Cardiac sector in India

Dr K M Cherian, Chairman and CEO, Frontier Lifeline Hospital, Chennai, talks about the current sector of the cardiac sector, the challenges invloved and the way ahead

India has seen a dramatic change in disease burden over the last two to three decades, changing from communicable disease to non-communicable disease (NCD), with cardiovascular disease (CVD) causing the largest cause of mortality, accounting for half of all deaths from NCDs. CVD’ is the fastest growing illness in India at more than nine per cent annually. The incidence of CVDs in the age group of 25 to 69 is close to 25 per cent. The age standardised mortality in 2005 for developing countries like India was 300-450 per 100,000 whereas it was 100-200 per 100,000 for developed nations like the US and Japan.

India has progressed well in treating CVDs, with major milestones such as legalisation of brain death and transplants taking place as early as 1994. India is also one of the countries where cardiac stem cell research is progressing at a fast pace, and our country has one of the largest series of cardiac stem cell studies in the world. Work on artificial hearts, synthetic biology, biomaterials, clustered regularly interspaced short palindromic repeats (CRISPR) technology applications for cardiac care etc are progressing in our country, though some of these are at early stages. While we are technologically advanced and at par with developed nations, affordability and reaching out to wider patient population remains a big challenge.

Growth in India’s younger working population is also posing challenges we have not seen before. High stress levels, unhealthy and sedentary lifestyle, increased intake of processed foods, increased tobacco/ alcohol use etc are giving rise to other co-morbidities like diabetes, hypertension and dyslipidemia/ obesity which in turn accelerated the growth of CVDs in India and incidence of premature deaths.

The major challenges being faced in cardiac care in India are low availability of quality The future of cardiac care should have a holistic outlook treatment. There is limited availability of preventative and curative cardiac care facility across India. There is also shortage of trained doctors, nurses, technicians and specialists. In addition, with a majority of the hospitals with cardiac facilities being located in urban areas and major cities, the rest of the country is faced with no access to quality care when it comes to CVD.

Incidence of Congenital Heart Diseases (CHD) is another major threat that the country is facing. India has a high number of children with CHD and many of the parents find it difficult to treat these children due to the affordability factors mentioned above. Many acquired valvar, myocardial and vascular diseases need treatment in childhood and adolescence. Although a few paediatric cardiology centres have developed in India, the requirement of paediatric cardiac care and paediatric cardiac specialists is far in excess of what is available. There are no guidelines at present in India for uniform care or training in paediatric cardiology and surgery. As a result, a large number of patients with congenital heart disease remain untreated or partially treated. While many of them die prematurely, considerable numbers survive into adulthood with major physical limitations and causing serious complications from the perspective of health, economics and ultimate productivity of these individuals. Current knowledge and experience from established centers clearly show that most congenital heart diseases are correctable, and that early repair is the best way to achieve good long-term outcome. The challenge in India therefore, is to detect and correct all heart diseases in children before irreversible damage has occurred.

Low penetration of health insurance and lack of insurance coverage for preventive, diagnostic and outpatient care, along with affordability is posing a real threat. Affordability remains a key challenge, especially India being a country depending upon import for more than 80 per cent of our device and patented drug requirements. Lack of infrastructure for research and lack of understanding from banks, financial institutions and the investment community remains other key challenges. To address these challenges, public private partnerships (PPP) need to be strengthened in diagnostics and healthcare delivery systems. Product, process and business model innovation are already happening, but in piecemeal, and needs a more government policy led approach.

Another major challenge yet to be addressed is promoting indigenous healthcare research and providing adequate financial infrastructure for it. For example, a valve that is imported at about 25 lakhs, if manufactured indigenously, can be made available to patients at about 3 lakhs. While many patients can afford a 3 lakh valve, how many can afford a 25 lakh valve remains a big question. But the problem at hand is who will invest time and money for this and wait for five to seven years. The long gestation period involved in developing a drug or device has to be understood by the banking and financial institutions as well as the investment community, if our country has to progress on this and make healthcare affordable to all. Research is a business that can pay back handsome returns to the investor. The advantage is low capital outlay (provided the basic infrastructure is available) but the disadvantage is the long gestation period. In any usual business, returns come from the second or third year, but in case of healthcare research, it will take seven to eight years to start generating returns. This long gestation is offset by attractive returns, as evidenced by research based healthcare companies who earn anywhere between $20-55 billion (approx Rs 15,000 – 40,000 crores) in annual revenues. If research was a bad business, these companies would have been non-existent today, but the Indian mindset is yet to be adapted to long term thinking.

To address these challenges, the government has taken some drastic steps in this direction, including capping the price of stents. Majority of the medical devices and drugs are being imported. Capping of prices alone is not a permanent solution to the problem of affordability, the best thing that can happen is indigenous development of devices, implantables and drugs. Promoting indigenous research is easier said than done, but the current government is taking multiple efforts in this direction with new biotechnology strategies and policies being adopted. Providing industry status to healthcare research, building up infrastructure such as CROs and Animal Testing Facilities for drug and device development etc could go a long way to promote indigenisation of R&D. Policy level changes are required in this regard, and it is a good sign that the current government is coming up with commendable policy initiatives to support healthcare R&D in the country.

The 2017 budget has pushed for amending drug rules and ensuring that drugs are available at reasonable prices and focusses on new rules regarding medical devices, aimed at attracting investment in the sector and ensuring the reduced cost of devices. The new rules for pricing medical devices should benefit the common man, which has been clearly shown by capping the coronary stent prices (Drug eluting stents Rs 29,600 and bare metal stents Rs 7500). Finally, the ultimate way forward is to have a coordinated and concentrated effort by the government, industry and community towards improving service delivery, financing and infrastructure to provide affordable and accessible health care to reduce the growing burden of CVDs in India.

The future of cardiac care should have a holistic outlook with preventive care, rehabilitation, affordability and indigenous innovation as its main themes. We have to ultimately understand that healthcare may be an industry, but caring for the sick is never an industry. In matters of healthcare, the country should move forward with a futuristic mindset, tightly embracing the highest standards of ethics, and putting compassion and patient care as values ahead of business interests. This will have a cascading effect on the corporate and business side of healthcare, ultimately resulting in a well balanced development of social responsibility and business interests.