Monitoring Devices, Fetal and Neonatal Monitoring Devices, Temperature Monitoring Devices, Weight Monitoring Devices, Diagnostic Devices, Surgical ENT Devices, Endoscopes, Imaging Devices, Diagnostic Molecular Devices, Drug Delivery Devices, Surgical Devices, Bio Implants and Stimulation Devices, Treatment Equipment, Infusion Pumps, Medical lasers and LASIK surgical machines etc.

An estimated 30-40% of capital costs of setting up a tertiary care hospital is attributable to medical technology. Additionally, depending on the hospital type, cost of medical devices and diagnostics contribute approximately 20%-25% to the cost of medical services.

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Trends – Healthcare: The latest trends in healthcare includes: rising prevalence of chronic diseases; shift toward homecare settings boosting demand for portable devices; growing customer preference for Wearable Devices; and rising number of hospitals, clinics and diagnostic centers. The rise in sedentary jobs, busy lifestyles and changing consumer preferences are affecting the disease profile of the world population, especially non-communicable diseases such as cancer, diabetes and cardiovascular diseases. Long working hours, less physical activity, and unhealthy eating and drinking habits are major causes of chronic diseases such as diabetes. According to the WHO, chronic disease prevalence rose by 57% globally, in the year 2020. India is expected to have about 101 million diabetic patients by 2030.

As per the Global Healthcare System (GHS) study, India has improved in detection and reporting category, but there has been no enhancement of its prevention protocols, health system or rapid response processes. The study also stated that although countries built new capacities during the Covid pandemic, many of them are temporary.

As per Niti Aayog health index 2021 (24 indicators), Kerala is at the top with 77.53% followed by Punjab with 65.83%, Tamil Nadu with 64,05% and UP at the bottom with 34.44%. Among smaller states, Mizoram was the best performer with 73.70% and Nagaland was at the bottom with 37.59%. And, among the union territories, Delhi at the top with 59.84% followed by Chandigarh  at number 2 with 58.35%. Only five larger states and two smaller states showed good Overall Performance and continued to improve on their Health Index Score from the Base Year (2018-19) to Reference Year (2019-20). Nearly half the states and UTs did not reach the halfway mark in the Composite Overall Index Score.

Healthcare Sector Growth Projections and Opportunities: The current value of the Healthcare industry in India is  $372 billion by FY22. And, the  Hospital Industry contribution is 80%  – $132.84 bn FY22. The Indian Healthcare industry is on a high growth trajectory having evolved significantly since 2014.   The Indian market is among the top twenty in the world by market size, and fourth in Asia after Japan, China and South Korea.  The Government is planning to introduce a credit incentive programme worth Rs. 500 billion (US$ 6.8 billion) to boost the healthcare infrastructure.
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Almost all countries in Europe spend over 9% of GDP  with  the USA having reached an all time high of 19.7% of GDP in 2020. As per the World Bank Report, the USA is now 16.77% of GDP. Even the Middle East countries spend over 4% of GDP.  Whereas, it is only 2.1% GDP.  The current spending is 2.73 lakh crore in 2019-20 (pre-COVID-19) to ` 4.72 lakh crore in 2021-22 (BE), an increase of nearly 73 percent. As per the World Bank report, India’s global ranking  is 183 out of 195 countries. The Central government is planning to increase public health spending to 2.5 per cent of the country’s GDP by 2025.

However, healthcare provision remains inequitable and challenges in access to quality, affordable healthcare persist in large parts of the country. The per capita spending on medical devices in India is the lowest among BRIC countries at US $. 3 (US $. in China, US $.21 in Brazil and US $.42 in Russia). It is significantly behind developed economies like the USA – US $. 340. This current under penetration of medical devices in India represents a sizable growth opportunity.

Most importantly, the global medical devices market was valued at US$ 550 billion in 2021 and is expected to reach US$ 850 billion by 2030, poised to grow at a compound annual growth rate (CAGR) of 5.5% during the forecast period 2022 to 2030.   Rising number of medical facilities will boost the demand for medical devices in the market. Various government initiatives such as ‘Production Linked Incentive (PLI) Scheme for Medical Devices 2020’ and establishing medical parks will augment demand.

The global smart healthcare market size was estimated at USD 153.6 billion in 2021 and is expected to witness a compound annual growth rate (CAGR) of 13.3% from 2022 to 2030. The rising adoption of mHealth, government initiatives to digitize healthcare, and the prevalence of chronic disorders are likely to accentuate the demand for smart healthcare systems. Digitalization is transforming the healthcare industry and around 80 per cent of healthcare systems are aiming  to increase their investment in digital healthcare tools in the coming five years.

