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Understanding the relevance of healthcare research

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India as a nation has followed the west for decades when it comes to research-based treatments. The sun is fast setting on this methodology and there is a massive need to invest in healthcare research in the country By Prabhat Prakash

“I believe in innovation and that the way you get innovation is you fund research and you learn the basic facts,” Bill Gates.

Research is the fundamental aspect that can change the way we look at things and find answers that we are seeking or provide us with other vital information that can lead to a breakthrough in technology, market, medicine, treatment and every field that it is used in.

Over the years we have looked up to the West seeking answers for the problems faced by Indians at large. Eventually we have realised that one size doesn’t fit all. We as a country need to invest in research so that we have the answers to our healthcare woes. Hence, it becomes all the more important for India as a nation to invest in clinical and technological research. In this article we seek to examine ways by which India can create a research culture in healthcare.

Scope of research and how India can gain from it

India’s healthcare scenario is quite different from the western countries. With a large and diverse population, varied demographics and socio-economic status, our healthcare problems and demands are unique. For example, (See Box 1 and Box 2). Therefore, experts feel the need to develop a healthcare ecosystem that thrives on evidence-based research for India. Dr D Nageshwar Reddy, Chairman, Asian Institute of Gastroenterology and Asian Healthcare Foundation states, “Today by and large we follow western standards in treating patients, which may not be the right way in the changed global scenario. Therefore, conducting India centric research will lead to improving standards of healthcare. For example: We at AIG Hospitals and others have observed that Indian population does not follow the western pattern of polyp to cancer sequence in Colorectal cancers. Hence for these colorectal cancer patients in India we need to develop separate SOP’s from western counterparts. Such situations are enormous.”

Ramanan Laxminarayan, Founder, HealthCube mentions “In any country, long-term growth comes from innovation and improvements in productivity, both of which are facilitated by research. Without research and innovation, India will remain a laggard in economic growth. The days of copying western products (whether in pharma or auto-mobiles) are over. India is home to many of the world’s health problems and at a scale not seen elsewhere.

Laxminarayan further adds “In cancer for instance, there is an opportunity to both study a variety of cancers but also to develop novel therapeutics and diagnostic approaches including using genomics and organoids to tackle cancer not just in India but the world over. As paradoxical as it may sound, our problems are our strength, if we choose to leverage these to create solutions that can benefit the whole world. Imagine the kind of studies we could do on mental health disorders or brain research and the value it could have to much wealthier populations! When India developed the 115E rotavirus vaccine along with the Americans, that created an opportunity to lower the cost of vaccination for everyone in the world while creating a whole industry in India. That’s the kind of progress that will take us to a $5 trillion economy.”

As pointed out by Laxminarayan and Dr Reddy, we can gain a lot from investment in research and also provide solutions to the world. We are the pharmacy of the world and even the treatments that we offer are world class with one-third of the price charged world over, finding answers to solve large healthcare problems can make us the healthcare provider of the world.

Zoya Brar, Founder and CEO, CORE Diagnostics shares, “The most common form of research is the clinical trial, which enables the testing of medical innovations on patient volunteers. The future of research though, is going to be in data. I often say that 2020-2030 will be the decade of data in healthcare, and I am convinced that this will also be the case in research.”

Brar is of the opinion that India will only gain from this wave of innovation if we solve the fundamental challenges in data curation and collation. These include federation and quality control of data and change management so that people that work with patients and healthcare information both understand the vision as well as the ethics of collecting such data. Research in India is still in infancy. Though, we have made inroads in research it is still inadequate as the funds are aren’t enough, there are not enough volunteers, lack of leadership and vision are some of the other reasons.

Investment in research

According to R&D Expenditure Ecosystem Current Status & Way Forward, India spends 0.6 per cent of it’s GDP in R&D in various sectors.* However, the research spend for healthcare is miniscule. Nevertheless, coming as a new lease of hope,the annual budget for 2020 was declared and an allotment of Rs 69,000 crore was made for the healthcare sector. But looking at the staggering 1.3 billion population in India and their need for a strong public health system,the need for more focus and investment heightens.

