Event Live: What Will Healthcare Look Like in 25 Years?

By Dr. David Katz / New York

The Aspen Ideas Festival, an annual event in which I had the privilege of participating several years back, is now convening in that rarefied Rocky Mountain air. Those heights perfectly suit the venue, in which thought and idea, examination and exhortation, are intended to take flight.

As they do so, one of the more popular destinations is, inevitably, the future. Even our scholarly examinations of history are of greatest current relevance in helping us sidestep repetition of well-worn folly. The deep thinking we do today is frivolous and futile unless it informs potential action, and cultivates favored opportunity. The Ideas Festival is willfully, and all good ideas are perhaps ineluctably, tangled up with tomorrow.

‘Trumpcare’ Is Dangerous to the American Healthcare System

Congressional efforts to do away with Obamacare threatens leaving millions of Americans without any health insurance.

The American healthcare system is in danger. The Senate’s new Bill, the Better Care Reconciliation Act (BCRA), released in June, is an effort by the Republican Party to “repeal and replace” the Affordable Care Act (ACA), or ‘Obamacare,’ put forward by the Barack Obama administration.

Healthy Business: Will Medical Tourism Be India’s Next Big Industry?

No Other Choice: Why Medical Tourism Continues to Thrive: President of the United States Barack Obama recently urged Americans to seek medical treatment at domestic health care facilities, rather than traveling overseas. In India, where so-called "medical tourism" (known internationally as the global health care delivery system) is a booming industry, his statements have created quite a stir. In this opinion piece, Ravi Aron, a professor at Johns Hopkins University and a senior fellow at the Mack Center for Technological Innovation at the University of Pennsylvania, argues that people can't take advantage of something that doesn't exist. Until affordable universal care is a reality in the U.S., Aron says, Americans will continue to travel abroad for health care services.

President Barack Obama has asked Americans not go to India and Mexico for medical treatment. There are reasons why these appeals will have no impact on global health care delivery. Patients do not travel to India for health care services because they have a choice and they choose to go to India. They travel to India because they have no choice. They are either uninsured or grossly under insured and they cannot afford the cost of care in the U.S.
If a consumer exercises choice -- among comparable options -- then he or she can be asked to buy American. But the choice that these consumers of global health care services face is between care delivered overseas (Mexico, India or elsewhere) and no care at all. So asking them to stay in the U.S. is pointless. Until affordable universal care is a reality in the U.S. they will continue to travel abroad for health care services. This is not a discretionary spending that they can postpone or redirect.

Characteristics for Success
The globalization of health care services is inevitable in this environment. What are the characteristics needed for the industry to flourish? Look at it at the level of the multi-specialty hospital. The hospital needs to address the patients' sense of risk. If somebody in frail health is going to fly 12 hours to reach a point on the other side of the globe to get a bypass surgery or a hip replacement done in a country that they know very little about and one with a strange culture, they experience anxiety that stems from risk. Most of us weigh the choice of a vacation destination carefully; these people are literally entrusting their lives and well-being to a hospital and doctors that they do not know. So this is a decision that is characterized by a great deal of risk. Hospitals like Bumrungrad in Thailand go out of the way to address this risk. There are four levels at which they do this:

The Four Levels of Addressing Risk
The physical environment: The hospital lobby and the building feel like an excelsior hotel in a first world country. They go out of the way to showcase the sense of order and calm that prevails everywhere. The western patient would instantly feel at home with the Starbucks Café and Wi-Fi-enabled waiting lounges. The hospital and its lobby, lounges and wards gleam in their antiseptic cleanliness.

Process discipline: Bumrungrad hospital is pretty close to what we call a 360-degree automated hospital. From the point the patient has been admitted (from his overseas location) till discharge, all processes are centrally linked to the patient's records and care delivery, and support services are delivered and monitored at the level of each patient. They have extraordinary efficiency in the way they support clinical care with other services -- travel, hospitality (accommodation), transport within the city, billing and post-procedure follow-up.

Excellence in clinical care: Many of their doctors are board certified in the U.S. and in Thailand and Bumrungrad was the first hospital to get the JCI [Joint Commission International] accreditation in the region. On most parameters of medical care -- these statistics are available at the hospital site -- they compare more than favorably with the median hospital in U.S. and the E.U. (They were in the 90th percentile in patient satisfaction scores compared to similar hospitals in the U.S. and Europe).

Strategic use of IT: They use IT both to offer fine-grained information about the hospital, treatments and procedures at the hospital, and physician background to overseas patients, as well as information as a tool for monitoring and delivering clinical outcomes.

In terms of clinical information, they have been able to automate three crucial elements of clinical information flow: (i) Physician-level information from multiple physicians attending on the same patient; (ii) Information from clinical sources pertaining to a patient (tests, labs, nurses and clinical support services); and (iii) patient case history. This, in turn, has allowed them to implement a variety of innovations in care delivery that minimize medical errors, infection rates, etc. It also allows them to monitor patients and their progress in fine-grained detail. (Automating these three kinds of clinical information flows is very critical not only to deliver higher quality of care, but also to create "patient information portals" where the patient can constantly access his or her EHR (electronic health record) after the procedure from his or her country of origin, as well as schedule repeat check-up visits. Automating these three kinds of information flows is one of the reasons that Bumrungrad is referred to by some as the "gold standard" in global health care delivery).

First World Skills in Emerging Regions
So why is all of the above important? These are first-world institutions of skill and service excellence located in developing regions. The developing region economics makes these regions attractive from a cost (price) standpoint to overseas consumers. The first world skills and service excellence makes them attractive from the standpoint of actual care delivered to patients. For the paying patient, it is important to signal that the hospital is an island of calm and order founded on a reliable first world infrastructure and where care delivery is monitored with great precision and discipline. The patient needs to feel that this hospital has been insulated from its environment.

India is not lacking in clinical skill (quality of physicians). Traditionally, Indian hospitals were seen as weak in post-procedural care delivery (sometimes referred to as "post operative care"). But that, too, is changing. Some hospitals are beginning to get their acts together on post-procedural care in terms of significantly lowering medical errors and hospital infections, and improving nurse and support clinician hygiene standards. There is still much that can be done in this regard.

An area that is often overlooked by the Indian care delivery establishment is that of support services: travel, logistical support, accommodation and hospitality, transport within the destination city, billing, etc. Overseas patients are probably comfortable with the quality of Indian physicians; they are more concerned with clinical post-procedural care, support services and the infrastructure.

Medical services in India are where the IT-enabled services and the business process outsourcing (BPO) industries found themselves in the mid 1990s -- the challenge is to convince the customers that these hospitals are islands of excellence that have been insulated from the frailties of India, even as they draw upon its strengths. These services are not branded as "made in India" as much as "made in spite of India."

The Advantages of India
The one advantage the country has is that a doctor in India -- especially a surgeon -- would have acquired in 10 years' time more experience -- both in terms of scale of procedures done and the exposure to varying levels of complexity -- than what a surgeon in the U.S. would get in, say, 30 years of practice. So a doctor with about 15 years experience will probably be unrivalled in the scope and scale of his exposure.

In the well-run hospitals and multi-specialty centers, they have deep reservoirs of capability to treat patients who come in for a procedure with comorbidities [the presence of one or more disorders in addition to a primary ailment]. Not only can they perform the procedure, but they can also deliver related chronic care where necessary (procedure plus care for cardiovascular disease, diabetes, etc). Specialists are readily available to deliver care for comorbidities from a single location.

Almost all these institutions are private hospitals that cater to the needs of India's wealthy, powerful (Anglophone) elites. They are used to delivering services to a demanding clientele. This serves them well with overseas customers. A large number of physicians in the U.S. and the U.K. and in some Gulf countries are of Indian origin. So, overseas patients do not have the problem of entrusting themselves to Indian doctors.

The doctors of Indian origin can also serve as a distribution channel of sorts to hospitals in India. These institutions can tie up with these doctors to deliver some measures of post-procedure diagnostic care and ongoing care in the countries of origin of the patients.

