An interview with Anand Kumar who runs Super 30

In the ever expanding market of coaching institutes, Anand Kumar's Super 30 is an anomaly. For the past 8 years, students of Super 30, an education programme, for students from economically backward sections, run by Ramanujan School of Mathematics have consistently performed well in the joint entrance examination for the Indian Institutes of Technology.In an interview with Arunima Rajan, Anand Kumar, architect of the programme, talks about expansion plans,trends, challenges as well as skewed gender ratio at his institute which has often been considered as one of the most innovative schools in Asia.

You had got an opportunity to study at Cambridge and could not pursue it due to financial constraints.Do you still think about what you could have done ,if you had gone to Cambridge?

No, I don’t think of what I miss. May be, the God had willed it this way and I am happy with whatever I have achieved. In Cambridge, may be
I would have achieved success for myself, while here I see success in the smiles of my students.

Did you face any problems while running this school?
The problems were there in the beginning, when coaching Mafias got unhappy with my concept of Super 30. They attacked me and my people.Later, some people tried to defame me by starting different coaching institutes with a prefix or suffix of super 30 to their institute’s
name and they received huge amount as donation from government as well as from private agencies.

What is the selection process for Super 30?
Students are selected on the basis of their performance in a screening test. Preference is given to poor students, irrespective of caste or creed.

How does Super 30 sustain itself? Is Super 30 financially supported by government or other external agencies?
It does not accept any fund from any government or private institution.It is solely run by the income I generate from Ramanujan School of
mathematics, where we provide tuition for school students for a modest fee.

Why are there not so many girls in your institute?
May be, because of the social structure, in which people devote more attention to son than daughters. But now, things are gradually
changing. The government, the society as well as the families are paying more and more emphasis on girls’ education. In the years to come, may be there will be a lot many girls.

Does your students keep in touch with their alma mater, even after they clear the entrance test ?
Yes, many of those who cleared IIT-JEE 10 years ago and well placed in different countries are also still in touch with me. They also come to
me whenever they get an opportunity to visit here.

What are the expansion plans of your institute?
I will like to double the intake due to growing demand with in two years. But more importantly, I want to set up a school from class 1 to class 12 ,so that I could groom the poorest of students into the most successful citizens. This will have a lasting impact.

What do you think about promotion quota bill? Should reservation be given for economically backward or backward caste?
It is a sensitive issue, which should be best left to politicians to deal. But yes, I do feel that even the most backward people can go up
the ladder with merit if they get the right opportunity.

Is the new format of IIT JEE fair?
No, it is heavily tilted against the urban elite. I have also spoken about it. And more importantly, it is still not clear if the JEE board is itself convinced with it. Who knows, we can get back to subjective type once again, at least for the Mains examination.

Is there a dip in the success rate of Super 30?
Super 30 does not work for success of failure. It will be as successful if it is able to shape the life of one poor student. If itis 30 out of 30, as it happened for three years, it is a bonus. I was happy with 28 our of 30 and 24 out of 30 also, because those who miss the IIT bus end up in other good institutions or crack it the next time.

Who is the star of this year's Super 30?
For me, all 30 are stars. Luck and opportunities make stars. One question can be the difference. At Super 30, there is equal love for all and they all respond with equal hard work.

Recently people's magazine chose you as people's hero, how do you see these accolades?
This is a recognition that inspires me to work harder.

Though Bihar is an underdeveloped state, a big chunk of students clear competitive examinations every year. What is the reason for this success?
Heroes always emerge from adversities. Here students excel because they have the passion to excel. They want to shed their painful past
and start a new journey. Talent-wise they are second to none. Once they have the opportunities, they make it doubly count.

There have been reports about how Bihar has started developing at at a faster rate in the last ten years. How fast is the education sector in
the state improving?

The government has definitely very done good work. But, in the education sector, there is no magic wand. If one invests in education sector today, the results will show 15-20 years later. It is not like an industry that can start production straightway. The government is definitely trying positively and is busy developing infrastructure and busy in searching good teachers . The intent is there. The enrollment has improved, but now is the time to sustain and consolidate it.

Freeing campuses from the death row

Elite campuses are fast turning into death traps. More and more starry-eyed students, pushed by ambitious parents and demanding tutors to prepare them for a ‘bright future’, are crumbling under the pressure.

Students’ suicides have become a topic of much concern for the government as well as the educators. While policy makers have so far been debating but doing little to remedy it, school and college managements have been mostly wary about confronting the issue. But it is time to act as grim statistics justify. According to a National Crime Records Bureau report, 5,877 student suicides were reported in 2006 and the number of youngsters succumbing jumped to 7,379 in 2010. While the reasons may be many, the immediate challenge before teaching institutes is to balance academics with students’ and parents’ varied aspirations.

Targetting professional education and research institutes to begin with, a task force constituted by the Central Human Resources Development Ministry to study the increasing number of student suicides recently recommended that all centrally-funded technical institutions must earmark Rs 50 lakh a year for student support services, including counselling and activities to promote emotional well being of students. Many of these institutions have taken the advice in the right spirit and some have even begun to initiate measures.

So, why should educational institutes offer student support services? The number of student suicides has been increasing each year, not to mention the increasing cases of stress, anxiety and depression. In every premiere institute, young students are thrown into a highly competitive environment away from the comfort of their homes and loved ones. Some cope, while many struggle and ultimately succumb.

Reaching out

Shamnad Basheer, Ministry of HRD professor in IP Law at National University of Juridical Sciences, Kolkata argues that providing support services is the responsibility of college managements for ensuring that their students blossom to their full potential. “Robust support systems have to be built up through peer networks that can provide emotional support, appoint senior students as mentors who can shepherd young entrants, and importantly faculty members who have considerable sway over these young minds can provide guidance and support from time to time,” says Basheer.

But, merely appointing a counsellor may not be enough. “One must also ensure that the counsellor builds a good rapport with students to make them feel comfortable enough to speak to him/her. Given the way counselling is perceived in this country, it may be a good idea to also have counsellors situated outside campus (though close by), so that students feel free to approach them without worrying about being judged by their peers. The counsellors chosen must be ones that have a holistic approach to mental well being and not those that are overly technical and narrow in their orientation," concludes the professor.

With students landing from various parts of the country and family backgrounds, handling their numerous problems is quite mind-boggling, opine managements. “From social network addiction to depression, we have to handle a whole lot of problems. That’s the reason, why we have employed three counsellors in the campus. We are also planning to employ two more,” says Sharad Kumar Gupta, Dean of Student Affairs at IIT Delhi. The Student Affairs Committee of IITD has also tried to branch into other services like communication courses to help students with a heavy accent. “You have to remember that high IQ- exam crackers from different states study at IIT. So, the pressure to fit in and perform is much higher than in any other institute,” adds Gupta.

Life of a student at most of the elite colleges of the country is governed by strict codes of conduct. Pramod Kumar Verma, the student council chairman of Indian Institute of Science (IISc), Bangalore, admits that students often get so caught up in academic work that they don’t get time for extra-curricular activities. “A PhD student does not know when the course will finally get over. At times, it can even go on for eight years. It is extremely difficult to organise even a fest in the middle of so much academic work,” says the 29-year-old student. Interestingly, the institute has not hosted cultural fest for the last two years.

To combat the stigma associated with seeking help, IISc, Bangalore has recently launched an online counselling service for its students. According to Varma, the option to chat anonymously with a professional psychologist has received good response from the student community.

However, the management of Christ University, Bangalore which offers a wide variety of courses, has found face-to-face counselling more effective than online services. Father Abraham, Pro Vice Chancellor of the University, says that the stigma associated with seeking help is often the biggest hurdle. “We used to offer tele-counselling services for students. But we stopped it as there were not many takers for it. Currently, the institute provides four full- time counsellors as well as 300 student mentors,” says the academic.

Another way of tackling stress related issues of students, which institutes like Tata Institute of Social Sciences, Mumbai have tried is traditional Indian practices like Yoga and meditation. “We are offering yoga and meditation classes for our students so that they can handle their issues through simple breathing techniques,” says CAK Yesudian, Dean of School of Health Systems Studies at TISS. The Indian Institute of Management, Bangalore has a two-week long mentorship programme for students who need academic support, even before they join PGP, their flagship programme. The budding managers also get an opportunity to interact with IIMB alumni to understand the ethos of the institute.

School stress
Academic stress is not limited to colleges but also exists in schools. The Delhi Public School branches in Bangalore have roped in external agencies like Amelio, a childcare service provider to counsel both students and parents. Instead of focusing purely on the next exam, the school also offers students long term plans like career guidance. The school also guides students to healthier diets during stressful exam season.

Capt. Unnikrishnan, Managing Trustee, Primus Public School says that teachers at his school act as gatekeepers and address various emotional as well as academic pressures of students. In fact curriculum of the school is designed in such a manner that students can easily approach teachers, if they are reeling under pressure to perform. Unnikrishnan is of the opinion that for young, impressionable minds, support systems have to be subliminal. “We conduct special training programmes for our teachers to cater to the needs of students in a sensitive manner,” says the trustee. The school also screens movies which inculcate the right value system in students.

The ball is in the educational institutions’ court. Would they care more about their budgets or the young lives left in their care, remains to be seen.