AiMed reports increased growth rate of Indian medical device industry during Covid-19Medical Devices Industry: In India, the medical devices industry is small, with a disproportionate reliance on imports – 70-80% imports from the US, China and Germany – and a complex regulatory environment. The current market size of the medical devices sector is estimated to be $11 billion and its share in the global medical device market is estimated to be 1.5%. It is projected to reach US$ 50 billion by 2025.  And, export of medical devices from India stood at US$ 2.53 billion in FY21, and are expected to rise to US$ 10 billion by 2025.

The Indian medical devices sector has  grown considerably since 2014 and plays a critical role at each stage of the healthcare continuum. In FY20, foreign investments in the medical devices sector increased 98% YoY to US $.301.01 million, as against US $.151.87 million in FY19. FDI inflow in the medical and surgical appliances sector stood at US$ 2.41 billion between April 2000-March 2022.

Most important, the current demand and supply side dynamics provide a significant opportunity for manufacturing medical devices in India.  The Government of India’s ‘Make in India’ initiative presents a platform for advancing the medical devices sector. In November 2021, the Indian Council of Medical Research (ICMR) collaborated with Indian Institutes of Technology (IITs) to establish ‘ICMR at IITs’ by setting up Centres of Excellence  for Make-in-India product development and commercialization in the medical devices space.

Ipso facto, India depends on 100% import for MRI machines ¬ 3500 MRI scanners today which includes low field, 1.5T, 3 T and refurbished machines – which cost exorbitantly between ₹2,500,000 – ₹125,000,000.  “T” means tesla which is a unit of measurement quantifying the strength of a magnetic field. Approximately 350-400 machines per year are likely to be installed. A 3 tesla or 3T MRI uses incredibly powerful magnets that generate a magnetic field that is twice as strong as our previous machine. This power leads to clearer, more complete images. The strongest MRIs measure in 7 Tesla which is new and can cost about $6.5 million and up. In September 2021, the 11.7 Tesla MRI of the Iseult project, the most powerful in the world for human imaging, has just unveiled its first images. Adding to the cost is the room that will house the MRI machine, known as the MRI Suite. SIEMENS, PHILIPS, GE, HITACHI and  TOSHIBA are the leading manufacturers of MRI and CT Scan machines. At present, China is the biggest exporter of MRI machines to India.

Trivitron Healthcare, Mumbai based healthcare provider Company, and Voxelgrids Innovations Private Limited  are the two firms that are in the forefront of MRI manufacturing . The 1.5 T MRI machine developed by Voxelgrids Innovations Private Limited is entirely made in India in 2018. Its scan is projected to cost 60 per cent less than with the conventional alternatives. As per news on 8 Sept 2022 in public domain, recently, the IUAC has developed a 1.5 Tesla (T) superconducting MRI magnet system, which is like the heart of the MRI machine. This will not only make India produce cheaper indigenous MRI machines, but also put it in the league of select countries which produce these machines. Yet, there is technology lag which needs to be overcome by R & D.

Trivitron Healthcare acquired the US-based The Kennedy Company, which will help them to position among the global leaders in radiation protection and medical imaging products. Trivitron is planning to launch made-in-India CT-Scan and MRI in the financial year 2022-23.  It has manufacturing facilities in India, USA, Finland, Turkey and China and they offer more than 450 products to serve the healthcare fraternity. The Company has R&D facilities in India, Finland, Houston (USA), and Vienna (Austria) that are bringing technical excellence in the medical field to deliver exceptional products in the diagnostic imaging, NBS, and in-vitro diagnostics. The company also plans to set up its second ultrasound manufacturing facility in India at Patalganga Industrial Area, Mumbai.

Siemens Healthineers has developed the  first “Made in India” CT-scanner from its new state-of-the-art medical imaging factory with a total investment of INR 200 million in Bengaluru, inaugurated on September 19, 2019. Its scanners offer unique automated workflows that help users achieve profound clinical results. The next-gen manufacturing facility  produces solutions in Diagnostic Imaging and Advanced Therapies  CT scanners. Somatom go. platform CT scanners will help our customers expand their radiological portfolio, become more competitive and achieve consistent, user-independent quality.