The Low Cost Is a Given
The other advantage is, of course, cost. But there is no need to stress the difference in costs. The patient is usually acutely aware of the difference in the sticker price for care. The multiples range from eight to one to three to one, even after factoring in travel and other non-clinical costs. There is no reason to draw attention to this. It is far better to highlight capabilities and excellence for two reasons. First and less important, is that this will translate into "capabilities and excellence at an affordable cost" in the patient's mind. Second, and more important, the patient is worried about capabilities and support care and the risk of entrusting his life and well-being to a strange system far away from his home. So it is vital to address those concerns rather than emphasize "cheap." The patient is all too aware of the cost difference anyway.

Finally, the use of web-based channels to inform potential patients is key to running an efficient marketing operation. Hospitals should be able to offer information about JCI certification, physicians' experience and qualifications, the depth of their capabilities in performing specific medical procedures (coronary bypass, hip replacements, etc.) and give patients an accurate estimate of the costs.

Bumrungrad's use of electronic channels is a case in point in effective marketing. The hospital has developed a cost simulation where the patient can key in details of his or her condition and the simulation gives a clear estimate of the cost frontier that he or she will face: it gives the patient a distribution of costs that similar patients in the past faced -- including an average, a high percentile and a low percentile number -- allowing the patient to form his or her own estimate of the costs of care. This electronic estimate is based on actual costs of past patients and it is constantly updated from the hospital's database. Bumrungrad is able to do this because every element of the final cost the patient pays is itemized and categorized in the final invoice. This is yet another example of their strategic use of IT to both serve the customer and market their services effectively.

In the past, U.S. President Barack Obama has singled out India for what he sees as the country usurping American jobs and business. In May 2009, he removed some tax incentives for U.S. companies who allegedly preferred to outsource rather than create domestic jobs. "Buffalo before Bangalore" was his rallying call at the time. Now, India is back in his crosshairs. In April 2011, he told a town hall gathering in Virginia that Americans shouldn’t have to go to India or Mexico for “cheap” health care. "I would like you to get it right here in the U.S.," he said.

"It’s a 100% political statement," Gopal Dabade, convener of the All India Drug Action Network, told weekly newsmagazine India Today. Others in India were equally critical and dismissive. But some have taken more serious objection. "Not acceptable," says federal health minister Ghulam Nabi Azad. Affordable health care does not mean our medicine is inferior to any superpower’s. I would like to say our medicines are indigenous, they are superior, and superiority does not come by escalating costs."

The bone of contention is the word "cheap." Obama probably used the term in the sense of less expensive. But Indians have interpreted it as meaning "tawdry and inferior." Analysts don’t expect Obama’s political posturing to make any difference to the flow of U.S. medical tourists into India. But there is a lurking fear, nevertheless, that a nascent sector could be hamstrung at birth.

There Is No Choice
"Patients do not travel to India for health care services because they have a choice and they choose to go to India," says Ravi Aron, professor at the Johns Hopkins Carey Business School and a senior fellow at The Mack Center for Technological Innovation at Wharton. "They travel to India because they have no choice." Adds Rana Mehta, executive director, PricewaterhouseCoopers (PwC) India: "If patients see value in what India has to offer, they will continue to come."

Indians feel aggrieved that they have been singled out. In medical tourism, the country is still a bit player. According to a report by the Delhi-based RNCOS, which specializes in Industry intelligence and creative solutions for contemporary business segments, India’s share in the global medical tourism industry will reach around 3% by the end of 2013. The December 2010 report -- titled "Booming Medical Tourism in India" – says that the industry should generate revenues of around US$3 billion by 2013. "The Indian medical tourism industry is currently in its early growth stage," says RNCOS chief executive Shushmul Maheshwari.

Guess who’s the biggest beneficiary of medical tourism? It’s the U.S. "The largest segment, with 40% of all medical travelers, seeks the world’s most advanced technologies," says a McKinsey & Co paper titled "Mapping the market for medical travel." "These men and women take their search for high-quality medical care global, giving little attention to the proximity of potential destinations or the cost of care. Most such patients travel to the U.S." What worries the Indian industry is that this is not the first attack on Indian medical tourism. In August last year, leading medical journal The Lancet had published an article about a new superbug which it called the New Delhi metallo-beta-lactamase 1 (NDM-1). "The potential of NDM-1 to be a worldwide public health problem is great, and coordinated international surveillance is needed," said the article. Later, a co-author noted that some material had been inserted into the article without his knowledge; the editor of The Lancet had to apologize for naming the bug after New Delhi, and the Indian ministry of health had to weigh in. "The conclusions are loaded with the inference that these resistance genes/organism possibly originated in India and it may not be safe for U.K. patients to opt for surgery in India," said the ministry. "The medical journal's claim is not supported by any scientific data and thus tarnishes the reputation of the country." Rightly or wrongly, the government and many in India’s medical establishment believe that naming the superbug New Delhi was to keep U.K. medical tourists at home. "The superbug certainly garnered a lot of media attention given its name," says Preetha Reddy, managing director of Apollo Hospitals.

It won’t keep medical tourists at home, just as Obama’s appeal is likely to be ignored. "People will always weigh the cost and the benefit," says Reuben Abraham. "If there is a 10% saving and there is a danger of the superbug then chances are that people will not want to take it. But if you are offering an 80% discount, it is a different matter. If India continues to offer high quality health care at one-tenth the cost in the U.S. then these things will not make an impact."

The Next Big Thing
If all this is going to have limited impact, why is India getting so agitated? The answer lies in the potential of medical tourism. It could easily be the next big thing. Unlike business process outsourcing (BPO), which is on the whole very low-tech, health care -- particularly sophisticated procedures -- is very high-tech. India has not been able to set up an adequate health care infrastructure for its own citizens and it doesn’t have the money to do so. Creation of a sophisticated medical tourism structure will have a trickle-down effect.

"India has the highest potential in medical tourism in the world," says Maheshwari of RNCOS. "Factors such as low cost, scale and range of treatments differentiate it from other medical tourism destinations. Moreover, growth in India’s medical tourism market will be a boon for several associated industries, including the hospital industry, the medical equipment industry, and the pharmaceutical industry."His study shows that CAGR (compound annual growth rates) in revenue in 2011-13 will be 26%. In terms of medical tourists, the number would touch 1.3 million by 2013 at a CAGR of 19%. "Medical tourism can be considered one of the rapidly growing industries in the Indian economy on the back of various factors," he says. "However, the industry is at a nascent stage and requires a few years to reach the platform already established by the IT sector." "India has been ranked among the top five destinations for medical tourism," says Rana Kapoor, founder, managing director and CEO of Yes Bank, which has recently done a study on health and wellness tourism in India along with apex chamber of commerce FICCI.

The ranking by Nuwire Investors, an online source for news on alternative investments, puts Panama on top, followed by Brazil, Malaysia and Costa Rica. "India is looking at exponential growth as far as tourism is concerned," continues Kapoor. "Yes Bank forecasts that there will be an increase in domestic tourist movements over the period (2008-2020) by 118% and foreign tourist inflows over the same period will increase by 71.87%. What the potential for medical tourism from within this growth rate of 71.87% will be depends upon government policies, faith of the patients and many other external factors. We truly believe that this sector will play a significant role as a contributor towards the overall tourism growth in India."

"I strongly believe that many developments across the world will put India in a fantastic position," says Devi Shetty, cardiac surgeon and chairman of Narayana Hrudayalaya. "We produce the largest number of doctors, nurses and medical technicians in the world. Also, we have been traditionally linked with western health care because of the British influence on our medical education and the ability to speak English. This is extremely important for developing [global] health care. Our greatest asset is our ability to produce the largest number of technically-skilled individuals. We also have the largest number of USFDA (U.S. Food and Drugs Administration)-approved drug manufacturing units outside the U.S."