Alternative Schooling- A Closer Look

Despite the unfavourable climate in the state for how they function, alternative schools are making an effort to change the way knowledge is transferred. Is there only a single model for learning? Can a child learn at his own pace and explore his interest and gifts in a regular school? Do we need to compartmentalise children based on their age? Should learning also be based on a child’s interest and experiences? Is continuous evaluation and constant comparison required for good outcomes? Alternative schools use these questions in developing their unique approach to education. Alternative education defies any sort of definition, as there is no single learning approach or one teaching model. Hence, M Srinivasan, principal of Gear International Innovation School considers alternative education as a model where the need of the time and child is given importance. “The latest ideas in terms of research and best practices are brought together in alternative education," says the principal of Gear School, a mainstream school which has incorporated principles of non-formal education in its curriculum. "It is not restrained by any system and is driven by ideology.” History The concept of an alternative approach to the way children experience school is not entirely new. Long before the recent upsurge of alternative schooling, social reformers and thinkers had proposed non-formal modes of education in the country. Prominent thinkers and activists like Rabindranath Tagore, Mahatma Gandhi, Jiddu Krishnamurthy, Sri Aurobindo and Gijubhai Badheka have been proponents of a different form of education that was not regimented. Before the British established the current system of education in the country, knowledge was imparted through village schools like pathshalas, gurukuls and madarasas. Learning Approach Experiential learning is the catch word of several alternate schools. They teach multiple disciplines like pottery, tailoring, gardening, puppetry, dance, martial arts and farming, and the focus is on learning by doing things. Self learning and self assessment are also two important qualities stressed in experiential learning. For example, Gear school uses a learning approach which is based on Project and Activity as well as Inquiry and Research (PAIR). The school is divided in to four modes of learning based on the way learning takes place, how human brain functions, and various other factors. Exploration mode is for children between the ages of 2.5 to 5.5 years. Formation mode covers 5.5 to 9.5 years, experimentation mode is from 9.5 to 13.5 years and mass mode is 13.5 to 17.5 years. There are nearly 20 students in a section and four sections for each class. At Poorna, an alternate school in Bangalore, learning is personal and meaningful for the children, and teachers try to make learning deeply interesting to children without coercing or stressing them. “We try to co-plan a curriculum that keeps the children's needs and interests at the centre. We also want education to help children become caring members of society and develop mutual respect toward each other regardless of class, caste, or creed. In a nutshell, we want the experience of learning at school to be joyful one,” says Indira Vijaysimha, founder trustee of the school. Class Structure A class, or learning group, at the school has approximately 15 children of similar age. Children are not grouped according to ability. The evaluation methods for younger children consist primarily of informal assessment of children's learning. Lessons are planned around specific objectives, and teachers keep note of whether these learning objectives are achieved or not. This method is also used for older children who additionally may take examinations twice or thrice in a year. Children are encouraged to fill in self- assessment forms so that they can be partners in charting their academic progress. Integration to society The school authorities claim that students from an alternative school like Poorna are supported in their journey of self development and this makes them both resilient and reflective. “They will not merely fit into mainstream society but will more likely go out there and transform it, Indira Vijaysimha says. "We are all too aware that mainstream society is far from perfect, so why should we aim at fitting children into it - we want them to make a difference to society, not conform.” Several alternate schools are located in suburbs or rural areas, away from the hustle and bustle of the (what City?) city. One such school Vikasana, which is located on Kanakapura Road, focuses on educating children of migrant workers. The school has 32 students, from various states, between the ages of four and a half and sixteen. The founder of the school, Malathi MC, says that her institution functions on the basis of David Horsburgh’s(considered as father of non-formal education) theory of non-formal education. “A teacher in an alternative school is just a facilitator. The responsibility of the teacher is to help students discover fun in learning. The emphasis is on doing things. We ensure that our students master the skill and use it in their daily lives. If we teach them how to make dresses, we ensure that they learn how to make dresses, which they can then wear or they can sell.” Challenges In addition to financial struggles, the schools often have to deal with a lack of trust by the general public. They challenge people to think deeply and not just follow directions and face bureaucratic hurdles in getting registration from the government. “The only thing that at times prevented me from giving up in frustration is a deep conviction and an unwarranted faith in human beings,” says Indira Vijaysimha. There are also institutions like Poorna Pragnya Learning Centre, which had to be shut down due to expansion of a highway. Tara Gopinath, who founded the school as early as 1984, says that children of alternate schools might find it difficult to fit in to competitive society initially, but gradually learn the rules of the game. “Several of our alumni have succeeded in their respective careers, be it in art, science or academics.” Examinations in alternate schools In most of the alternate schools, examinations are not just another tool to get feedback about what has been learned or to evaluate the expertise of the teacher. Based on the examination results, those in charge of classes and curriculum may make course corrections and re-think the teaching methodology. Unlike the process in a conventional school, exams are not used as a tool to pass judgments on students and declare them pass or fail. Student of alternate schools often take examinations administered by the National Institute of Open Schooling (NIOS). Teachers who work in alternative schools say that it can be very liberating and exciting to teach in ways that connect with students and to watch the spark of understanding ignite throughout the class. “It can also be frustrating and demanding as we struggle with unruly children, heavy workload and lack of clarity about what the true aims of the school are," says Indira Vijaysimha. "It can also be frustrating, during parent teacher meetings, when parents unthinkingly expect teachers to fall back on traditional methods, or display little understanding about children's inner development. One learns to be patient and tolerant and also more forgiving of oneself.” List of prominent alternate schools in India Andhra Pradesh Timbaktu Collective Sumavanam Village School Rishi Valley Education Centre Gujarat Anand Niketan Shreyas Foundation The Riverside School Karnataka Gear Innovative International School Poorna Learning Centre Centre for Learning Kerala The Choice School Sri Atmananda Memorial School The Gurukul Delhi Ankur- Society for Alternatives in Education Saakshar Lavenir, The Gnostic Centre

Mission Healthcare

They had degrees from top universities, plum jobs and fat pay packets. Yet, they left corporate rat race and found silver lining in rural healthcare sector.