Pravara Institute of Medical Sciences University - Medical university, India offering medical education in medicine, biotechnology, physiotherapy, dental, bioscience management, nursing, MBA. Medical College Maharashtra India Medical College ...Medical Educational Institutions: Next, the increase in demand for medical devices is directly linked to an increase in the number of colleges, hospitals, clinics and diagnostic centers etc. Due to increasing population, the current yardstick to categorize SCs, PHCs, CHSs, Sub Divisional and District Hospitals needs review. For innovation and quality of healthcare, there is a need to upgrade education technology followed currently in  medical colleges, PG Colleges and higher institutions.

The Central Government Plan has been formulated under three Schemes in various Phases to create nearly 245 medical colleges. All of them must be suitably equipped with advanced medical devices to enable students to gain practical experiences. In retrospect, authorization of Doctors without medical devices and technicians serves hardly any purpose.  The Indian Medical Council must categorize all public and  private hospitals besides clinics and specify minimum scales of medical devices for them  separately. Similarly, specify scales of medical devices for SCs, PHCs and CHCs separately.  Qualified technicians must also be authorized at all levels.

All government 810 District and 1193 Sub-divisional Hospitals (SDHs) must be equipped with advanced medical devices particularly MRI, CT Scan, UltraSound, X-Ray and other monitoring devices like ventilators. Similarly, all the medical colleges must be equipped with advanced medical devices.

Is Latest Technology Benefiting the Pharmaceutical Sector?Pharmaceutical sector: Yet another critical domain that offers opportunities is the pharmaceutical sector.   The global pharmaceutical drugs market is expected to grow from $ 1,075.97 billion in 2021 to $1,136.23 billion in 2022 at a compound annual growth rate (CAGR) of 5.6%. The market is expected to reach $1,635.128 billion in 2026 at a CAGR of 9.5%. India ranks third worldwide for production in terms of volume and 14th by value. According to a FICCI-PWC report, the Indian pharmaceutical sector will be worth $65 billion by the end of 2022, and the API pharma companies in India are expected to grow at a healthy 16% pace over the next five years. Low cost of production and R&D boosts efficiency of Indian pharmacy companies, leading to competitive exports. The Indian pharmacy industry is expected to grow to $130 billion by 2030 and become the leading provider of medicines to the world.

India had exported Rs 90,415 crore worth of pharma products in FY14. In the pandemic year of 2020-21, pharma exports had grown by 18 percent to roughly Rs 1.8 lakh crore at current exchange rates. Indian pharma companies enabled by their price competitiveness and good quality have made a global mark, with 60% of the world’s vaccines and 20% of generic medicines coming from India.  USA, UK, South Africa, Russia, and Nigeria are India’s top five export destinations.

India imported medicinal and pharmaceutical products to the value of almost Rs. 517 billion in the fiscal year 2021. About 66%  of India’s API (Active Pharmaceutical Ingredients) imports come from China. APIs, also known as bulk drugs, are the key raw material used for manufacturing medicines. As per official news,  of the 53 drug raw materials for which India was dependent on imports, 35 are now being manufactured in India. Under the production-linked incentive (PLI) scheme, 32 new plants for the production of APIs  have been set up and production has now started in 35 of the 53 identified APIs. Under the scheme, the government is providing viability gap funding to reduce dependence on imports.

The FDI inflows reached US$ 19.41 billion between April 2000- March 2022. In June 2021, the Finance Minister announced an additional outlay of Rs. 197,000 crore (US$ 26,578.3 million) that will be utilized over five years for the pharmaceutical PLI scheme in 13 key sectors such as active pharmaceutical ingredients, drug intermediaries and key starting materials.

To sum up, the following are the imperatives to advance technology up gradation

  • To promote “Smart Healthcare” (Quality and Timely healthcare), increase Central Budget allocation to 5% GDP or additional Rs.80,000.00 crores in 2023 for completion of all Schemes to establish new medical colleges and upgrade  existing medical colleges earliest. Ensure all State Governments allocate 8% in their budgets.
  • Review criteria of establishing SCs, PHCs, CHCs and Sub Divisional Hospitals.  Prescribe scales of medical devices for SCs, PHCs, CHCs, Sub Divisional and District Hospital
  • For innovation, identify private R & D establishments/organizations  and incentivize them to develop a wide range of medical devices, pharmaceutical drugs and medicines.
  • Enhance quality of medical education vital digitized healthcare system.
  • Export promotion and Import substitution to exploit opportunities in global trade. Promote remaining APIs to be produced in India-
  • Attract FDI inflows and promote “Healthcare Tourism”.