Differences over Terminology
Shetty doesn’t like the term medical tourism. "Medical care is something that is very stressful and people consider this under tremendous pressure," he says. "It is an event where people are scared of losing their lives. It may not be appropriate to call it tourism. Tourism is a different business altogether." Adds Mehta of PwC: "The tourism component is really very weak. Most foreign patients come to India for chronic and serious medical treatment and I would call it medical value travel." Aron of Johns Hopkins has yet another view. "The world over it is known as the global health care delivery system," he says. Reddy of Apollo agrees with Mehta. Says she: "At Apollo Hospitals, we prefer to term this business opportunity as ‘medical value travel’ as people travel to our hospitals for serious life threatening health conditions, which essentially need highly skilled doctors and medical infrastructure and not mere minor treatments like cosmetic enhancements, dental work or wellness which can be coupled with holidays, as the term ‘medical tourism’ implies."

The multiplicity of names is accompanied by a wide range of numbers. The confusion was started by the McKinsey study on Mapping the Market mentioned earlier. The May 2008 report said that "medical travel has captured the world’s attention and imagination". But it went on to explain that the McKinsey definition of medical traveler was very different from what many others thought him to be. The first to be knocked off were expats looking for health care in their country of stay. That accounted for 25-30% of the traditional medical tourist pool.

Then was the segment categorized under emergencies. These were ordinary tourists caught up in accidents. That eliminated another 30-35%. McKinsey estimated the remaining at "between 60,000 and 85,000 inpatients a year", much lower than generally accepted numbers. For instance, a 2008 Deloitte Center for Health Solutions report on "Medical Tourism: Consumers in Search of Value" put the number of Americans who had traveled abroad for medical care in 2007 at 750,000. McKinsey excludes "wellness" tourists (acupuncture, spas, yoga, aromatherapy and the like), patients from neighboring countries, and outpatients -- those who don’t need to check into hospital.

The Deloitte report says that India is stepping on the gas; the medical tourism sector is expected to grow 30% annually up to 2015. An update on the report says that the U.S. recession is driving more people out of the country for health care; U.S. outbound medical tourism is projected to increase 35% annually from 2010-2012. "Medical tourism [today] represents the maturation of a cottage industry," the report sums up.

Maheshwari of RNCOS agrees that economic problems are driving more Americans abroad for health care. "Under almost stagnant salary increments, the disposable income and saving considerations of U.S. citizens are still well below the pre-crisis levels," he says. "In this scenario, the low cost treatment and nearly zero waiting time coupled with its proven track record offer convenient procedures for tourist arrivals from various geographical locations including the U.S."

"Over the past few years, the medical tourism story has changed dramatically in India," says a recent Cover Story in weekly business magazine BusinessWorld. (That it made it to the Cover is a reflection of the growing importance of the sector.) "Not because the government has figured out the solution. But purely because of private enterprise -- with a few corporate hospitals, chemists and freelance agents all working in tandem to build a thriving ecosystem that educates, facilitates and ferries medical tourists from across the world. Last year, this ecosystem was responsible for about 600,000 patients travelling to India and spending US$1 billion in getting treated here. (The numbers are industry estimates as the government does not have any official statistics on the subject.) Corporate hospitals such as Apollo, Fortis Hospital and Max as well as business associations estimate that the business is growing by 40% year-on-year." (Obviously, the growth numbers vary depending on who you talk to.)

Other Markets Will Turn to India
"India’s potential is huge," says Mehta of PwC. "Some 80% of foreign patients coming to India are from the neighboring countries and from Iraq, Afghanistan, the former Soviet Union, etc and now increasingly from Africa. But now with India proving itself as a credible provider of value health care, the western population ageing, and health care becoming more difficult there, I expect more people to come from the U.S. and the U.K."

Mehta says that some things went wrong with the earlier planning. "We expected most patients to come from the U.S. and Europe. We expected people to come for cosmetic and regenerative treatment and this is where there is more potential for tourism. But the majority actually came for cardiac treatment, cancer treatment, knee replacement and other serious ailments. Therefore, tourism was not really of importance. We did not get the cost factor right. We thought that typically in India it costs one-tenth of that in the U.S., so we could cost at 5X. But hospitals have not been able to charge very much. At present, with a foreign patient, there is around 20% more earning."

Cost is, of course, being underplayed in the marketing efforts; this is why the word "cheap" rankles. "The patient is usually acutely aware of the difference in the sticker price for care," says Aron. "There is no reason to draw attention to this.”That’s an area where India enjoys an advantage over other countries too. According to the BusinessWorld report, a heart bypass surgery costs US$144,000 in the U.S., US$25,000 in Costa Rice, US$24,000 in Thailand, US$20,000 in Mexico, US$13,500 in Singapore, and US$8,500 in India. "The quality is excellent," says Maheshwari. In India, there is also less waiting time and personalized services.

Becoming an Industry
Medical tourism is also taking shape as an industry, though there are some who feel that it will eventually fall in many buckets. (The recent FICCI-Yes Bank study talks of wellness tourism, health tourism...) "There are over 3,371 hospitals and around 750,000 registered medical practitioners," says Maheshwari.

Shetty says it is easier to get loans these days. "Earlier, it was difficult for us to mobilize huge financial support to create large hospitals. However, things have changed now," he explains. Indian companies are also taking over hospital chains in Asia -- Fortis has gone on a shopping spree, though it’s not been entirely successful -- and setting up front-ends in other countries for marketing purposes. Apollo has facilitation centers in Oman, Nigeria and the U.S. Max is present in Nigeria, Afghanistan, Bangladesh and Nepal. Says Reddy of Apollo: "There are several key players. Apollo Hospitals continues to attract the largest numbers of international patients followed by Max, Fortis and Workhardt."

"Another opportunity that Indian operators are now seeing is that you don’t have to offer these health care services from India," says Abraham of ISB. "For instance you can offer it from say, Cayman Islands or the Bahamas. Ultimately, the innovation is in the process and as long as you can bring the same process innovation, even if the cost goes up a little as compared to offering it from India, it will still be a substantial saving for the patient."

This is one area where China is no threat. Foreigners in China still rush to Hong Kong when they need treatment because they cannot communicate with local doctors.

But what the budding sector will have to contend with is the Indian government. Take one example. With the intention of making things smoother, the government introduced a medical visa (M visa), which was faster and easier to get. In its wisdom, however, it added a peculiar clause -- "Foreigners coming on M visa will be required to get themselves registered mandatorily well within the period of 14 days of arrival with the concerned Foreigners Regional Registration Office." The end result: even patients who have to be carried into India on stretchers are coming on tourist visas. If the government wants medical tourism to be the next big thing, it has to put its house in order.

As for the immediate controversies, Shetty is very clear. "President Obama’s statement or the New Delhi superbug will not affect medical tourism development in India," he says. "First of all, he was not criticizing India. He was just trying to put his house in order."

Girl Rag Pickers: Struggle for Survival

By M H Ahssan

The process of industrialization in India brought about fundamental changes in the mode of production and in the relationship of productive factors. The mechanization made agriculture capital intensive. Those with small and non-viable land holdings had to give up their lands and work for the richer farmers in the village or migrate to cities for their survival. The industries could not absorb the whole displaced labour, unemployment and poverty compelled the whole family, including the children to work. The profit motivated to traders and businessmen began to look for cheap labour. Child labour was found to be cheaper and easily available. Thus began the exploitation of child labour market, not only in India, but also in most of the developing countries.

The children engaged in the survival battle and that too, for a virtually subhuman existence, especially in unorganized sector. In this sector children have very limited occupational mobility, because of lack of education, skills, training and guidance, and have no occupational choice.

Their day begins with uncertainties and their work is irregular, some time it's depend upon season. The job they do show a wide range depending on availability of work- carrying load, vending, shoe shining, cleaning cars, and rag picking which require hardly any skills. It is one of the most common occupation in which thousand of children are engaged. It is estimated that six out of every ten children involve in this work to eke out their living. Motivations for the children to pick up this work for economic support is easy availability of rags in and around the towns without spending money and this work does not involved employers for employment.