Kanav Kahol, Swasthya Slate Kanav Kahol isn't your typical US returned researcher. He is an engineer by training, who got his PhD in computer science, when he was merely 26-year-old. And rather than sharing his success stories in US, he likes to talk about empowering rural health workers in the country. When we caught up with him, we were interested in understanding his extremely unconventional choice of leaving his cushy lifestyle and a promising career in US. Kahol was working as an assistant professor in Arizona University with a peer group comprising of Nobel laureates like Lee Hartwell and had secured a research grant of $4.2 million. So what prompted this young geek to comeback to Delhi? "It was a chance meeting with Dr K Srinath Reddy, President of PHFI, which helped me find my true calling, says Kahol, who was already thinking about ways of giving back to his community. What makes him unique is that he joined a public sector enterprise Public Health Foundation of India to fulfil his dream. In July 2011, he took charge of Affordable Health Technologies at PHFI. And soon his research and interactions with rural doctors and healthcare practitioners showed that the real power of mobile based health lies in point of care diagnostics. Being a researcher, he says, has worked to his advantage. "I showed up at five hospitals in Delhi with mild symptoms to understand the workflow of Indian hospitals and how they function. My average waiting time was 3.7 hours and after that the doctor spent 59.2seconds with me, explains Kahol. He soon extended his research to rural areas and started taking random bus trips to villages in various parts of the country." I used to land at the inter-state bus depot and travelled to villages and asked locals to take me to their healthcare practitioners. During these trips, I met several quacks, private practitioners, Auxiliary Nurse Midwives as well as Accredited Social Health Activists. "One of the important takeaways from these trips was the fact that ASHAs and ANMs are doing extremely good work, but they were bogged down by paper work. They needed some device to automate their processes at work and to integrate various activities they have to perform,” explains Kahol. Within a short span of time, he created Swasthya slate, a tablet device that allows users to perform 38 multiple diagnostic tests using an Android phone or tablet. He also points out that most of the interfaces developed for rural sector are not user-friendly. "If a device is fun to use, people would use it. Most of these apps developed for rural people use limited technology that doesn’t give a good user experience, that's why they don't use it," adds Kahol. "Unfortunately an Apple like interface is sold at an exorbitant rate. The more fun it is, the more expensive it,”explains Kahol, who did his engineering in Ludhiana. A solar powered Swasthya Slate kit includes an interface unit, a tablet, a bag containing all the equipment needed to perform the physiological analysis, and disposables like ECG electrodes. The health tablet covers multiple tests ranging from malaria, typhoid, blod grouping to testing purity of water and is priced at Rs 34,500. The project got $5 million grant from Norway India Partnership Initiative. The team also tries to stay ahead of the curve by adding new tests as well as adding multiple apps and features like a referral system for the users, which allows the health workers to sent all the data of a patient to a doctor, who will be informed by an SMS about the new ticket. The health tablet is being deployed in public healthcare facilities of six districts of Jammu and Kashmir, which caters to 25 lakh people, by the government. The maternal and child health statistics of these tribal areas are extremely poor. The government is hoping that the new technology would improve the quality of healthcare in these areas," says Kahol. Since the announcement of project in Jammu and Kashmir, curiosity has built up, word has spread and a willingness to introduce in other states surfaced. The short time in which he was able to lift his product to it's high status also makes him contented. "We want to pursue problems related to reproductive, maternal, newborn, child health and adolescent health, says Kahol. And then he adds happily, “It’s interesting when we go to rural areas for checkups of mothers. It's not only the mothers, but the mother- in-laws as well as father-in-laws who get checked." The Swasthya team also tries to be top-notch at everything that they try to do. "As important as creating a new device was incorporating other featured like referrals as well as suggesting medication for the patient. The rural health sector would transform due to the preventive, proactive and prophylactic approach,” notes Kahol. Currently, preventive care tops the list of priorities of Swasthya team. "Preventive care is the way to go. If India gets number of diabetic patients that International diabetes federation is projecting then roughly we need to spend of .8 percent of GDP to take care of them. Preventive cure is the answer for our problems," says Kahol. Every step in the journey is an accomplishment according to Kahol.”Whether it's getting approval from government going through multiple reviews, adding a new feature to the device or even creating the website for the product, everything is a little celebration," says Kahol. Two years in to his mission, Kahol also narrates an interesting story. "Recently, we noticed that healthcare data is not available to workers in languages like Pahari and Gujari. So ANMs started sharing their healthcare information data over social network. Some of the ANMs associated with Swasthya are creating videos and informational material and sharing it to the other members," adds Kahol. While SS is still a work in progress, the early success shows that the key is to create innovative solutions that have the potential to scale up and which can in turn help other players in the sectors. "With the help of the data collected from the patients, we can tell a private player where they should set up a hospital in each of these six districts where we have started working,” concludes Kahol. Zeena Johar, Sugha Vazhvu Healthcare From being criticised for her career choice to being one of the most talked about CEOs in the healthcare industry, Zeena Johar has come a long way. Right now, she’s on the same pedestal as entrepreneurs like Sabahat Asim and Rocky Philip. Last year, her entrepreneurship skill was rewarded, when she won the Ashoka Fellowship. Not only did the work of her company Sugha Vazhvu win her the fellowship, it also got her lot of recognition from the industry. “It feels great to be in the rural healthcare space. When I returned to India, after obtaining my PhD in Molecular Diagnostics from ETH, Zurich, I never thought that I would start a company in the rural healthcare sector. It was 360 degree move that I made, from being an academic to a social entrepreneur,” says Johar. It was her stint with IKP Knowledge Park that actually paved the way for the formation of Sugha Vazhvu Healthcare. “What worked in favour for me was my association with the incubation park of IKP group.IKP was incubating lot of pharma companies and there was direct application of many of my skill sets. It’s primarily due to the support of my mentor Nachiket Mor that I achieved this success. I can probably say that stars aligned on the right side at the right time for me,” says Johar. Even though healthcare in India is one of the thriving sectors, in challenging geographies, the plain vanilla business models dont hold their ground well. Carefully crafted USP of Sugha Vazhvu has helped them contextually evolve their model towards the local needs of the population. “It is true that we had access to a reasonable corpus due to our association with IKP. That definitely made our journey easy. But what fascinated us was how common medical treatments and tests are often considered as a luxury in villages. There was a great opportunity. But it was not a straightforward opportunity, otherwise lot of people would had done it by now,” explains Johar. However, she does not deny the fact that she didn’t have so much clarity about the enterprise initially. “It was a fledgling idea which later grew in to a full- fledged enterprise. We really thought the concept and brain stormed a lot about what we can bring to the table. Even though, the company was launched in 2007, the first clinic was launched only in 2009,” adds Johar. Amidst all that has happened to her during her roller –coaster journey in the Indian healthcare sector, the most crucial are the tie-ups and expansion plans with majors like Apollo. Currently, Sugha Vazhvu Healthcare has set up seven clinics in Tanjavur district of Tamilnadu, where the clinics act as the first point of reference for the locals and offer evidence based primary care. It will shortly launch two more clinics- a mobile clinic and a semi-urban clinic soon and caters to nearly 1, 50,000 people in the area. The social enterprise has also tied up with Apollo Hospitals to replicate their model in Aragonda, a village in Andhra Pradesh. The USP of Sugha Vazhvu is that it trains Indian medical practitioners and have partnered with the University of Pennsylvania, School of Nursing, to develop a bridge course. These alternate medicine practitioners are given training for six months, so that they can offer primary care to the rural population. Currently, the programme is being implemented in the centres of Sugha Vazhvu, where the practitioners are being trained in the new methodology. “The target audience of Sugha Vazhvu is in villages and all our customers have to travel at least two and half hours to reach a registered public healthcare practitioner. As government after government often finds it difficult to recruit staff for their rural PHCs, our solution can be used by the government also. Even the government of Maharashtra has passed an ordinance about training homeopathic doctors to fill the gap of doctors in rural areas,” adds Johar. Johar was also determined to create a platform for integrating all the technical solutions required for a healthcare enterprise. Today, Sugha Vazhva has its own proprietary software, Health Management Information system, which is completely developed in-house. “It does everything from patient record, mobile solutions to supply chain management. It’s a one stop shop for the technological requirement of an enterprise,” says Johar. It’s her unflinching commitment and immersion of herself in all she undertakes that, have established for long lasting relationships with senior business executives and leaders in the healthcare industry. “There is no organized rural entrepreneurship eco-system in the country. There might be some local players, but other than that there is not much activity. There is no organized / structured effort by the government to encourage entrepreneurship. When you look at rural entrepreneurship from a social angle (health, education micro-finance) there are very few players. It takes a lot to set-up a rural enterprise. We have been able to survive only because of the leadership / board we have. They have helped design the funding strategy, performance evaluation metrics, network extension and policy design aspects,” adds Johar. She also points out the long period between concept to operation in several cases. “It takes a long time to establish your idea. Research and understanding of the market in itself would take about 1-1.5 yrs. Our first clinic took 2 years. Technology investment took around 3 years. The first 3 to 3.5 yrs we were getting our act together,” adds Johar. Talk about her team and she admits that confides that she is emotionally attached to them. “We were fortunate enough to have tie-ups with the key networks very early in the beginning. It was crucial to position yourself and have a strategy in place. And this needs to be articulated to the team,” adds Johar. In India there is a lot of trust bestowed on the doctor. How did she gain the trust of the locals? “We have systematically integrated this need. In our model we have 2 resource persons; there is a doctor and health extension worker (physician extender). This physician extender is someone who is recruited from the local community. To deal with loyalty is a bigger issue. Most of our patients are geriatrics. Considering the cost effectiveness and availability of timely healthcare people would prefer us,” adds Johar. Interestingly, an average customer of Sugha Vazhvu is the member of a middle class family in rural areas, with an annual income of nearly 1.5 lakh. Typical treatments of the enterprise cover geriatric patients. Primarily people above the age limit of 40 to 45 years. The company also has a cohesive business plan. There are three major revenue streams of the company, namely consultation fee, diagnostic fee and prescription drugs. Plus, it also offers packages for diabetes, hypertension where customers can enrol for a yearly package for Rs 1200. “At a clinic level we believe the operational cost will be paid off by the revenue it generates every month. The key is to build many clinics to achieve economies of scale which then at the enterprise level will give cross leverage of revenue. However our model is not always dependent on grants. It is only the initial funding that is required for training and community engagement. Once rolled out the scheme will fund for itself,” says Johar. Now that they have stabilised in the difficult terrain, the team can’t be happier. “It is definitely a tricky terrain. The hope we have is in other countries