We as a nation need to prioritise research in healthcare as it has a direct impact on the GDP of our nation. The healthier our country, the better will be the productivity of the country leading to better GDP.

“Health research spending in India is woefully inadequate. The total budget for ICMR is about Rs1500 crore out of a government expenditure of Rs 27 lakh crore. That is 0.06 per cent of government spending! We spend as much on a single fighter aircraft as we do on the ICMR budget. This is not to say that defence is not important, but the health of India’s population is surely worth a lot as well. Even the limited spending on ICMR is used on keeping up a large base of personnel rather than funding innovative, investigator lead research. Setting up multiple institutes to satisfy political constituencies is not a good use of resources.” mentions Laxminarayan.

Comparing how a research culture is developed in India, Joy Chakraborty, COO, PD Hinduja Hospital and Medical Research centre says that abroad healthcare professional/doctors while they get trained in medicine, they get an opportunity/option to devote their time to research, education and healthcare delivery. Now when they decide to do that, they are rest assured that in a week they can see 20 patients, spend X amount of time educating themselves or teaching and spend the rest of the time in research which needs to yield results in a given time span of 2-3 years or more. But here in India, there is no such option given to doctors. In India, the economic prosperity of doctors depends on the number of patients they see while there are hundreds and thousands of patients knocking their door. Such is the state of affairs!”

Brar opines, “Each healthcare organisation should set aside, not just money but also mental and strategic resources to focus on this issue. That is the only way the human race will have a sliver of a chance of surviving all the disease pathways that the human body is creating as we speak.”

Boosting research

Research has a lot of advantages associated with it. It not only helps address pressing issues but also helps in the understanding of diseases in a better manner. It helps to secure the future with better methods of treatment helping curb the disease of in totality eradicate it.

There are other learnings from research as well, it helps create public awareness, leading to better understanding and participation in the research. It even helps address the limitations and the loopholes that may have occurred during the research itself. But effective research can be conducted if a strong ecosystem is created.

“The government needs to provide positive incentives for organisations that are investing in research. Private organisations need to prioritise this task, hire people dedicated to the job, create an inspiring vision and realistic plan and goal for the year and hand it over to the smartest in their teams to execute,” says Brar.

Hospitals such as CMC vellore, SRMC in Chennai, AIIMS, BIRAC, IITs and IKP Knowledge park in Hyderabad are some of the well-known institutes that have contributed immensely to healthcare research in India, informs Chakraborty.

Collaborating to create a culture for advanced research

Well, in recent times the government has been increasing its focus on research and is encouraging private sector players to collaborate. The government through it’s BIRAC programme is trying to create a culture of research and lead to the formation of start-ups investing in research funded by MNCs and Vcs.

Private organisations s well are investing in research based on the geography as well as the ethnicity of the diverse Indian population. There have been breakthroughs in certain fields in delivering better healthcare but this still isn’t enough to bridge gaps in making cutting edge healthcare services available to the masses.

Dr Reddy mentions, “It is not true that Indian companies are not investing in healthcare. Best example is vaccines, which have come out of research. 90 per cent of vaccines used all over the world are produced by Indian companies at affordable cost. AIG Hospitals and Asian Health Care Foundation invests large capital amounts in conducting basic research particularly with Indian context in unmet clinical needs, the outcomes of which have translated into clinical applications. However, such an effort is not noticed by public/government at large. There is need to enhance these investments in other areas such as medical molecular diagnostics, new drugs development based on comprehensive research to improve healthcare.”

Laxminarayan is of the opinion that Indian companies do not invest much in research. “That is because the returns to creating me-too products, whether in pharma or in medical devices has been easier than coming up with new innovation. However, in the absence of innovation, there is the risk of any product being undercut by a cheaper one whether made in Vietnam or China. Products in the US or the UK command a premium and higher gross margin because they embody knowledge that is difficult to replicate elsewhere in short order. We have to decide whether to be in the commodity game and be undercut on prices or in the innovation game.”

According to Brar Indian organisations are short-sighted. She further adds, “They don’t understand preparing for the future. I am extremely fascinated by the Japanese way of doing things. Their plans are often a minimum of 50 years. It is only in the context of such vastness of time that we can see the evident fallacy of not investing in research.”