Therefore, their work is either controlled by their own interest or by their family. They are called as such though they pick anything but rags. They collect scraps from streets, market places, garbage bins and waste dumps, picking up material such as paper cardboard, plastic, iron scrap, tin containers, and broken glass, in fact anything thrown away by households, shops, workshops, or other establishment that can be sold to dealer who buy these for the recycling industry.

Undoubtedly, the present work expose them to the several types of health hazards like infection form coming into contact with foe cal contaminants, dead animals and hook worm, gastrointestinal infections and danger of accidents; injuries and disease through contacts with sharp material and poisonous substance as they scrounge with bare hands and sometime even bare feet. Such kind of situations become worst in the case of “girl child”, when they are exposed to the risk of sexual harassment and physical exploitation by the people of outside world. Because of which their moral and psychological development is at stake.

The participation of children in economic activities reflects the socio economic status of the nation. The poorer the nation, there is likelihood the large number of its children are found more in work places rather than in schools. Children are required to work supplement their family income or acquire skills to become self employed or independent persons. While child labour is a product of poverty, illiteracy and ignorance of parents, girl child labour is the result of many complex issues. There is discrimination amongst male and female starting from their conception. Most of the female fetuses are brutally killed even in their embryonic life.

The misery does not end there, even if they survive some how, they are discriminated at home, school, social places and place of work. As soon as the girl child starts walking and is able to understand language, work is entrusted to her as a routine affair. The girl child has to understand a variety of tasks in and outside the house. There is a strong sex typing of roles as regard to the work that female and male children do. The burden of household duties falls largely upon the female child. At the same time female children are also faced to work and earn for the family.

Without realizing the consequences the girl children are made to shoulder many responsibilities. They are groomed to behave in a different way from the boys. By the time they are 11 or 12, they generally become docile, obey the order of elders in the family and are destined to do whatever is entrusted to them. Girl child labour is not only deprived of their education and recreation, but their overall development also gets affected. A study shows that the female child labour in rural areas is 6.9 million and in urban areas is 7.94 million. In fact in many places of work, they out number their male counterpart (Jawa, 2000). These female child workers earn less wages and work for more hours, both at home and at work place.

Girls are the most unprotected among street children and are more vulnerable to physical and sexual abuse, especially those who have crossed puberty. They have no guidance on the changes that take place with puberty and on sexual matters. While engaging in rag picking they come into contact with several types of health hazards like skin infections, cuts, T.B, malaria and develop other social evils such as gambling , drug abuse, prostitution and different kind of exploitation-physical, sexual which effects their over all development.

It is a matter of great concern that majority of girls (69%) start rag picking at the age of 6 years and work continuously for long hours without any rest. Thus they are deprived of opportunity for any active and organized play, which could provide some leisure and psychological satisfaction to them. Because of their dirty and shabby appearance they are not allowed to use recreational parks and other places, hence they find satisfaction in seeking excitement by way of indulging in addiction and other social evils. It has been reported that 80% of girls are addicted to one or other type of drug, in which tobacco chewing is the most common drug i.e., 60%. It is evident form this that the children between the age group of 13-16 years and above are most vulnerable to addiction of one or the other and need focused intervention.

As far as concern about duration of working hours, the children working in the “informal sector” are not governed by any regulation. It is ironical that, while the society has not accepted children to work, no such body of rules for those working in the informal sector has been constituted. Nor is there any supervision by the government of the kind of “informal sector” in which the children are engaged. The consequence of which is that majority of girls 63% work 11-12 hours a day and some works more than 12 hours a day, which is more than the working hours prescribed under the factories Act and that too is for adults. A study(bose,2001) reported that 70% girls faced problem of eve teasing, physical abuse and also sexual abuse by the outside people which include watch men, guard, , shop keepers, tea shop and other general public.

Health is one of the basic human needs and access to health services is right of everyone. Health has a broader meaning referring to “a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity”. In other words, health encompasses psycho-socio-somatic development in medical science and improvement in provision of health services, but this has not occurred every where and benefits have not percolated to everyone. The rag picker children constituted that section of population who has not benefited form these advancement and services. The social conditions in which these children live have often precluded them from actual enjoyment of the right to have access to health facilities at per with other sections of the society. The situation turns out to be further worse due to neglect towards the health of the girl child in our society. In addition, shortage of health facilities and functionaries in the localities where they live adds to the neglect of their health needs. Added to this is the greater degree of malnutrition due to poverty. All these handicaps on health front combine together to affect the health of the rag picker girls. It is an important point to note that rag picker girls did not get regular meals or got only one meal in a day. It is unfortunate that they worked long hours and walked 10-15 miles each day virtually on empty stomach. The major circumstances responsible for malnutrition and addiction are “environment” in which they work and live. Most of the girls have cuts, injuries, joint pain, skin infections, stomach pain, body pain and the possibility of STD, AIDS and other infectious disease are also prevalent among this group(Khan, 2006).

Undoubtedly, numerous effects have been made by the government with the help of voluntary welfare agencies to promote general health status of women and children. But, by and large, the health status of women and children, especially girl children, remains unchanged among the rural poor, urban slums and tribal areas.

A matter of great concern is that with the urbanization, and the increase in volume of throwaway packing and waste material, the numbers of such children are growing. The present work exposes the children to health hazards and they also develop social evils and different kind of problems, which affect their overall future development. Moreover rag picking has not even been recognized as an occupation by the census. Since most of the children draw their livelihood out of rag picking work and it has got all the components of an occupations defined by Webster’s encyclopedia unabridged Dictionary of English language, which says that “occupation is an activity in which one regular devotes oneself, especially one’s regular work, or means of getting a living,” therefore it should be considers as an occupation so that plight of all those who are involved could be improved.. The future holds no promises for them. They are thus who are denied the joys of childhood, a favorable living environment, and opportunities for stable adult life.

Chhattisgarh's 'Blooming Health Business': Where The Doctors 'Getting Rich' At The Cost Of 'Women Uterus'

Since the state of Chhatisgarh was carved out of Madhya Pradesh in 2000, Chhattisgarh has descended on its poor women with a spate of public-health messages: Have fewer children, don’t deliver babies at home, and only trust health professionals, not your age-old beliefs, for decisions about well-being. From the remote villages in the rural grain bowl of the north to urbanised extensions of the capital city Raipur, women are listening.

In 2014, more than 124,000 women received tubectomies, a sterilisation procedure that accounts for 92% of all family-planning methods, according to the National Health Mission.

Are Doctors Asked To Treat Rape Victims With Suspicion?

By Siddharth Pal (Guest Writer)

FEATURE CEHAT (Centre for Enquiry Into Health and Allied Themes), the research centre of Anusandhan Trust, that is involved in research, training, service and advocacy on health, released a series of documents after the second season of TV show Satyamev Jayate aired last Sunday. Some guests invited to the first episode of the second season had alleged that doctors are trained very early on to treat rape victims with suspicion.

The allegation undoubtedly caused uproar in the medical community. The newest episode of the show hosted by Bollywood superstar Aamir Khan questioned the role doctors played in exacerbating the trauma of a rape survivor by putting them through the ignominy of undergoing harrowing medical examination. Added to the mental trauma, often the physical examination is painful and traumatic. In extreme cases, it was alleged that doctors do not administer painkillers to victims before examining their bruised private parts.

Apollo Hospitals' Suneeta Reddy: 'Medical Tourism Is a Huge Market'

Medical tourism -- the phenomenon in which hospitals in emerging markets offer "sun, sand and surgery" at low prices to patients from North America and Europe -- is gaining in popularity. While India lags behind countries like Thailand as a result of airport infrastructure and other bottlenecks, health care providers such as Apollo Hospitals are expanding at 10% a year. In an interview with HNN chief M H Ahssan, Suneeta Reddy, Apollo's executive director of finance, discussed the company's opportunities and challenges in this fast-growing market.