like the USA is took at least 50 years to get the model right. Our proposal is only for places where there is nothing available. Not for the urban areas. Given the demand we have in rural areas for immediate healthcare, we believe this will be sustainable model. The nurse practitioner model in the US is something we have looked at. The reason we tied up with University of Pennsylvania is for the fact that they were involved in this movement in US,” adds Johar. Ask her whether her company bothers about attrition, pat comes the reply,” We do have attrition as any other new enterprise. And the skill-set differs for different stages. For example the kind of resources you need at the design stage is very different from what you need at the implementation stage. Typically it is during the growth stage that we start building some hierarchy in the team. We brought in senior management at this stage, prior to that we were not structured.” Coming to something more personal, she adds that defining a clear value proposition is critical and deep understanding of the offering is a must for a budding entrepreneur. “You need to know to whom you want to sell, what you want to sell and what the customer can afford and will want,” says Johar, whose company has enrolled 70,000 people in various schemes. Shyam Vasudeva Rao, 3Nethra Taking the plunge in to non-corporate world is not so easy to deal with. It doesn't really matter, how old you are or how matured you are-truth is you can never be quite prepared of it. However, if someone has emerged triumphant from it, it is Shyam Vasudeva Rao. He left a successful career as technical director of healthcare division of Philips to follow his dream of entrepreneurship and founded Forus. "There is nothing like the work of an entrepreneur. The main reason for me leaving a comfortable and high profile job at a multinational company and starting Forus was to get out of this work mode and pursue my passion for reaching out to the society with affordable healthcare and wellness. I am now living my dream day in and day out. The world is going through a big health crisis and engineers like me can do a lot of things to solve this problem. Our effort at Forus is a small example. So, I do not find any time to anything other than perceiving my passion." There were few incidents which led him to take the decision. The first incident which clearly stood out was when he was awed by a talk of eminent eye surgeon Dr Aravind, who is also the chief administrator of Aravind Eye Care. "The story of how the world's largest eye care hospital reached out to a large section of society through their products and services, was not only inspiring but also a eye opener for me," says Rao. Even after Dr Aravind finished his talk, Rao thought about how he can strike a balance between his current responsibilities and his own space in the world. After the talk, he walked up to him and asked many questions related to scaling up the model. Dr Aravind told him that eye care needs lot of test and diagnostic equipments and 90 percent of these costly equipments are imported. The essential problem at hand was equipments, without which very few eye problems could be addressed, especially in rural areas. "Chronic problems of eye like diabetic retina, glaucoma, maculla degeneration require expensive and portable equipment for screening alone. People having such chronic eye problems do not realise this until the disease condition has gone worse and then when they come to the hospital, we can only arrest the problem from getting worse and getting blind, there is no cure for any of these chronic problems and the only solution is to catch them early. This led me to think of an all in one eye screening device. And by combining several appropriate technologies together, we invented this device 3nethra," says Rao. 3nethra is an eye screening device which can be taken to the field or used in OPD of large eye hospitals to screen people for any eye problem. The device is so simple that even a trained technician can operate this device and through the tele-ophtalmology platform get the specialist / doctors to report. The product soon won over the minds of patients who got the right doctor, who can solve his/her eye problem. It uses Cloud computing, image processing, mobile computing, communications engineering, intelligent and self learning systems and data analytics for decision support. Remembering about the heady early days of 3nethra, he tells about how it was like to provide care at the door step of the villagers. "Without doctor travelling to these places, we were in a position to connect the patients to the doctor via the mobile network with our 3nethra and tele- ophthalmology software Forus Care. It was extremely exciting to change the paradigm and make making eye care really affordable and accessible. In line with the tag line created by my partner and CEO of Forus K Chandrasekhar we were "Democratizing eye care," says Rao. It took almost two years for Rao and his team to reach eureka moment. Little did he know in the beginning that 50 percent of the solution was in defining the problem and rest was technology, which he puts as 3Cs, computation, collaboration and communication. What helped him survive was the vast experience and research capability of his team. “The solution is a well knit combination of utilizing PC /Laptop standard computer for image acquisition and processing information. On the device we only have an image sensor and lighting electronics, rest is all driven by the PC and with a simple USB interface. This is the most rugged, cost effective and universal mechanism for the compute part. We adopted the mobile technology to reach every nook and corner of this country. One big problem all hospitals faced was data storage and management.. We adopted cloud computing and with that we are in a position to offer large data storage space. Our application also encapsulates patient’s confidential information and we have incorporated a simple EMR system with unique patient ID. This will also be made National UID compatible when it is rolled out across the country. The last bit of the puzzle was who will operate this equipment as the doctors or trained paramedics are always in demand and quite expensive. The only way is to get the user interface intuitive and easy to use. Some amount of intelligence is also put into this and the images captured will be immediately graded and any trained technician can manage getting diagnostic quality images. By using some of the "user centric design" design principles we have come up with a very easy to use and ultra low power consumption device which is not only easily portable but also a locally trained person can operate it and send across the images to the specialist in the city for diagnostic reporting,” explains Rao. Today 3nethra-stamp of care is palpable everywhere and has dealer and distributor networks all across India. What makes Rao proud about the device is that Forus has sold out equipment to 14 neighbouring countries and developing economies."We are now looking at how we can take this product and services to Europe and US. The initial response has been very encouraging, we see this also as a big opportunity to take this Indian technology to international markets," says Rao. When one looks at how the product has fared on the sales front, both in India and abroad, China has the highest number of installations of the product. "In the last few years, the company has to its credit 275 installations all over India and 50 in 14 countries, among them 12 installation are in China. Now we see even the developed economies like Europe, USA and Australia are facing severe problems due to raising healthcare costs and they are very interested in working with companies like Forus, to see how they can get healthcare costs under control. The choice is very simple, it is all driven based on demand and we package our solutions in India and developing countries as preventive eye care and in developed countries call the same as convenience screening, with the same products and services," says Rao. Forus caters to two categories of customers, one is the conventional market like eye care centers and optical stores and other is non ophthalmology which is the unconventional one. "Under conventional market, we have sold our products to large eye hospitals like Aravind Eye Care, LV Prasad Eye Hospital, Shankara Nethralaya, Narayana Nethralaya, Adaty Jyot Eye Hospital, Sharoff eye hospital. We have also sold our product to optical stores like Essilor, Lens cart and have also installations at medical colleges and teaching hospitals like KMC Manipal, "says Rao. In the non conventional segment, Forus has Diagnositc centers, Diabetic centers and Dialysis centres. "There is also a rural entrepreneurship model where we attach these trained technicians to large eye hospitals and they rent our device and screen people in their small tows/ villages and send the patients who need treatment to these hospitals and charge a small fee for the screening services. Our products and services are designed in a manner that it is affordable for all types of customers and intern the service is made affordable for all sections of the society. The big cost savings come from the fact that there are no consumables to carry out the tests, not even an eye drop as our device is designed such that it works without any pupil dilation (non-mydriatic). The simple and intuitive usability will help trained technicians to do the imaging in the field or Hospital OPD and we do not require paramedic or doctors at the screening stage. Large Hospitals and diagnostic centres can afford purchasing this device and small ones or individuals can get this on a pay per use model. Each screening is charged between Rs.100 to Rs.250 depending on the situation and in a day more than 200 patients can be screened as each screening takes less than 5 minutes," says Rao. He also goes on to trace the value proposition of his product. "We are trying to eradicate needless blindness and act as technology enablers for solving this problem. Ultimately, it is the medical fraternity which solves this and we provide them with the right technology, products and tools. We are very different from rest of the players in this market by the fact that, we are offering a end to end solution and the device or software is just a consequence of this solution. Other medical device manufacturers first get their device out and then try to fit the solution around their product, which is not always sub optimal or feasible. The very concept of preventive care and the paradigm of hospital go to patients has attracted a lot of people and in the last 2 years we have screened more than 7, 50,000 patients. This number is just growing with more and more installations and we expect to screen more than a 1.5 million patients this year and 4 Million in next 2 years," says Rao. Right from tying up with hospitals, where their device was used in OP departments, to their tryst, with small towns and villages, Forus had its own set of trials to reach its target audience. "We tried to reach out through regular eye camps and mobile vans fitted with our 3nethra. They also set up small screening centres equipped with 3nethra in slums," says Rao. He also reveals that they have regular screening camps at factories, schools, Hostels, Book exhibitions, shopping mauls, IT centres and even wedding halls. The appreciation that he received from the various corners of the world has even made Hillary Clinton to take notice of 3nethra. "We have bagged awards like DST Lockheed Marten Gold medal for Technology innovation, Sankalp award for social innovation and Anjani Mashalkar Inclusive award for Inclusive innovation,”says Rao. Ask him about the challenges and he says briefly, "There are several problems and challenges reaching out to rural masses." He confides that healthcare organisations cater only 7-10 % of rural population and treat mostly cataracts and refractive errors." These constitute to 60% of the eye problems which need just one time correction/ intervention. The burden is high when it comes to the other 30% which require special instruments and chronic in nature like diabetic retina, glaucoma and AMD. This calls for a special device which can test all these problems in few minutes." He also doesn't want to ignore the problem of scale in the country."We have only 20,000 eye doctors and 50 % of them are anterior segment doctors, basically catering to cataracts and infections of the cornea. If we are talking of preventive care through screening large population with the eye doctors, then one eye doctor needs to attend to 70,000 people. This is humanly impossible. The obvious choice is that the doctor will need to be at most densely populated area, i.e., cities and towns rather than going to less populated rural areas. Hence there is a need for technologies which can extend the reach of these eye doctors to rural masses.” Where power supply problems are concerned, having been operating in rural areas, he is still searching a solution for the power problems. The third challenge in rural "During day time there is hardly power supply to these villages, so if I have a equipment which needs more than 200 watt power to operate, it becomes very difficult, back up batteries or generators will only add up to cost and not easy to use and maintain. So we need devices which operate on low power or no alternate sources like solar power," says Rao. How did he feel about the initial resistance from hospitals? He takes a minute, and replies, "Yes, we had lot of reluctance from the eye hospitals to accept and use this product which costs less and does lot more functions. People were looking at this a bit sceptically. Once we got this clinically validated at world class hospitals like Aravind eye care and KMC Manipal and we also got device certification like CE and ISO, they started using it and now we have lot of demand." All this has only made Rao positive that the going is only going to get better. But what is the price of 3nethra? "We have 2 models of our product 3nethra called classic and Royal. This is bundled with our tele- ophthalmology software called Forus Care and auto -detect software. 