The way forward

For India to be a leader in world class healthcare delivery, India needs to improve its expenditure in healthcare R&D. The government plans to allot 2.5 per cent of the GDP to overall healthcare by 2025 but how much will be allotted to research? And how does the government plan to improve research activities at institutional levels?

We are on the verge of surpassing China with the highest population in the world and with the rise of lifestyle diseases, the need of the hour is innovation in healthcare which is only possible through evidence based research that solves India’s complex healthcare problems. As digital technologies and personalised care takes precedence in healthcare, India will need to devise strategies that build a uniform research culture.

Brar adds, “Personalisation will, without doubt, make health research more meaningful to individuals. However, investing financial resources alone will not be enough. There will need to be a visionary and concerted effort to educate, inspire, and communicate the need and urgency of medical research.”

India certainly holds a lot of potential, we just need to work out the flaws which can only be achieved with combined efforts of the government and private players with participation from the public.

A letter from Dr KM Cherian, Chairman& CEO, Frontier Lifeline & Dr KM Cherian Heart Foundation

As a physician in his seventh decade of life, I am overwhelmed by all that remains to be done. The dawn of dusk has heightened my impatience and urgency. Yet, my burning passion to forge new advances in cardiac healthcare and Bio Medical Engineering are being slowly extinguished not by time but by a central government that is stubbornly apathetic to the possibility that millions could have access to better healthcare and that India could pioneer cutting-edge research. I share my plight here with the hope that my brief narrative will inspire a groundswell of support to upend a system corrupted by ineptness and indifference.

I direct Frontier Mediville, a medical science park in Thiruvallur District, Tamil Nadu that was designed to offer cutting-edge medical education and high calibre research opportunities. This initiative has enjoyed deep support from the Tamil Nadu Govt. Through collaborative ventures with colleagues in Australia and the United States, Frontier Mediville has completed challenging research designed to build and validate a bio-prosthetic valve and even an artificial heart. Likewise the ability to generate decellularised skin from animal sources. We all know large solid organs comes only from human donors (supply and demand ratio as a wide disparity, hence many patients die due to lack of donated organs. Today the stage is evolving into a time where solid organs could be manufactured using your own cells and a biological scaffold where it could be grown, example shark fin and it will be available even on a shelf)We have taken preliminary steps and unfortunately again due to ignorance on the part of regulatory bodies and other law enforcing agencies, even the licence for growing these. Stem cells have become difficult in-spite of having the knowledge and the facilities. As a primary stakeholder, I resorted to bank loans in order to personally sponsor many of these expensive research undertakings that offered so much promise to save many lives. Such borrowing was not fiscal imprudence but based on the secure knowledge that the budget for these multiphase, multi government vetted projects had already been approved and that it was only a matter of time before funds arrived. I also believed that the agreements between our central govt and foreign counterparts as binding and meaningful. However, the repeated bottlenecks posed by different central government regulatory agencies, the unreasonable feet dragging and the lack of transparency in decision making at the highest bodies have collectively precipitated a crisis with banks threatening to tighten the noose of liquidation on Frontier Mediville being the 1st SEZ and 1st basic medical science park in India located in a village. For a researcher-physician on the cusp of major advances not just for India but for peoples of the world, my colleagues and I are deeply disappointed that our intellectual leadership and expertise are nullified by our central govt that is oblivious even to a “MAKE IN INDIA” advance at the highest echelons of medicine. No pain stings more than that of abandonment.

I do not want my waking hours to be consumed by bureaucratic skirmishes and deprive my much needed presence at the surgical theatre or research laboratory. But I seek lasting solutions to ensure that injustices that I have suffered do not recur. While there is no judicial recourse to the neglect of its own citizenry by a govt, I also know that nothing is more powerful than the voice of the people.

“I am of the opinion that my life belongs to the community, and as long as I live, it is my privilege to do for it whatever I can. I want to be thoroughly used up when I die, for the harder I work, the more I live. Life is no ‘brief candle’ to me. It is a sort of splendid torch which I have got hold of for a moment, and I want to make it burn as brightly as possible before handing it on to the future generations.”~George Bernard Shaw

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