An edited transcript of the conversation follows:

How has medical tourism grown over the years?
Reddy: It has grown...I wouldn't say substantially, but it's grown by 10%. Ten years ago, Apollo started focusing on patients outside India. It didn't happen as a result of marketing; it was more of a pull of customers towards good quality medicine, rather than our pushing them through advertising and marketing. The reason it happened was that all over Southeast Asia, people began to see a value proposition -- which was high value in terms of clinical outcomes and high-quality care -- at one-fifth of what they would traditionally pay in the U.S., and probably a third of what they would pay in a country like Singapore. As a result, we started attracting patients from all over Southeast Asia.

As it progressed, people began to realize that the India story, where health care was concerned, was improving dramatically. Just two years ago, we got the JCI [Joint Commission International] accreditation which puts us on par with hospitals in the rest of the world. We are now shoulder to shoulder with the Mayo Clinic and the Cleveland Clinic. And with that we started getting patients from the West as well. Most of them use the Internet as the medium through which they schedule their appointments and arrange consultations with doctors. But again, it's this value proposition that is really driving consumers. I would say that currently 10% of our total revenues come from medical tourism. That is not really a large amount, and it has grown by 2% to 3%.

There are obstacles in the way of what is happening. One is our airport facilities. If you look at the hospitals that are really doing well, they are connected to international airports that have around maybe 50 to 60 flights a day. Compare us with Thailand, which has 260 international flights flying into Bangkok every day -- that makes it very easy for patients to go to Bangkok for medical tourism. If you compare that with the Chennai Airport, where our largest hospital is, there are about 15 flights. So, I think that you have to look at the airport infrastructure.

Secondly, the case mix of most of the work that comes to India is tertiary care and acute care. It's not the plastic surgeries that you see in Bangkok. It's high-end orthopedic work, it's cardiology, and some of it is oncology. Patients come to us for really high-end work. To do that, because we are recognized for that sort of work, it is quite uncomfortable for patients to make this journey. We need to smoothen out that process -- so that our patients don't have to spend 12 to 14 hours in Immigration and Customs -- and we are working on that. We now have people to facilitate and assist these patients as they come across.

Finally, I would like to say that there is a huge opportunity here. If you look at the U.S. alone, there are 40 million people in the country who are not insured. If you look at the U.K., there are about 250,000 Asians who are in the waiting line at NHS [National Health Service]. Medical tourism is a huge market. I believe the way to address it is to create a package that will enable these people to use Indian facilities. We tried talking to governments and asking, "Why don't you send patients who have no treatment options to India?" Then again, we've spoken to benefits companies, etc. The only single hurdle facing the U.S. and foreign patients coming here is legal liability and the fact that they cannot address their concerns through a legal forum in the United States. They could, of course, use the Indian legal system, but it's become a way of life; people want the legal system to back them up in case there is a problem.

Now, the incidence of problems is not even 0.01% so far, because the success rates are very good and clinical outcomes are so good -- we are JCI accredited -- and patients have the same rights in India as they would in the U.S., so they are protected. But I think that it's just a hurdle that we need to overcome. Once we have done this, we will be tying up with insurance companies and benefits companies to see how we can assist people who need that type of health care.

Have you seen a discernable increase in your Western clientele over the past few years? I know the story has been out for a while now. I was curious to know if you've seen an increase.
Reddy: Yes, we have. There has been a rise of about 5%.

What do you attribute that to, if it's difficult to access these people through insurance programs or through the government? Is it direct advertising?
Reddy: It's not advertising at all. It's the fact that people are so confident that the clinical outcomes will be good. And it's testimony from patients who have been through the whole process. As I said, it's pullingpatients to the system. This is because we don't market. I mean you don't see advertisements. But, we are now working with CII, the Confederation of Indian Industry, which is doing the branding in India. There is a branding foundation in India, and they have a campaign called "Incredible India." We work with them, and we are now doing a promotion around, "Experience Indian Health Care." It was just launched and hopefully we will see a lot of results from that.

Your program combines elements of both Western care and also Eastern medicine. I noticed that in a lot of your materials, you advertise the point that there are centuries of Eastern medical practice that you rely on as well. Can you talk specifically about what some of those elements are?
Reddy: We believe in an integrated health care package. In that sense, we talk about allopathic medicine for the actual treatment, in terms of surgery, diagnosis, etc., but where rehab and wellbeing are concerned, we've tried to integrate the systems of ayurveda [traditional Indian medicine] and yoga. This has helped because when patients go back [after their surgery] they need to readjust to a lifestyle that emphasizes continuous wellbeing. The key here is that there's a lot of value that they will get from ayurveda and yoga.

It is certainly a big market in the U.S., or at least a growing market, correct?
Reddy: It is. It's strange, but when Patanjali introduced Yoga thousands of years ago, there were very few Indians practicing it. And now, 6% of the world practices yoga. It has become famous because the movie stars in the West and people all over America are doing it. Now it has come back to India, and people are now saying, "Okay, this should become a way of life." Ayurveda is the science of life.

You are one of the largest health care systems in India, correct?
Reddy: Yes, we are.

How are you reaching out to poorer populations? Can you tell us a little bit about SACH and maybe some of your other community initiatives as well? The acronym stands for: Save a Child's Heart.
Reddy: I will start with SACH. SACH is Save a Child's Heart; it also means "the truth" in Hindi. The reason we started SACH is that we came across so many children who had heart disease. We believe that if there is an intervention at that stage, when the child is young, it will given them a more productive future. So, we said let's do something for children and make them productive adults, because that is what India really needs.

We started this foundation where the hospital does everything free of cost. The money for the consumables comes from donations, and people have donated in a large way. So far, we have completed 500 free surgeries and our target [this year] is to do 1,000. We would like to do 1,000 surgeries a year. The surgeon does not charge and the hospital does not charge. It's just 50,000 rupees for the consumables which comes as a donation. People have found it to be not so difficult to give a check for 50,000 rupees [$1,170] -- especially when you know that you are saving a child's life and you're assuring him or her of a good future.

The second thing we do is outreach at the village level, where health care is not available. We wanted to create a sustainable model and not really do it as charity, but to create something that was sustainable for the future. In fact, Bill Clinton, when he was the U.S. President, inaugurated this initiative in a village called Aragonda, a small town in the Chittoor district of Andhra Pradesh. We set up a small hospital, which was a primary care facility. We connected it through tele-medicine to our tertiary care facility.

Then we created an insurance product which was 1 rupee (0.02 cents) a day, which allowed people access into the primary care facility. If they fell ill, they would be treated here. They wouldn't have to pay anything, except for the 1 rupee a day or 325 rupees a year [$7.60 a year]. And, if they needed some tertiary care work, they would be connected by telemedicine to our specialists in the main hospital. They would only have to travel to the city when they needed acute care. I think that is an excellent model. Currently, we have 64 telemedicine centers that connect us to many centers in India. We are going to work on this model and set up more primary care initiatives.

The third activity we do is to organize medical camps. We go into the villages and screen people for cancer. You know, India is the only country where cervical cancer still exists. The numbers are growing exponentially, and we believe that early intervention and screening is one of the ways to check the growth and mortality from cancer. There are many camps that we do work with from each of our hospitals that have to do with cancer screening.

The fourth activity has to do with wellness, because preventive health care is a big aspect of health care. It will be a $1 trillion industry in the next five years. Without looking at it from an industrial viewpoint, health care education is important; Apollo tries to do that through its preventive health care schemes and our outreach programs, where we do these check-ups in villages.

What would you identify as the biggest challenges facing the industry?
Reddy: I think there are two challenges; the main one is skilled manpower. The fact that the government has not allowed the corporatization of colleges means that they still function at a trust level. This means that people pay capitation fees, and the number of seats is limited by state governments. Health is a state subject, so there is a dichotomy there; I believe there should be a Central government policy on health care. It's not a fundamental right that people get health care; in each state there is a separate policy.