3nethra classic costs approximately Rs 5 to 8 lakh and Royal Rs 6.5 to 9 lakh. This is less than a third of any imported or equivalent system in the market. The product idea, patents, concept, design, 75% of the components are all locally made and with the cost of developing the software and manufacturing being less compared to western world, our costs are lower," says Rao. While he may be happy about bright prospects of his device, he continues to set new targets for the company. “There is a fortune at the bottom of the pyramid as Prof. CK Prahalad says, but in addition there is a lot of satisfaction if you do that for making people’s lives better by enabling better health care. It is not just doctors and medical professionals who carry the healthcare burden of the society, even engineers can help and we can act as enablers,” concludes Rao. Pradeep Nakhate, Head India, EyeNetra Calling Pradeep Nakhate an entrepreneur would be an understatement. The India Head of EyeNetra is not a fresh face for the Indian healthcare sector. He has been an entrepreneur for over 16 years and prior to which was in leading positions in MNC healthcare companies. In his words, he has been involved in the medical devices, software, health and human services for the last 26 years. And the most recent addition to the many feathers on his cap is the fact that he has been involved in bringing EyeNetra’s products to life and to India for the past two years. Talking about the genesis of EyeNetra, he says, “EyeNetra was born at MIT while experimenting with mobile phones and optics which finally resulted in a PhD thesis by Vitor Pamplona that formed the foundation of EyeNetra. After a few months of discovery and trials, EyeNetra was incorporated and an effort to develop and commercialise the technology began with the help of Khosla ventures as our investors. During its formative period, EyeNetra and its founders won many awards and accolades.” He mentions that idea behind EyeNetra is simple. “Can a mobile phone which is ubiquitous, all over the world, be used to detect refractive error (power of the eyes) of the human eye? The phone being portable and easy to use would require very little skill to conduct an eye test. Currently, across the globe, eye-care equipment is expensive, not so portable and requires highly skilled people to use. In addition, globally, there is shortage of trained personnel to do the tests. Due to poor awareness and lack of access to testing, more than 4 billion people have limited or no access to eye testing and glasses. EyeNetra aims to be part of the solution to provide access to eye testing and eyeglasses.” The senior executive who is gearing up for the launch of the product notes that it is now nearly fully developed, uses many patented technologies to conduct and interpret the test. “It uses an android phone for the purpose of testing and an android tablet that is used to guide patients how to do the test, as well as collect their relevant information for the purpose of e-health records, analytics etc. The test is presently a guided test, guided by a Netra trained vissionaire (Netra operator). The test takes about 4-5 minutes,” says Nakhate, who also mentors lot of young professionals and budding entrepreneurs. So, what is his definition of NetraG? “It is a portable, inexpensive, accurate device, connected to the web and requires minimal training (even a high school graduate can do it) to conduct the test. The data is collected and stored on the cloud for analytics etc.” Having handled various enterprises, he knows that the product cannot be slotted only for a specific target group. “EyeNetra team imagines that Netra-G will be used in various settings. Just about anywhere where there are people. In work place settings, airports and train stations, shopping malls and colleges, Primary Healthcare Centres, pharmacies, dispensaries and clinics, eye hospitals and also in optical shops and other retail spaces,” explains the senior executive. And what would be the profile of a NetraG customer like? “Our customers are global and they include first world and developing country citizens. Creating a suitable testing experience along with providing access to eyeglasses for each kind of customer and use case is our aim. For this we shall work with various customer access channels, try and test them so that we can give the best access and service to our customer – the person who needs eyeglasses,” says the serial entrepreneur. Pradeep is also excited about the product trials in rural areas. “In the second phase of our product roll out, we shall access rural populations through non-governmental, governmental agencies and by creating livelihood opportunities among rural youth. We shall begin with product trials in the rural setting shortly,” says Nakhate. He also knows that introducing their flagship product won’t be an easy task.. “By and large, in India, the concept when shown and discussed, has met with positive response. We have noted the expectations of our users and customers and are making sure that the product has excellent usability qualities,” says Nakhate. “Largely in India, people don’t pay for eye testing. The cost is subsidized through the sale of spectacles. This is true in many parts of the world but not everywhere. We have therefore, for markets like India, are looking also at various ways to subsidise the cost of the test so that by and large the test is free or at a negligible cost,” adds Nakhate. Pradeep also sheds some light on the founding members of EyeNetra. It was first incorporated by three founder members - Ramesh, Vitor and David. Khosla Ventures and Khosla impact fund invested initially. The enterprise is almost 2 years old and it will need another few months to get into a position where can bring this product to market commercially. Pilots are already underway,” says Nakhate. Currently, EyeNetra is based out of Somerville, Massachusetts. “In the US, we have a lead technical and engineering team and a product and market development team. In India, through a technical services arrangement, we have design and engineering and an independent product and market testing team along with consultants and associates for clinical trials etc. Both teams are small but are fast expanding,” explains Nakhate. He also talks about the learning that came out of his association with the project. “EyeNetra is a true representation of how good science can result in spawning various technologies which can have, in a very significant way, a direct impact, both socially and economically, in solving real world problems faced by a large number of people, across the globe,” concludes Nakhate. Myshkin Ingawale, Biosense/Inter Institutional Inclusive Innovation Centre Myshkin Ingawale could have become a jet-setting business consultant in McKinsey &Co. Yet, he chose not to succumb to peer -pressure and rather focused on creating a social impact in his country. He might have names like MIT or IIM Calcutta in his resume, but when it comes to the crux, he is a simple Mumbai boy. He points out that it is a great time to start enterprises in India. “Small scale enterprises have always been understood to account for most of the jobs in an economy- and at present, the Indian economy is at the stage where there is aspiration and demand from many sectors. Any entrepreneur or government agency with a vision, and a clear idea of which consumer demand they wish to address, have a wonderful opportunity at present with a right confluence of local skill sets and funding complimenting increased buying power and evolution in the mindset of consumers in India. The key determinant of success would be the managerial excellence of teams who set out on new ventures,” says Ingawale. The mention of healthcare delivery has him beaming. And he tells that the main obstacle to healthcare delivery in India is lack of access to appropriate technology. “The key word is appropriate-just importing the same tools and devices used in the West do not work because of the difference in personnel available on the ground in India. The tools and devices have to be developed for field conditions, by use by ASHA workers and other relatively low-skilled non-medical personnel, and that too, optimized for the population that we have. The challenge is for India's engineers, designers and entrepreneurs to come up with solutions,” says Ingawale. Myshkin has been on a high with variety of challenges that he has accepted as an entrepreneur from Biosense to Inter Institutional Inclusive Innovation Centre. His first big break came, when he founded a for-profit company - Biosense - with Dr Abhishek Sen, Dr Yogesh Patil and Aman Midha - medical doctors and designers who had a vision to solve the problem of lack of access to appropriate technology. Biosense now has 15 employees and multiple distributors across different states in India. Today, the company develops game-changing medical tools and devices are designed for and work for the Indian healthcare system. Notable examples are uChek, the Android based platform for urine and blood testing, that is helping thousands of patients manage diabetes and its complications, pregnancy related complications as well as critical liver and kidney problems. This device is built on top of the popular Android platform, and can monitor more than 17 body vitals, and is capable of providing diagnostic assistance for more than 25 medical conditions. It was developed in collaboration with the Department of Science and Technology, and Indian Institute of Technology, Bombay. “I personally got involved in this, because my friends Abhishek and Yogesh had seen the big problems in healthcare in the "real India" - in villages where they had interned as part of their MBBS course. I think there is a tremendous opportunity for technology to solve big problems - and even do so profitably and sustainably,” says Ingawale. He is currently also involved with a non-profit organisation called the Inter Institutional Inclusive Innovation Center - I4C - set up under the guidance of the Governor of Maharashtra. “I am trying to address the challenge of how we can get our engineers and designers to work with success on big problems, and encourage, nurture, promote inclusive innovations that can benefit large sections of society. Last year, this initiative promoted 150 innovators from across the country. The Expo organized by this organisation - called the Inclusive Innovations Expo, was the largest of its kind in India - and attracted more than 1,50,000 visitors,” says Ingawale. Several social entrepreneurs have pointed out quacks as one of the biggest problem in Indian healthcare sector. Mention this to Myshkin and he begs to differ. “Quacks have been a problem earlier. However, increasing education levels are to some extent making a difference. In many areas the problem remains strong, however, I can see already that in other areas, people have grown sceptical, and are moving to evidence-based medicine. Basically - people are not stupid. A repressed, uneducated population can be fooled for large periods of time, but increasingly, increased education and media exposure are ensuring that knowledge of what is good and what is bad is out in the open, and old assumptions are being openly challenged. Again - the change will not be overnight, but I do think we will move most of India out of the dark ages in this decade.” Be it evidence based medicine or a new delivery model, getting people to understand healthcare is a step-by-step procedure is not an easy task. Ask him about this and he replies, “Healthcare is not only about doctors but also about engineering, about finance, about marketing, about quality and everything else that is interconnected to it. A successful operation depends not only on the skill of the surgeon but also on everything that preceded and will superseded it - starting from the right and timely diagnosis, the right pre-operative care, the right and high quality equipment and medication, the right post operative advice, adherence by the patient, family support and of course financing.” It’s no wonder that the non-conformist thinks that compared to US Indian healthcare sector is doing a fair job. “The best way to address the health system would be to look closely at failure - look at the problems currently facing the US, UK systems, and at the same time, look at some of the failed experiments in Africa, and learn from them. There are many good things going for us, and the Indian health system may not be perfect but to some extent, it works. So we should not be clamouring for radical changes until we have established which parts of our system are working to the best of their capabilities and which can be improved further,” concludes Ingawale. Shelley Saxena , SevaMob For someone who has been in toppers list of Ivy League institutes for most of his academic life, Shelley Saxena is appallingly simple. Post IIT and Cornell, he started a mobile technology company in 2009. The company thrived selling mobile solutions to customers and the turning point in the entrepreneurs life came, when he decided to market a knowledge base to farmers in UP. However, selling his product to sleepy little hamlets of UP soon turned out to be an uphill task. He soon figured out what was wrong with their model. The farmers were not able to operate mobile device. The trick is to give people who can explain things to them. He knew this because, when SAASMOB conducted surveys, several farmers suggested need for a primary healthcare model in their locality and their inability to use complicated devices. The first thought that crossed his mind, when he came across survey results for a mobile knowledge base for farmers in UP, was opportunity. The second was how to develop a primary care delivery model. The third thought, was how to recover the cost. Once he and his team brainstormed about this idea, they pursued this idea with gusto and eventually led to the formation of Sevamob. "The tag line of our company is transforming primary healthcare," says Saxena. He says, earnestly, "It offers primary healthcare and insurance via mobile clinics to groups on a monthly subscription model. Sevamob also offers an online health exchange that connects patients with healthcare providers.” The mobile clinics which operate in rural districts of the country are manned by BDS doctors, helpers as well as nurse practitioners. The field team offers primary care and in-case the patient needs advanced care, the doctor raises a ticket addressed to the back office or the call centre. In addition to farmers, it also offers primary care for schools, orphanages, old age homes as well as NGOs. The social enterprise approaches their customers by partnering with not-for profit organizations already present in the area. In addition to screening, field teams also offer medicine for de-worming, calcium deficiency, frolic supplements as well as multivitamins. At mobile clinics, BDS doctors are hired as skilled workforce in rural area is a huge challenge. The doctors have been given the mandate to do initial screening based on strict protocol and feed patient details in to a mobile app, and create an online as well as a hardcopy health card for the patients. Based on appointment given to them, patients can visit the back office and meet the doctor or receive referrals for meeting specialists. The customers have several subscription options, which range from Rs 150 for children and Rs600 for adults. With multiple services for their customers, Sevamob is also slowly widening its catchment area. Saxena refers to his branches in Bangalore, National Capital Region and Luknow. Most of the areas don't have a good hospital within 10 kilometre radius and the nearest hospital is at least 25 minute drive away from their location. By now the story of Sevamob has been well told, and Sevamob has won several accolades. The website of Sevamob has a list of all the honors and awards won during the last three years and a brief biography that identifies it as a platform which uses cloud, big data and mobile technology. Ayesha Chaudhury Windmill Health Ayesha Chaudhury’s rise from a Biotechnology student in Banaras Hindu University to a Stanford India BioDesign fellow can only be described as meteoric. She received her Doctoral degree in biomedical engineering from IIT Mumbai in 2010 and authored several articles in international journals. It was during this time that she developed an interest in entrepreneurship. “I wanted to be close to science and create an impact for the society. The one year fellowship with Stanford was an eye opener. Spending time in hospitals made me realize that the ground realties are very different from what is being projected and perceived. These experiences during my fellowship made me empathize with people and think towards creating a solution for their problems,” says Chaudhury. In 2011, she started Windmill Health Technologies along with her classmate Dr Avijit Bansal. It was their first innovation, NeoBreathe that won them grants from various agencies. So, how would she describe NeoBreathe? “NeoBreathe is the first innovative product from Windmill. It helps with reducing infant death. It enables paediatricians and hospital care specialists to prevent death of infants who have breathing issues. We have 800,000 infant deaths every year. And the primary reason has been resuscitation. Windmill has developed a simple to use infant resuscitator that helps infants resuscitate effectively,” explains Chaudhury. “The idea was generated as part of the structured process of the fellowship which includes three major steps-identify, invent and implement. We spent a lot of time in hospitals across India covering both primary and secondary healthcare and came up with a 500-600 observations. And as a team we had to look for solutions to address these observations. We also had collaborated with doctors to understand to identify the compelling problems, which can have an impact on the society with a simple solution. We zeroed in on the problem of “resuscitation” and finding a solution for the same,” recollects Chaudhury. “Initially there were four members working on the theme, later Avijit Bansal and I decided to continue on this and take this to market,” adds Chaudhury. At this point she also lets us in about the launch plans of her product. “The team has started working on the project two years ago, with a tag line innovating healthcare for everyone. Our product is still in the development stage. It will take another 6 months to get the final product out. And we are 1.5 yrs away from taking it to market. Our focus is towards Tier 2 and Tier 3 cities where there is a dearth of healthcare professionals providing resuscitation interventions,” explains Chaudhury. Would she call user friendly nature of her product its USP? She thinks for a minute and replies. “NeoBreathe enables new born infants to take their first breath. Our product doesn’t require extensive training. Hence it enables even the lesser trained front line health care professionals to act immediately and prevent infant deaths. For this particular problem the entire world is currently focusing on training professionals to perform a procedure. Our differentiator is design innovation rather than training.” Of course, the team has a strong marketing plan in place. “Initially our in-house sales and marketing team would be focused on point selling to specific institutions in the cities we target. We then plan to move to larger institutions in Tier 1 cities. We have had several meeting with government agencies and the response has been positive. Our product is low maintenance one and hence it has generated a lot of interest in the sector,” adds Chaudhury. The team is hoping that they should be able to scale and penetrate in all tier 2 and tier3 and tier 4 towns. “Once we have achieved the scale required we would move to the next project in terms of providing social impact,” adds Chaudhury. The company is also planning to roll out two versions of the product, one for the rural sector and the other with more advanced technology for the private sector. On pricing, she says that the device could cost between Rs5000 to Rs10, 000. “It’s too early to talk about it. But it would be in this range,” adds Chaudhury. Be it in Mumbai, Chennai or Hyderabad, several entrepreneurs often find it hard to raise funds. How did Windmill tackle this problem? “Funding was not difficult. But it was a little time consuming. It required a lot of paper-work and has huge turnaround time. We have grants from Bill and Melinda Gates Foundation which is $100,000 and also from institutions in Canada, adds Chaudhury. Besides stating that it is difficult to estimate market size in India, she also confides that it’s also tough to estimate the demand. “The other challenge is to find a team which is aligned. Finding people who are willing to work for cause and not money is difficult,” concludes Chaudhury. PR Ganapathy, COO, Villgro Villgro Innovations Foundation is one of the oldest social enterprise incubators in the country, supporting innovators and entrepreneurs during their early stage of development. Since 2001, Villgro has incubated 71 such enterprises, generated around 3803 jobs and secured Rs 200 million in funding. It has provided Seed funding and has assigned experience advisors to guide rural healthcare start-ups like Windmill Health in its customer development, helping to create its business model and expand sales, marketing and distribution. PR Ganapathy, Chief Operating Officer of Villgro, is an experienced business executive with global leadership experience. In addition to mentoring rural social enterprises in the Villgro portfolio, he also volunteers a portion of his time to help Teach for India Chennai. From an entrepreneur to COO of an incubator, it’s been a many-splendored journey for Ganapathy. However, he admits that he is still fascinated by the sector. He concedes that it is relatively easy to build a product in the IT space and take it to market. “All it takes is a good idea to be supported by a capable talent. One person can sit in his / her dorm and create IT products and take it to market through the internet. There is very less capital that is required to build a product and marketing and testing is easy because of internet. The time taken from ideation stage to going to market to getting it commercialized is very less, in comparison for the med-tech space there is whole lot of research required. This in itself takes time. After research you need to develop a product. The product needs to go through rigorous certification process. And then you take it to market for testing. Then you change the product basis the feedback and then commercialize. The whole process takes a very long time. As the product you develop in med-tech directly impacts lives, the process involved to getting it to market is very stringent. Hence it is understandable that young people who want to make quick returns will always turn to IT. Med-tech space is not for the faint hearted. It is for those who are entirely committed to making a change and impacting society. And this does take time,” says Ganapathy. He is also not averse to the idea of foreign investment in the social sector. “There has been a lot of money that has been raised through investors from foreign investors. We are seeing initial signs of this investment increasing in India. For example the Indian Angel Network has created an initiative to identify investors in the domestic sector to fund social enterprises. The reluctance in domestic sector is because of the time it takes for them to see valuable return and also time it takes to scale,” explains Ganapathy. Being part of one of the few social incubators that has been flourishing despite the odds, he enlists the criteria for funding a rural start up. “We look for 3 broad criteria. First is the team, how competent is the team and talent. Secondly we check the technology differentiation and idea and the last one is the target / market segment and competitiveness of the product or idea. On all of these 3 areas we do a thorough due diligence post which we fund the start-ups,” says Ganapathy. He is also all praise for Gen-X entrepreneurs “There are many exciting ones. In our own portfolio we have Bio-sense, Windmill Health and One-breath. We have 3 bio-tech engineers in our GIR program who are working to create low-cost glucose monitoring. Outside of our portfolio, in the health care delivery side we have been very impressed with SugaVazhvu. We have two entrepreneurs who we are interacting with who are working on foetus monitoring. We are quite happy with the level of activity and interest the youngsters are showing,” adds Ganapathy. He also adds that though they have a cap on funding, the enterprise hasn’t reached a situation where they haven’t been able to fund a good idea. “This year around 50-60 enterprises will work through our various programs and get support from us. Last year, we funded 29 enterprises,” adds Ganapathy. Talking about impact investment in India, he points out that there are 23 impact investors in India. “There is a lot of funding but there is a dearth of ideas. My message to entrepreneurs would be to work on a good idea and there is no short of funding that is available. There would be a lot of global MNC’s that would be interested in acquiring these small companies once they have a proven and scalable model. Therefore it’s an opportunity that exists and it’s a real possibility. I am seeing a trend where experienced healthcare executives are getting into this. The CEO of One-breath used to run BPL Healthcare. There are people who have worked for companies like GE Healthcare and Philips Healthcare for over 15-20 years getting into med-tech industry to create a social impact. This is a great trend which significantly increases good execution,” says Ganapathy. But what does he think is the reason for the increase in the number of the new tribe of entrepreneurs? “It’s a combination of all these things. One, more and more people want to create a meaning / purpose for their lives. Two, people are getting the confidence from their well-built careers & experience and hence are not averse to taking risks. If they fail they can always fall back on their sustainable careers. There is a lot of opportunity for funding and also high returns which acts as an additional motivation. When they get into med-tech they get a sense of satisfaction of touching many lives because what they create impacts lives directly. This is not the case if you are on a traditional work path,” concludes Ganapathy.