The need for health care education is tremendous. First, people should learn about health care, and second, we need to get skilled manpower. That is a huge challenge because our nurses and doctors are migrating to the U.S.; in the past, they went to the U.K. The U.S. has at least 40,000 doctors who were trained in India at subsidized rates. These hospitals are run by trusts, so the doctors really don't pay that much for their education and training. But we need to double the capacity in terms of training colleges. This is because if you are going to create the 80,000 beds that are required for us to meet the World Health Organization's norms, then we need to staff those 80,000 beds.

Yet another challenge has to do with the high cost of real estate -- to set up a hospital, you need real estate, you need land. Property prices have almost doubled. Traditionally real estate was 40% of project cost and now it has increased to 65%. We may need to set up a health care real estate investment trust (REIT)like you have in the U.S. to overcome this hurdle.

Where Are India's Heat Hotspots?

Heat waves across the world have killed tens of thousands of people since the turn of the century. In the U.S., more people die from deaths related to heat than all other natural phenomena combined. Parts of West Asia are expected to become inhospitable to human life by the end of this century. 

And in recent years, India and neighboring regions have experienced several devastating heat waves, causing the country to increasingly focus on a growing global concern—rising temperatures as a public health threat.

By 2022 India’s population is projected to exceed China’s, making it home to one-fifth of the world’s population. As a developing country located in the tropics, India suffers from factors that make it vulnerable to heat waves: persistent poverty, poor sanitation, a precarious water and electricity supply and low rate of access to health care.

Spurring the market for high-tech home health care

By M H Ahssan

A daunting array of financial and operational barriers is holding back growth. What can be done?

On the surface, technology-enabled home health care should be thriving in the United States. The country’s aging population and the transformation of acute illnesses such as heart failure into chronic diseases mean that the number of patients is growing. In addition, new medical-technology devices could help keep patients at home rather than in costly institutions, such as assisted-living facilities or nursing homes—leading to potentially big savings for the health care system.

Instead, the full potential of the technology-enabled home health care market remains to be tapped. In the United States, home care accounts for about 3 percent ($68 billion a year) of national health spending. The market is increasing by about 9 percent annually,¹ solid but hardly booming growth, especially since labor (mainly nurses and aides) accounts for about two-thirds² of the expenditure and home-monitoring technology represents a small fraction of it. What’s holding the market back? We observe a daunting array of financial and operational barriers, including the misalignment of incentives between payers and providers, the need to demonstrate a strong clinical value proposition, and the problem of designing attractive, easy-to-use products that facilitate adoption by patients.
Technology holds a central role in expanding the market for home health care. Historically, most of its infrastructure and equipment consisted of durable medical products: walkers, wheelchairs, wall rungs, safety rugs, and the like. That infrastructure enabled basic home care but could not substitute for the more sophisticated capabilities of specialized care settings, such as on-call nursing in long-term-care facilities. In recent years, however, new home care technologies—Internet-enabled home monitors, apps for mobile health, and telemedicine—are bringing aspects of advanced care into patients’ homes. These technologies are finding a place in all parts of the globe.
Expanded technology-enabled home care offers a promising pathway to bend the cost curve for ever-growing health care expenditures. Independent of the economic benefit, the moral value of enabling older members of society to live in grace and dignity in their own homes, with a ripple effect on their caregivers, is arguably the most important—if unquantifiable—benefit of home care. It will move ahead, however, only if stakeholders develop more equitable reimbursement models that create greater incentives to participate in the technology-enabled home health market. In addition, medical-device makers must focus on technologies that are easier to use, have a real impact on patients’ conditions, and make it possible to measure results.
An understanding of these issues is important for all stakeholders: medical-device manufacturers, insurers, doctors, hospitals, and government regulators seeking to optimize investments in home health care. With the market growing, and expansion opportunities available both domestically and internationally, this is a promising time to be in the business of home care technology.

Where technology-enabled home care can help

The goal of technology-enabled home care—the delivery of health diagnostics or therapeutics in a patient’s home—is to prevent or reduce the need for institutional care, alleviating the financial and emotional burden upon society and individuals. Its central thesis is that some chronic illnesses can be treated through monitoring and interventions in a patient’s home rather than in higher-cost institutional settings.

Of course, the 65-and-over age segment forms the bulk of the home care population and fuels the market’s growth. These men and women experience care primarily in four settings: their homes, assisted-living facilities, acute-care facilities (hospitals), and long-term-care institutions, such as nursing homes or skilled-nursing facilities. Clinical or economic factors propel patients from one care setting to another. The shift from homes to assisted-living facilities is typically driven by a gradual decline in cognition or physical capacity, from homes or assisted-living facilities to acute-care facilities by events such as fractures or heart attacks, and from homes, assisted-living facilities, or acute-care institutions to long-term-care institutions by movement across a financial or clinical breaking point (for example, bankruptcy or a diagnosis of dementia or other chronic illness).

The most important value offered by technology-enabled home care is preventing or delaying the shift of patients to acute- or long-term-care settings. Technologies used in home care cannot address all the potential factors underlying such shifts—for example, trauma from a car accident lies beyond their reach. The medical conditions that can be addressed successfully by technology-enabled home care meet three criteria:

• They are chronic—persisting for years rather than days or months.
• They can be prevented or addressed by protocols—repeatable and standardized step-by-step instructions executed by nonphysicians.
• They are nonintensive—there is no requirement for round-the-clock attention or human monitoring.

Diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and fracture prevention³ are high-prevalence medical conditions that satisfy these criteria. They are important disease targets for current and future technological advances in home care.

Choosing the right business model

To date, technology-enabled home care in the United States has succeeded in only a few settings: most notably, integrated payers and providers such as Kaiser Permanente (through its KP OnCall subsidiary) and US Department of Veterans Affairs (VA) medical centers (through the VA’s Care Coordination/Home Telehealth program). There is increasing evidence of the value of such programs. A 2008 study of Telehealth found that hospital admissions dropped by close to one-fifth, while its cost was up to two orders of magnitude lower than that of alternatives.
Given the potential savings, why do home care technologies have such low penetration? We find that eight key success factors, falling into three categories, must be satisfied simultaneously for a model to be commercially viable. Entrants into the home care technology market should cast a critical eye upon their offerings to verify that all eight success factors have been satisfied. Failure to meet even one can cripple an otherwise-promising business model.

Financial factors

1. Alignment between payers and providers. Episodic hospitalization reimbursements for congestive-heart-failure patients, for example, are misaligned with hospital-based technology-enabled home care programs: every patient successfully kept at home means less revenue for a hospital. A critical reason for the success of integrated payer–providers (such as the VA) in technology-enabled home care is their capitated reimbursement models—by patient per year, so each patient who avoids hospitalization represents a boost to the bottom line.
Stakeholders, particularly payers and providers, must cooperate to ensure that incentives for relevant technologies are aligned. That means either creating new reimbursement models, such as direct payments for the use of home care technologies, or adapting existing models, such as bundled reimbursements that cover a comprehensive set of clinical activities across care settings.
2. Remunerative. A home care technology’s return on investment must be clear to patients and, where different, to purchasers. Personal-health-record software aimed at individual patients, for example, remains unpopular because each user must enter a great deal of information manually in return for ambiguous benefits. On the other hand, at-home glucometers, which measure the concentration of blood sugar, have succeeded because the value to patients is simple, clear, and immediate.

Effectiveness factors

3. Having significant impact. A home care technology must affect a patient’s clinical course of care; conversely, if it merely provides information that cannot change the course of disease progression or treatment, its value is negligible. Monitoring the weight of a patient with congestive heart failure, for example, effectively alerts clinicians to an imminent worsening of that condition. The at-home interpretation of new chest pain experienced by recovering heart attack patients is not useful, because the appropriate course of action is to go to the hospital—no matter what.

4. Actionable. Merely observing or flagging an event is not enough; a home care technology must be accompanied by some way to take action—through a device, a nurse, or the patient—when an intervention is required. A nursing intervention prompted by alarming weight gain in a congestive-heart-failure patient is an effective action; displaying a stand-alone Web page with a chart of recent weight gain by a patient, leaving it up to him or her whether and how to do anything, is an ineffective one.