CODE BLUE: An investigation in to how well India is preparing for emergencies.

Nirbhaya, the young physiotherapy intern who was gang raped in a private bus in Delhi last year, became a household name in India for several reasons. Sadly, one of the reasons why she died was the delay of emergency care provided to her in the nation’s capital. Her companion had told in an interview, that passers-by did not come for their rescue for 30 minutes after they were thrown out of the bus and they lay by the road side naked and bleeding. And the police who reached the scene wasted more time by debating about jurisdiction. Today whether you are a resident of Mumbai or Assam, Kerala or Punjab, it is simply a matter of luck, whether you will get good medical care during an emergency. “There is a general lack of awareness among public and policy makers about what emergency medical care is all about. In most cases it is only understood to be an ambulance intervention, where a vehicle would be deployed,” says Piyush Tewari, founder of SaveLIFE Foundation. “Majority of ambulances are not able to provide any care to the victim. They only transport from point A to point B and are not able to stabilize the patient. The equipments or trained professional required to save someone’s life are missing,” explains Tewari. Emergency medical care is a systemic paradigm, where an entire system works towards saving a patient’s life. The chain of survival includes three major elements- What happens to the victim when he/she is lying on the road, when he/she is transported to the hospital and the care provided to victim in the hospital. Clearly, today nobody has moved the cheese when it comes to standard ED protocol or training practices for the existing workforce. “At present at most of the hospitals across the country, Emergency Medical Services are provided by MBBS graduates who work as Casualty Medical Officers (CMO) s or Medical Officers on the basis of whatever knowledge they received from their course and nurses who assist the doctors,” says Indrajith Khandekar, associate professor at Mahatma Gandhi Institute of Medical Sciences in Maharashtra. Last year, he submitted a 40 page study entitled “Emergency Medical Care in India-a cause of concern” to union and state health ministries and Medical Council of India (MCI). “Today at MBBS level there is no syllabus and university exam for emergency medical care,” adds Khandekar. Hiring of trained doctors also remains a challenge. “Majority of the hospitals in India have primitive 'casualty departments' which are manned by untrained doctors, many who are not even MBBS qualified. The biggest challenge is to get the hospitals to recruit qualified emergency medicine doctors, nurses and ambulance paramedics to take care of their emergency patients,” says Imron Subhan, a consultant emergency physician, at Apollo Health City, Hyderabad. The expert also says that acceptance of EM speciality within the hospital eco-system is still a challenge. “It takes time and effort for a new EM physician to prove that he/she is an expert in emergency care,” adds Subhan, who is also the administrator of the website According to Khandekar, an average Indian is vulnerable even after reaching the hospital during golden hour due to inadequate training in relation to emergency care. Khandekar also shares an anecdote to prove his point. “One of the patients brought to ED department of my hospital died due to incompetence of a young graduate. This is primarily because of inadequate practical emergency teaching curriculum for undergraduate students and interns prescribed by MCI. As interns they spend only two weeks at casualty during their internship period,” adds Khandekar, who had filed four PILs regarding this issue. Another source of concern for several EM physicians is that MCI has not included emergency/casualty department as academic specialty department in the list of 21 departments (as minimum requirement to run a medical college in the country). “The same is true with nursing education,” adds Khandekar. So what is the price paid by a nation of 1237 million people for the gaps in our emergency medical systems? One look at the survey conducted by SaveLIFE Foundation will tell you the whole story. The survey conducted by SaveLIFE Foundation last year states that 74 percent of bystanders are unlikely to assist a victim of serious injury irrespective of whether they are alone at the spot or in the presence of others regardless of whether there were others on scene or not. But why is it that citizens are reluctant to help victims? 88 percent of respondents who were unlikely to assist injured victims stated that they were reluctant to help for fear of legal hassles including repeated police questioning and court appearance. Interestingly, 77 percent of respondents, who were unlikely to assist injured victims, also stated that hospitals unnecessarily detain good Samaritans and refuse treatment, if money is not paid. The survey findings gain added importance in light of more than 1,35,000 deaths caused by road accidents in 2012 alone and the on-going debate that calls for a ‘Good Samaritan Law’ for India especially after the Delhi gang rape incident. No legal framework for Emergency Medical Services One strand of debate regarding emergency medicine is whether an appropriate legislation on emergency medical service can save lives. Piyush Tewari’s observation that a Good Samaritan Law can save lives of people is representative of this view. But before we inquire in to how a law can improve the quality of care, let us look in to some of the examples of countries where similar legislations have been enacted. “Many European countries with good EMS systems have a good Samaritan law that protects the citizens who help trauma victims and provides them immunity from civil or criminal liability. “In India because of the legal hassles most of the citizens are reluctant to come forward and help the victim,” says Tewari. “If we pass a law like Emergency Medical Treatment and Active Labour Act (EMTALA), which defines how emergency care is to be provided in the country to different kind of victims and create a systemic approach to trauma care, large number of people can be saved every year, “explains Tewari. Jesse Pines, professor of emergency medicine and health policy at George Washington University in Washington seconds his view. “The first thing that India can emulate is the legal framework in US that requires hospitals that accept government funding (i.e. Medicare and Medicaid insurance payments) must provide a medical screening exam and stabilize patients who present to the emergency department. EMTALA was passed in US in 1986,” says Pines. Beyond that, there is much that other can learn from the emergency care system in the US that does a great job taking care of the critically ill and injured. “However, the US is going through major reform in payments, which will make emergency departments focus more on care coordination,” adds Pines. The Law Commission of India has also taken up this issue and in its 201st report entitled ‘Emergency Medical Care to Victims of Accidents and during Medical Condition and Women under Labour’, mentioned that there is no appropriate legislation regarding the subject. It has given recommendations and a draft model bill for the purpose of emergency treatment of victims as early as 2006. Law Commission acknowledges that the state government must frame a scheme of reimbursement to hospitals, medical practitioners, ambulances and those who provide vehicles for transport. According to the draft model bill submitted by the commission the state must notify an authority which will deal with reimbursement. “The state must set apart substantial money for purpose of reimbursement. The scheme must provide for the procedure for reimbursement. This scheme must be published in State Gazette,” states the report. Numerous judgements of Supreme Court of India also reflect the fact that emergency care is part of right to life enshrined in Article 21 of the Constitution of India. The corner stone of several campaigns regarding the right to emergency medical care is the Supreme Court ruling on ‘Paramanand Katara v. Union’ of India. The verdict came on petition filed by Paramanand Katara regarding the death of a motorist severely injured in a road accident. He was refused admission when taken to the nearest hospital on the excuse that hospital was not competent to handle medico-legal cases. The apex court in its landmark judgement said that “Article 21 of the Constitution casts obligation on the State to preserve life. A doctor of the Government hospital positioned to meet this state obligation is, therefore, duty-bound to extend medical assistance for preserving life.” Then court also said that not only Government hospitals, but also “every doctor whether at a Government hospital or otherwise has the professional obligation to extend his services with due expertise for protecting life.” Initiatives to address emergency care With mounting pressure to increase emergency services, even the government has taken some concrete steps to improve the quality of care. Today, there has been an active transition from private ambulance services to public ambulances. Most private healthcare facilities realize that their earlier thought of increasing ambulance fleets to provide coverage to catchment areas is no longer a viable strategy. Most institutions have scaled back their EMS programmes as the quality and availability of public ambulances has risen. Many of these public/not-for-profit agencies have realized that it’s not just important to have the equipment, it’s more important to focus on what can be achieved with that equipment. So, while the initial challenge was building a quality ambulance, today this has transformed in to a renewed focus on paramedic and EMT education and training in India today, which is essential towards the delivery of quality pre-hospital care. The National Skills Development Council (NSDC) has been instrumental in developing criteria and scope of practice for EMS personnel in India. “Today Indian healthcare as an industry is bursting at its seams. There have been many dramatic changes in healthcare sector over the past decade and I believe many sectors in India are waking up consciously to the concepts of Emergency Medicine,” says Anunaya Jain, national service line manager of neurosciences and emergency medicine at Apollo Hospitals. Yet, it has taken the sector sometime to internalize the concept of emergency medicine. To put it in another way, part of the problem in India has always been and will always continue to be-barriers to access quality healthcare for the majority of rural population. So, while the central bureaucracy for a majority of the 1990s and early 2000s focused their energies on the daunting task of reinvigorating a dysfunctional primary healthcare system in the country, there was a parallel move by the private healthcare sector to channel their interests on delivering acute care to patients in urban and semi urban areas. “Although this did start for most institutions as a marketing exercise, it has quickly transformed in to a quality differentiator and a source of competitive advantage. Many institutions now have specific budgets allocated for development and recruitment within the Emergency Departments. Further, there are significant investments being made in to procuring technological advances from point of care testing to diagnostic imaging equipment dedicated for the EDs,” explains Jain. In theory, some of the most significant changes in the Indian EM scene have come in EM education. The Medical Council of India (MCI) approved emergency medicine as a speciality in 2009. There is also transition in both the type of specialists-development of the specialist emergency medicine physician instead of untrained MBBS or cross trained anaesthesia and critical care physicians- and the content of their training (development of comprehensive EM residency programmes instead of shorter training courses focusing on basic resuscitation skills). “There continues to be a dominance of joint residency/training programmes crafted with universities from outside of India and perhaps a dilution of the skill and competence of physicians who have practiced and developed emergency medicine at the frontlines in India itself. The introduction of DNB and MD Emergency Medicine courses should hopefully help us to course correct in that direction. Many young graduates today are more aware about the global scope of emergency medicine and pursuing this as an active career choice,” says Jain. Interestingly, it’s the desire to overcome issues of access in healthcare that gave birth to the idea of using IT in emergency departments. “While the latter half of the last decade saw an increasing focus on electronic medical records systems, there is a significantly increasing focus from the health information industry towards the development of an IT backbone to support clinical decision making and research activities within the Emergency Department, as well as resource planning and management in the EMS sector. There is also a growing focus on e-Health and Telemedicine to support outreach during medical emergencies, strategies that are perhaps essential to overcome access blocks that exist in our country,” adds Jain. Perhaps, the best way to understand emergency medicine is to see it through the eyes of those who see it most clearly- as a clinical issue. Venugopal PP, chief of emergency medicine at Malabar Institute of Medical Science (MIMS) in Calicut is a man who has experienced best and worst of trauma care in private healthcare sector. “In order to chart a better course for our future, we should focus on community based initiatives. Our laws and blind spots have created conditions that lead to the death of thousands of citizens every year,” says the physician. Through his initiative Active Network Group of Emergency Life Savers (ANGELS),Venugopal had created a network of bureaucrats, physicians, medical students and ambulatory care providers to offer pre-hospital care to the citizens. In doing so, he tapped in to the community, and led to the development of a not-for profit trust, which won several international accolades including the Asian EMS award. Today the range of services offered by ANGELS includes ambulatory care to training for volunteers as well as emergency technicians who are absorbed for the network. “The core issue at the heart of emergency medicine in India is shortage of trained professional to offer the services. Even though Medical Council of India has approved the specialty, it is still in its birth pangs. It will take at least ten years for the specialty to completely evolve,” says the deputy director of MIMS academy. Imron Subhan agrees that community based training can have a huge impact on Indian Emergency Medical Services. “In fact, the Indian Medical Association (IMA) has a 1 year part-time training program in emergency medicine targeted at doctors in PHCs and District Hospitals. Such doctors also choose to enroll for a 1 year Diploma in EM which are conducted by many other institutes,” explains Subhan. No single emergency response number Several experts also suggest that our policy makers need to take a lesson or two from west regarding emergency response number. While other countries had implemented a three-digit number to reach their emergency services several decades ago, Indians still have to call multiple numbers for police, reporting a fire or request an ambulance service. England was the initial pioneer of in 1937 after the fire brigade was unable to be promptly summoned to a 1935 fire where five women lost their lives. And the first 911 system implementation and phone call occurred in Haleyville, Alabama on February 16, 1968. “In modern systems, the level of response required is no longer decided by the call receiver, but by a set of algorithms usually found in a card set the call receiver has in front of them. The call receiver has a set of questions to ask the caller, and based on those answers the algorithm will determine what resources are actually dispatched to the call,” says Dave Koing, in his book ‘You Called 911 for What’. Sudip Bhose is an Emergency Medicine physician in the United States and also a first-generation American whose parents emigrated from India. He strongly advocates a single telephone number as one of the pillars of EM. “As a medical practitioner in some of the busiest emergency rooms in the United States, I can attest that an important aspect of effective emergency care is an EMS system with a standard emergency response phone number such as 911 in the US,” says Bhose, who is also the medical director for local Emergency Medical Services (EMS). “Educating the public through nationwide media will help citizens identify when emergency medical care is needed and publicize the standardized emergency phone number. By establishing a consistent contact number, people across the nation will know who to contact in emergencies, regardless of where they live or travel,” explains Bhose. However, one of the significant strides made by India in the healthcare sector is 108 service provided by government in association with GVK group. According to Subodh Satyawadi, CEO of GVK Emergency Management Research Institute (EMRI) the problem of emergency care to poor is a management issue rather than a medical issue and professional management of services can bring in outstanding results in India as this was neglected and unexplored area. “108 service of EMRI was started in 2005 and within a span of eight years, covers sixteen states. Unique PPP model is the back bone of the model,” says Satyawadi. The requirements of our country in area of emergency services are huge. “To ensure pan-India services with access to all without differentiation on economic grounds a robust framework of operations is essential. Such framework can only be derived from government machinery in terms of investment and continued service support requirements,” concludes Satyawadi. There are, of course those who disagree with the view and suggest some of the funds allocated for projects often do not trickle down. Having braved several challenges including indifference of some of the private hospitals during mass emergencies, the co-founder of ANGELS, PP Venugopal notes that several key schemes of government often does not reach the citizens. He also spills the beans about corruption in allocation of various projects of the government across the country. “There were several media reports about scandals related to allocation of funds for ambulance services in areas like Rajasthan. There is no miracle formula for perfect execution of emergency care. However, a legal framework might bring some order in to the sector,” says the physician. What can the west teach us? So, where should we look for answers for our questions regarding the challenges towards delivery of quality and patient centred care during medical emergencies to patients in India? Does the solution for our problems lie in western models? Today majority of physicians in the specialty of Emergency Medicine in the USA would probably not call the specialty new any longer. That is not to say it isn’t relatively new compared to pillar specialties in the medical arts such as Internal Medicine and Surgery. The specialty really began in the 1960s and as such, a generation has passed such that most of those practicing then are not now. To many who are now practicing, like Gary Starr, it seems in many ways as if Emergency Medicine is well established and even the leader in many areas. “Of course, every specialist has his or her own biased opinion,” adds Starr, an emergency medicine consultant in Greater Minneapolis. Garry was originally trained in Family Practice and then completed a second residency in Emergency Medicine. “Both specialties are ‘newer’ and are less tied to specific procedures in our fee-for-service system. In this light, Emergency Medicine as a specialty will be very challenged in the coming years as we institute major reforms in our health care system. Questions about where emergency care fits into the new payment systems will be difficult. Additionally, the common perception that emergency care is expensive and wasteful is easy to sell to the public and the politic, but is not precisely true,” says Starr. Sharing the criticism about emergency care, he says that it is often branded expensive when seen as a separate expense, but when tied together with the overall cost of a patient’s care over time, the cost of the care provided in the emergency setting can save a patient delay in diagnosis and greater cost later on. Additionally, some care must be performed emergently regardless of discussions about cost. “Finally, the emergency care system must be operable 24/7 and capable of sustaining great flux in patient volume and acuity. This is the “safety net” function. Without this capacity, emergency medicine as a specialty would be unable to adequately provide care in unpredicted disasters. This redundancy or “over-capacity” may seem wasteful at times when argument about financial efficiency takes the stage, but, much like the military we hope we never use, we can’t chose to have it after–the-fact,” adds Starr. A major challenge for EM physicians is in expressing this complex argument to the public and to our elected officials says Starr. “Telling the story of emergency medicine to someone who is not being affected by an emergency is not very effective. Telling this story will be needed though because funding in our system is quickly changing. Our emergency medical care system in the USA unfortunately also serves as our universal health care coverage system. Though the USA does not have such a system in place, the EMTALA laws guarantee the right of all persons to be cared for in the ED regardless of ability to pay. Unfortunately, the government made this mandate an unfunded one – which renders care provided to those with insurance even more expensive so as to cover the financial losses to the system. Since we are at the epicentre of this problem, it remains one of our challenges to try and help solve,” says Starr. It’s no secret that Indian healthcare can still learn few lessons from western models, though we cannot completely emulate them, say experts. “While there are strict proponents of theories that India is a different environment and no systems can be photocopied from the West and put to in place here, there are definite models that we can draw inspiration from,” says Anunaya Jain. If the most clich├ęd argument regarding delivering care in India is physician is the only person deemed eligible to deliver care, successful western models give high priority to training paramedical staff. “The Paramedic and EMT training programmes are important to implement, because a good EMS system is definitely one of the most acute gaps in our healthcare system. Strategic implementation of telemedicine and technology can definitely help to overcome our problems,” says Jain. A study of other EM models also shows that the practice of developing Advance Practice Providers can overcome the shortage of physicians in several areas. “This is especially important for a country with wide geographic variability. APPs could serve as useful front line for delivery of emergency care in rural and semi-urban areas within our country,” says Jain. Thirdly, another aspect of western emergency medicine which can be adopted here is centralization of all hospital capabilities, both private and public. EM is a key area where public-private partnership definitely needs to come to the fore. A centralized network that informs patients/EMS providers about the capabilities and availability of services at the nearest hospitals is essential in our country as well. “Every EMS service in the west has up-to-the minute information on capabilities, certifications, vacancies, ER loads, ICU beds etc for every hospital in the region. There are also routing rules that are prescribed by the state and adhered by EMS providers in these countries, which helps patients to actually get the appropriate level of care when required. Today the choice of hospital during emergencies is almost always arbitrary in our country, and often wastes significant time to get appropriate care. An example of this system has just been initiated in Kolkata. It would be interesting to see how it evolves,” adds Jain. Disaster response planning and training Undoubtedly, disaster response planning and training is also a key component of Emergency Medicine. While there has been a significant effort to develop these capabilities in India, this has not percolated down to the grass roots. Placing the issue in a larger perspective, Anunaya Jain thinks that many institutions in our country even today openly flout fire and safety recommendations. He says that in the west every staff member at every institution is keenly aware of his/her role during an emergency. “The best way to respond to emergencies is to prevent them and have a plan to prevent loss/provide care if they do arise. These exercises need to be undertaken by every healthcare institution, every economic entity and every residential facility in our country. In keeping with the above chain of thought strict regulations and their implementations especially for road safety which are given in the west need to be implemented in India as well,” adds Jain. He also cites accountability for care as one of the best practices that can be replicated in the country. “This perhaps is the Northwest quadrant need for our country, one that has high reward in exchange for high effort input. It crosses specialty barriers for our country. Mortality and morbidity reviews that have meaning, public reporting of outcomes and quality of care delivered, and developing a culture of equality between care providers are some of the essential tenets of accountability of care,” adds Jain. One way of dealing with emergency medicine, is to see it through the prism of an HR manager. As with any new employee within a company, the principal challenge for Emergency Medicine is to prove to other employees and the management that the care they deliver actually makes a difference to patient outcomes and hospitals financial measures/patient satisfaction in a competitive environment. Another challenge that goes hand in hand with this is the ability to convince hospital management to actually continue to invest in a responsive system of emergency care delivery, because every ER will fall short for its demand in about 4-6 years time. “Although not immediately apparent in private sector, Emergency Medicine in our public sector does need to project problems of the future and start to somehow convey to our population the concept of triage, and why some patients are given more priority over others,” says Jain. The country’s influential think that the emergency medicine in public sector hospitals need major overhaul. “I am a believer in the public sector hospitals and in order to improve the quality of care, agencies should invest in initiatives like Code Blue in Thiruvananthapuram,” says Tamarish Kole, president of Society of Emergency Medicine India (SEMI). SEMI conducts workshops for volunteers as well as training programmes for physicians to bridge the gap in the sector. Perhaps one of the most important events in Indian emergency medicine is the decision of Medical Council of India to approve Emergency Medicine as a specialty in 2009. After that lot of young graduates had taken up this specialty. However, experts admit that there are multiple challenges for the new specialty. “Several medical colleges rely on universities to make curriculum for EM. But as per the national board of examination is concerned, we have our national curriculum, which will be implemented from July this year. There are lot of US universities doing programmes in India, where they follow US curriculum with Indian inputs. Clearly, there is a need to constitute national curriculum,” says Kole. SEMI bats for national curriculum for EM Instead of simply expressing their angst over EM, Society of Emergency Medicine India is planning to create a comprehensive curriculum for aspiring EM physicians. “SEMI has started the process to create a national curriculum with the help of International Federation of Emergency Medicine and we will be able to finish it within six months, with inputs from various stakeholders,” says Kole. The chief mentor for this project is Prof. V Anantharaman, the Asian representative of IFEM. Nagi Souaiby, Chief Editor of Med Emergency, the Mediterranean Journal of Emergency Medicine, agrees with Kole. “It is a big challenge to design a curricula adapted to each setting. What’s applied in Europe or the USA can’t be adopted in Asian countries,” says Souaiby. But what’s it like to be an emergency physician? “As EM is a transversal specialty combining medical knowledge and performance of difficult techniques sometimes the first challenge is to train and educate people for a high level and to keep this high level knowing that when professionals become fully efficient they are a little bit old(forties) to continue having the same stressful rhythm,” says Souaiby,. “So we should have a good training early and not to wait till people acquire the experience alone. This is the case when it is fully supported by the academic corps which is not the case in many countries where emergencies are managed by juniors,” explains Souaiby. There is one more thing that Souaiby is absolutely sure of: emergency physician cannot maintain same rhythm for life. “As they approach their fifties, he or she starts to find other ways of evolution if they don’t have an academic position,” says Souaiby. But what should be the game plan for existing physicians, considering EM has already been approved by MCI? “Doctors must be able to identify and effectively treat all types time-sensitive and life-threatening emergencies including heart attack, stroke, traumatic injuries that threaten limbs, brain injuries, and more. Specialized residency training and board certification in emergency medicine will help ensure that these physicians have the skills and knowledge necessary,” says Sudip Bhose. “Equally important is training all specialists such as orthopaedists, neurologists and surgeons to respond to emergencies within their own fields in cases where a patient cannot receive all necessary treatment in the emergency room,” adds Bhose, a former Major in the US Army. Experts also point out the need for a concerted effort by the specialty to convince people about their capabilities as a medical specialty, what individuals should do to get to an Emergency room during acute medical scenarios and who should use/not use an emergency room. Changing Equations in EMS Little did Rajib Sengupta know couple of years ago, when he met his friend Tanmay Mahapatra at his house in Florida, that he would change the rules of the game. The engineering graduate from Jadavpur University was CTO of a Florida based start-up in US, responsible for the deployment of proprietary Healthcare System in the Cloud. After listening to his area of expertise, Tanmay explained his project in University of California Los Angeles which was in Public Health Research in India. He pointed out that due to vast, diverse population in comparably smaller geographic area India is an ideal place for public health research. But the lack of quality health and patient data is big hindrance for any research work. The friends soon realized that it was an issue that worth channelizing their energy and Mission Arogya Health and Research Technology Foundation was born. Rajib Sengupta came to the attention of the healthcare sector, when he launched Kolkata Medical Emergency System (KMES), which gives highly relevant emergency medical data available to all citizens irrespective of social or economic status. KMES is a real-time Emergency System that connects Sense, Reach and Care, the three cardinal principles of medical emergency care. The system is accessible via internet, SMS, phone and operated by an emergency control room. “A medical emergency system consists of three stages: sense, reach and care. The sense is to locate the nearest facilities, reach is to get to the facility under proper-care and the care is handled by the respective facilities upon arrival –often the sense and reach is seen together,” explains Sengupta “But with an unorganized and often without properly equipped ambulance services in India, these two cannot be clubbed into one. It got very evident to us that in Kolkata, the hospitals are doing a great job in the care part, but the sense and reach are the two most important aspects which are severely lagging,” adds Sengupta. According to the co-founder of KMES patients lose lot of time shuttling between hospitals during the golden hour, in search of a vacant bed. KMES provides them information regarding availability of bed in a hospital near their location either over a phone or by accessing their site. Today Kolkata Medical Emergency System (KMES model), which went live on February functions on two cardinal principles. “Instead of introducing new emergency service enhance and strengthen the existing emergency service and empower citizens for crowd-sourced quick response,” adds Gupta. Within a short span of time, KMES has bagged several accolades including the Rockefeller’s Innovation Challenge and Healthcare Innovation award by AIIMS. But what is the USP of KMES? “The USP is instead of introducing new emergency service, we will like to enhance and strengthen all existing medical emergency services, integrate them under a common emergency response centre and empower citizens with information for crowd-sourced quick response to cater critical patients within golden hour of emergency in an innovative yet practical and feasible business model,” says Sengupta. KMES has tie-ups with 15 hospitals in Kolkata and have plans to collaborate with five more hospitals. Being one of the few social enterprises also brings its share of challenges for KMES. “Convincing hospitals to join the network was extremely difficult, as several managements were worried about whether we would highlight a specific hospital by taking more money from them,” says Sengupta. In order to resolve operational hurdles, the team of KMES provides easy interfaces for partnering hospitals. “The only thing that the hospitals need is a good internet connection to be part of our network,” says Sengupta. Budgeting for an Emergency Medical System The question of what EMS will cost and who should bear the cost is indeed a highly debatable one. Defenders of state-funded EMS tell that there are numerous examples in the world that demonstrate the inability of an absolute state sponsored healthcare system. With rising inflation and shrinking employment opportunities, relying on government alone might not be a viable idea. Anunaya Jain points out that it is clear that a tiered system of healthcare delivery that thrives on public-private public partnership is the need of the hour. For instant the frontline levels of care-i.e. primary healthcare, preventive healthcare and emergency pre-hospital care would be state sponsored. This is not an impossible task. The primary reason to have this state sponsored is to remove the access block that would be born otherwise for those located in non-strategic geographies. This also means that the decision making behind hat level of care to seek for the patient is taken out of corporate hands. This would also work in favour of developing a single number for all emergency services. “The real significance of this move is that as the burden of non-communicable diseases rises in our country, it would be in our country’s economic best interest to avoid diseases as much as possible and that is why the investment on preventive healthcare,” says Jain. Then of course-the government would need to budget for developing primary healthcare centres staffed with physicians/nurses/advance practice providers who are trained in basic Emergency Medicine. “This centre would serve more as a triage centre for those who face an access bloc. A responsive EMS service would be essential to make the model work and so the government would also have to invest in developing these ambulance services and train the paramedics/EMTs staffing them. However, there is very little revenue that would actually come out of any of the above and therefore government partnered care is the answer,” says Jain. Some of the other correctives desired by experts are state regulated secondary and tertiary care facilities with a varying mix of state private equity investment. This would be essential to both minimize cost investments required at the governmental level to develop facilities of this level (freeing up resources for investment in primary care and EMS) as well as have revenue sharing arrangements based on equity sharing with private investors. The equity investment by the government would enable the government in many ways-actually buy regulated care at these facilities. The government would control the protocols of care delivery and the procedures for reporting of outcomes are followed. “Adherence to above regulations and performance on quality measures would determine payment scales for insurance companies and patients at each of these facilities. This would push the private facilities to focus on quality of care and accountability over care that is being delivered,” says Jain. It is essential for the government to control the number of facilities being opened up or being credentialed under this system to make this work. This will ensure that the Government is actually able to control development of facilities in any given area, preventing a hospital ‘arms race’ that has driven up costs of care in most developed countries. When asked about budgeting model for EMS, several experts mentioned that it is the responsibility of the state to protect the interests of the economically challenged population. A state sponsored insurance support with a co-pay component that is derived from the annual family income for each insured patient is the need of the hour. “While cost and charge controls do get placed on facilities because of the above, the economically backward classes could still potentially face challenges around receiving care. Hence the requirement to have a state sponsored insurance support (co-payment of which is a factor of the annual family income),” says Jain. “By controlling the costs and charges of emergent care at each of the facilities above, the government would more or less obviate the need for reimbursement/subsidization for care,” concludes Jain.