5. Timely. The home care technology must be sufficiently rapid and reliable to be useful in guiding decisions or initiating interventions. An always-on accelerometer, for instance, quickly detects a fall. A daily automated phone call to check on a patient at home to see if a fall occurred does not.
6. Closed loop. A technology must contain a “closed feedback loop” to measure progress against goals and to verify whether effective actions or treatments actually occurred. Without such a loop, a technology’s value cannot be proved, measured, or optimized. A technology that enters a patient’s after-treatment physical-activity levels directly into a provider’s electronic medical records through a wearable device has a closed feedback loop. A technology that enters a patient’s physical-activity levels into a stand-alone system requiring a separate provider login has an open one. Without seamless processes, feedback data may be overlooked or ignored. To fulfill a closed loop, a home care technology must be tightly coupled with processes and tools to ensure that measurements reach their intended recipients in a timely and easily viewed way.

Accessibility factors
7. Usable. Technologies must be available and understandable to the right users at the right place and time; poor user interfaces or immobile physical locations can doom business models. A wireless blood pressure cuff at home is easily usable, for example; a fixed blood pressure kiosk in a retail pharmacy is significantly less so. Further, if a technology has been tested only with tailored populations or under special conditions (such as clinical trials) it is important to verify that it will be scalable to larger populations and real-world conditions.
8. Repeatable. A technology must be used frequently—typically, at least daily—over the course of a chronic disease. Infrequently used technologies do not generate good habits among home care consumers and are eventually forgotten or ignored. The daily measurement of body weight on an electronic scale by congestive-heart-failure patients is repeatable. On the other hand, a device that performs an annual eye exam for diabetic patients works too intermittently to be compelling for home use.

What the future holds

The environment for home care technology is likely to change in the coming years. Greater adoption has two key drivers.

Health care reform

At a time of general fiscal stress and specific concern about billing fraud, public or private payers are unlikely to increase funding or coverage for home care. The Congressional Budget Office estimated that the 2010 Affordable Care Act, for example, will pare a cumulative $39.7 billion from federal home-health-care reimbursements over the next decade.⁶ Payers are more likely to pursue various forms of capitation (payment per person rather than, say, per service) and shared-risk models, in an attempt to give providers an incentive to subsidize home care technologies and services.

Misalignment between buyers and beneficiaries is an important brake on the penetration of home care technologies. They are likely to benefit if reform efforts successfully accelerate the alignment of incentives—for example, through the creation of Accountable Care Organizations (groups of coordinated health care providers) or bundled payments between payers and providers.⁷ Indeed, the spread of home care technology has an especially strong potential to accelerate under such a scenario because care pathways that rely on skilled labor—pharmacists, nurses, and doctors—are most vulnerable to labor shortages and to eventual augmentation by technology-driven approaches.

Increasing the evidence base

As multiple technology-enabled home care pilots, at public and private organizations alike, have rolled out over the past decade, data accumulated on both sides of the ledger for clinical value and returns on investment. In some cases, technology-enabled home care pilots have produced compelling successes; in others, they have done less well.

Fraud remains a looming concern in home care; the US Government Accountability Office reported “estimated improper payments for Medicare of almost $48 billion for fiscal year 2010,” including expenditures for home oxygen and other home health claims.⁸ To qualify for coverage from payers or to generate incentives within insurance for individuals, home care technologies may also offer new avenues to address home care fraud, in addition to improving patients’ health and quality of life and saving money.
We see substantial growth potential in technology-enabled home health care. An aging population and an increasing chronic-disease burden point to a large and growing market. But home care stakeholders must get the reimbursement models right and ensure that the technologies coming to market truly make a difference for patients and the bottom line alike.

Vaccine-Derived Polio Found In Hyderabad Sewage Is An Outcome Of India’s immunisation Strategy

By NEWSCOP | INNLIVE

Public health experts expect to find vaccine-derived polio virus in the environment for at least the next year.

On Wednesday, Telangana health authorities announced a polio vaccination drive because a strain of polio had been found in the Amberpet Nala in Hyderabad. The announcement triggered alarm that polio had resurfaced in India, a country that the World Health Organisation had declared polio-free in 2012. However, the presence of vaccine-derived polio viruses is expected in sewage systems across the country for at least the next six to 12 months, say public health experts, reiterating the government’s position that there is no cause for alarm.

World 'No Tobacco' Day 2009

By Suman Ranganathan

The World Health Organization selects "Tobacco Health Warnings" as the theme for the 20th World No Tobacco Day, which will take place on 31 May 2009. Tobacco health warnings appear on packs of cigarettes and are among the strongest defences against the global epidemic of tobacco. WHO particularly approves of warnings that contain both pictures and words because they are the most effective at convincing people to quit.

Tobacco health warnings appear on packs of cigarettes and are among the strongest defences against the global epidemic of tobacco.

WHO particularly approves of tobacco health warnings that contain both pictures and words because they are the most effective at convincing people to quit. Such pictorial warnings appear in more than a dozen countries.

On World No Tobacco Day 2009, and throughout the following year, WHO will encourage governments to adopt tobacco health warnings that meet all the criteria for maximal effectiveness, including that they cover more than half of the pack, appear on both the front and back of the pack and contain pictures.

The WHO Framework Convention on Tobacco Control obligates its more than 160 countries parties to require "health warnings describing the harmful effects of tobacco use" on packs of tobacco and their outside packaging and recommends that the warnings contain pictures. WHO works through its Tobacco Free Initiative department to help the parties to meet their obligation, providing technical and other assistance.

As WHO Director General Margaret Chan says, "We hold in our hands the solution to the global tobacco epidemic that threatens the lives of one billion men, women and children during this century."

Tobacco health warnings are a big part of the solution about which Dr Chan speaks.

Please return soon to this website for a richer explanation of why the World Health Organization chose "Tobacco Health Warnings" as the theme for World No Tobacco Day 2009 and about what the warnings -- pictorial ones in particular -- can do to fight tobacco.

A Possible Remedy for Poor Health Care in India

By M H Ahssan

India wants to be a preferred destination for medical tourism, but its health care offering for its own citizens is lacking. The doctor-to-population ratio for the country is 6:10000, compared to a global ratio of 14:10000. It is estimated that over the next two decades, India will need twice as many doctors, three times as many nurses and four times as many paramedics it has at present.

With 60% of the hospitals and 80% of the doctors belonging to the private sector, and 70% of the health care resources in India concentrated in the top 20 cities, rural India is hit the hardest.
To address this problem, the Medical Council of India (MCI) has proposed a truncated medical course for practitioners in rural areas. Called the Bachelor of Rural Medicine and Surgery (BRMS), it is a three-and-a-half-year course aimed specifically for students from rural India to take care of the basic health care needs of the target population.

The proposal for the BRMS, initiated by the MCI a couple of years ago, has recently received the backing of the country’s Planning Commission. A report released by an expert group within the Commission notes that the course should focus on “high quality of competence in preventive, promotive and rehabilitative services required for the rural population with a focus on primary health care.” It also recommends that by 2020, India should have BRMS colleges in all districts with a population of over 500,000. The report clarifies that this is not a shortened version of a traditional medical degree (MBBS) course, but a unique initiative to address the country’s rural health care issues.

Not everyone is convinced of the efficacy of the BRMS course. In an address on the website of the Indian Medical Association, its president, Vinay Aggarwal, points out that the course is akin to “promoting and legalizing quackery.” He adds: “While modern medicine is experiencing a knowledge explosion, and a five-and-a-half-year MBBS course is insufficient to provide basic information to would-be doctors … how can reducing the duration of training be the remedy to the maladies plaguing rural health? Compromised education, and training in institutions where infrastructure and faculties have been compromised, will compromise the health of villagers …. An army of half-baked doctors for villagers with a three-and-a-half-year curriculum is a gross injustice.”

Rana Mehta, executive director, PricewaterhouseCoopers, India, disagrees. “I see it as a positive step,” he says. “In one way it is a compromise, because you don’t do the [traditional-length] course, but given the huge shortage of doctors in India, this is a very good and innovative move.” The only caution that Mehta adds is that BRMS practitioners “need to keep within the paradigm of the knowledge that they have.”

There have been other innovations in India’s health care sector. At Devi Shetty’s cardiac care hospital, Narayana Hrudayalaya, for instance, patients are treated for heart ailments at a fraction of what it would cost elsewhere across the globe. Shetty attributes this to “process innovation.” And at the Indian arm of GE Healthcare, the goal is to innovate and make affordable and accessible health care products to meet the specific needs of the Indian population.
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It now remains to be seen whether the BRMS ranks among these and other innovations from India — or whether it will prove the skeptics right.

U S AUTOMOBILE INDUSTRY - The Jurassic auto and idea park

By M H Ahssan

The U.S. auto giants are an example of how things work in the age of unbridled corporate power. Of how the collapse of restraint on that power fractures economy and society.

It is unfair to call the United States auto industry dinosaurs, as some now do. It is certainly unfair to the dinosaurs. The 'Terrible Lizards' did not lay the basis for their own extinction or that of myriad other species. The U.S. automobile companies did - and will take large numbers of jobs, workers and businesses with them.

It is more like the asteroid hit on the earth which is presumed to have fried the dinosaurs. But that's unfair to the asteroid. The U.S. auto giants General Motors, Ford and Chrysler are more a fine example of how things work in the age of unbridled corporate power. Of how the collapse of restraint on that power must fracture economy and society. They also set the very standards that the Indian elite lusts to emulate.

Metal lizards
The original dinosaurs (which scientists now tell us were neither all that terrible nor lizards) were great examples of success and adaptation. Good enough to rule the planet for 150 million years. The U.S. auto industry is the opposite. It's not just that the Terrible Metal Lizards opposed fuel efficiency standards. Of course, they did. They also promoted gas-guzzling SUVs as a lifestyle must. They cranked out cars many did not want to buy. They wielded heavy clout in Congress. And were able to sponge off public funds in the name of saving jobs as they have yet again. Having received $25 billion earlier, their hats are in their outstretched hands again.

But that's the easy part. There's a lot more they did, as a major sector of industry - and as part of the larger corporate world of the U.S. Over decades, they destroyed both existing and potential public transport. The 'American Dream' so far as the automobile went was an imposed nightmare. In Detroit itself, you can see the skeletons of a once alive transport system. All across the country, for decades from the 1920s, they bought up public transport systems and shut them down. Trains were shifted from electric to diesel engines. Sometimes, they were simply done away with and replaced by buses and then cars. Together with Big Oil, Big Auto converted electric transit systems to fuel-based bus systems. In one estimate: In 1935, electric train engines outnumbered diesel train engines 7 to 1. "By 1970, diesel train engines outnumbered electric ones 100 to 1. And GM made 60 per cent of the diesel locomotives." The electric rail system in and around Los Angeles was almost erased.

Fostering the cult
Fostering the cult of the individual-owned automobile was a major goal. By 2001, that goal was achieved beyond belief. Some 90 per cent of Americans drove to work by that year. The findings of the 2001 National Household Travel Survey are striking. Only 8 per cent households reported not having a vehicle available for regular use. The survey showed that "daily travel in the United States totalled about 4 trillion miles, which works out to an average of 14,500 miles per person over a full year." Trips by transit and by school bus each made up just 2 per cent of daily trips taken in 2001.

Not just a cult but a culture grew around the Metal Lizards and fossil fuels. Even an economy that goes to war to deal with perceived threats to oil. (As Robert Fisk often asks: would there have been a war in Iraq if Iraq's national product had been asparagus?) Again together with Big Oil, Big Auto for decades crushed all serious moves towards cleaner energy sources.

Almost everything grew dependent on it. From agriculture to aviation, individual to national needs. When oil prices rose (before their present crash) thanks to heavy speculation, countless households in the U.S. were paralysed. Hundreds of little family trucking businesses went kaput. People in outlying places who drive many miles to fetch things like bottled water and provisions found their budgets burning. An average American family in 2004 spent up to a fifth of its income on transportation. That's against 13 per cent on food. In "automobile dependent neighbourhoods," according to the Bureau of Labour Statistics, that could go up to 25 per cent. In bigger cities, the traffic only gets worse, never better. There were over 135 million passenger cars in 2006. Overall, registered vehicles clocked in at more than 250 million.

Imagine the centrality of oil, autos and private vehicles to just about everything. This is the very model our own Indian elite seeks to transplant. Private automobiles at the cost of public transport. Never mind the latter is a lot cleaner and creates large numbers of jobs. And so we add thousands of such vehicles to the roads each week.

But back to the Metal Dinosaurs of Detroit. Their asteroid hit will impact on far more than the nearly quarter of a million workers directly stranded on their turf. There are also more than a million retirees and dependents in trouble. The retirees now watch their health benefits vanish. That's not nice in a country where health costs are the largest single cause of bankruptcies. At age 75 or 80, it is misery. Then there are millions of other workers in associated sectors. In part-makers, supplier companies, in dealerships.

The health issue is also vital. With all its wealth, the U.S. has no decent public health system. The corporate world as a whole has never allowed that to emerge. The health insurance mob, Big Pharma, huge corporations in the medical field, and so on. Take the loss of jobs in the automobile sector to Canada. One reason is simply because Canada has a much better public health system. Even GM (which also exists there) has lobbied in the past in that country to see that Canada's universal health plan was not scuttled! It has saved GM countless dollars.

Each car that GM puts out carries a healthcare cost of around $1600. For Chrysler, that's $1500. But for Toyota, that cost is under $300 per car. Japan has a far superior public health system. In the corporate-media of the U.S., this does not lead to calls for a good health system. Or for making health access cheaper. It leads to calls for doing away with the union contracts that guaranteed auto workers health benefits for life. For retirees, the pullback has already begun.

India even now has one of the most highly privatised health sectors in the world. Yet it exults in emulating the worst of the U.S. model. The Indian elite boasts of India as one of the hottest destinations in 'medical tourism.' Sure, Americans might fly to India to get their surgeries done (which would cost them an arm and a leg in their own country). But close to 200 million Indians have given up seeking any kind of medical attention at all - simply because they cannot afford it.

'Too big to fail'
Meanwhile, the logic of "too big to fail" keeps Big Auto and others of its ilk going. There is never any debate in the U.S. on whether they should have been allowed to get as big as they did. President-elect Barack Obama says he will aid the auto oligarchs who he calls "the backbone of American manufacturing." Sure, with that many jobs at stake, any government must worry about the consequences of letting them sink. No question about it. It's on the basis of that very fear that the Terrible Metal Lizards are able to bargain for handouts from public money. This economy has lost close to a quarter of a million jobs in the month of October alone. So the thought of many more simply vanishing is scary. The U.S. has already lost over 1.2 million jobs this year. Close to half of those in the past three months alone.

So there is a good chance that more public money will be thrown at the auto giants. And that, without larger strategic shifts being imposed on them. Yet, everyone knows this does not mean an industry saved. They could be back soon with demands for still more. At which time, with things being even worse (quite likely) the pressure to save jobs by pouring in public money will be still greater. This is the United States.

The money given out in the bailout so far has delighted the Tuxedo dinosaurs - CEOs and senior executives. As The New York Times notes ruefully in a lead editorial: "Just weeks after the Treasury Department gave nine of the nation's top banks $125 billion in taxpayer dollars to save them from unprecedented calamity, bank executives are salting money away in billionaire bonus pools to reward themselves for their performance." Other bailout bandits have held meetings at resorts costing hundreds of thousands of dollars.

Remember the 'debate' over CEO compensation in India? The media shouted down their favourite Prime Minister when he made a few meek sounds of protest over inflated CEO pay. Well, there too, we were and are on the very track that has helped the U.S. land itself in the mess it now is in. Welcome to the Jurassic Auto & Idea Park.