Technologies and Strategies for Achieving Excellence in Health care for Indian Masses

1. Technologies and Strategies for Achieving Excellence in Health care for Indian Masses V. M. Katoch, MD, FAMS, FNASc, FASc, FNA NASI-ICMR Chair on Public Health Research at RUHS, Jaipur Former Secretary, Department of Health Research, MOHFW, GOI and DG, ICMR, New Delhi B-16, GovindMarg, Jaipur-302004 Email : vishwamohan_katoch@yahoo.co.in

2. Access to Health Services in India in an Equitable and Affordable Manner • Health has been accepted by all member countries of WHO including India as a basic human right. • Our Constitution also has provisions and commitment for the same. • Adoption of Bhore Committee Report (1946) in 1952 • Mudaliar Committee ( 1959-61) • The Declaration of Alma-Ata , September 1978 called upon all member countries to provide Primary Health care to its citizens • National Rural Health Mission ( 2005) followed by National Urban Health Mission ( 2013/2015) ; National Health Mission ( 2013/ 2016); Universal health coverage ( 2011/ 2016), are the efforts made by the Government of India during last 10-12 years to strengthen the access to Health Services

3. Alma-Ata Declaration • Alma- Ata declaration (WHO 1978) stated: • “1. The Conference strongly reaffirms that health, which is a state of complete physical, mental and social well being, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many social and economic sectors in addition to the health sector. • II . The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries”

4. India : Spirit of Bhore Committee (1946) Recommendations • Nobody should be denied access to health services for his inability to pay' and that the focus should be on rural areas. • The Bhore Committee observed ,"If it was possible to evaluate the loss, which this country annually suffers through the avoidable waste of valuable human material and the lowering of human efficiency through malnutrition and preventable morbidity, we feel that the result would be so startling that the whole country would be aroused and would not rest until a radical change had been brought about." • The Bhore Committee provided the outline for setting up an organized public health system in India and it was deeply inspired by the welfare state movement and socialist developments in different countries at that time

5. Major efforts by Govt of India • The National Rural Health Mission - NRHM (2005-2012)was a major initiative of Government of India to improve rural health by focusing on access to primary health care, this also had supplementary strategies including regulation of Private Sector to improve equity, and ensure availability of quality services at reasonable cost • NRHM and NUHM are important subcomponents of comprehensive National Health Mission ( 2016) which aims at achievement of universal access to equitable, affordable and quality health care services that are accountable and responsive to people’s needs

6. Universal Health Coverage • During 12th five year plan, an High Level Expert Group ( HLEG) was constituted by Govt of India under the chairmanship of Prof Srinath Reddy. • Report of this group submitted in 2011 provides the vision for universal health coverage by the year 2022. This is in conformity with goal enunciated by WHO of all people receiving health services that they need without financial hardships when paying for them. • Universal Health Coverage : Vision 2022 ( Govt of India, Health Portal 2016) commits about guaranteed access to primary health care. • While there has been continued commitment of successive governments, the real issue / differences lie in the approaches to achieve the same.

7. Health Care in India – Current Scenario • In the area of health care India has achieved major successes during the last seven decades of post-independence period. • Today our country has world class institutions in both government and private sector which provide excellent health care. • Impact of this progress is reflected in many a health standards, health indicators and also emergence of India in health care tourism. )

8. Gap- The Dark Side • Our success is patchy and many sections/ sub-sections of our society live in very poor conditions with limited access to modern health care that is available to other Indian citizens in well developed states and good cities. • All of these problems are old, persisting and were identified & some solutions prescribed more than 70 years back in Bhore Committee Report. • Most of us are aware of reasons about the current state of affairs – we need to act.

9. March towards Excellence in Health Care • Several states such as Kerala, Tamil Nadu, Himachal Pradesh achieved good health care indicators several years back – which shows problem with access rather than knowledge and education. • States which have done comparatively better are thinking of achieving excellence as is evident from the report of committee constituted by Govt of Himachal Pradesh which was led by Prof Bhan. • State Health Commission Report ( Prof Bhan - Chairperson, Prof Prof V Paul, Prof Raj Bahadur, Prof Sharma and several other eminent persons) stated - Given its policy and the socio-political moorings, Himachal has a true opportunity to emerge as a State with an affordable, sustainable Universal Health Care model (outside the Nordic countries). • Others States - Kerala, Tamil Nadu, Maharastra, Gujarat, Goa, West Bengal etcare also attempting to achieve excellence

10. Key Principles Emphasized by Bhan Committee i. Universal coverage of a reasonably comprehensive package of primary, secondary and tertiary healthcare without financial hardship or point of care payments. ii. Clinical excellence at all levels of care iii . Clear focus on the emerging chronic diseases (in particular, hypertension, diabetes, cancer, accidents) in addition to family health and communicable diseases iv. Public health action to address modifiable social determinants of health v. A measurement and accountability framework that drives coverage, quality, equity, innovation and impact. vi. Implementation research as a source of problem-solving and of innovation in reaching the hard to reach.

11. Important Elements of Strategy Recommended by State Health Commission (Bhan Committee) • Address residual maternal & child mortality through high quality emergency obstetrical & neonatal care, and better performance at primary health centres, sub centres & home care. • Address the unmet need for detection, treatment and follow up chronic diseases that are amenable to detection and readily treatable such as hypertension and diabetes. • Demonstrate integration of disease marker and risk factor surveillance with clinical care excellence and take agenda beyond MCH to cover chronic diseases • Achieve clinical excellence with effective secondary prevention • Entail most effective incorporation of point of care diagnostics and technologies at all levels

12. Comparison with Globally best • Excellence has to be targeted at all levels. • Best among our institutions have to compare themselves with globally best in terms of best cost effective technologies, infrastructure and human resource. • Same has to percolate downwards strictly according to local/ regional needs . • Actions have to be targeted to achieve health standards given priority at a given point of time.

13. Health Care standards • Several health care standards developed by WHO, Governments of various countries, as well as NGOs are available currently. • Health Standard Organization (HSO) offers more than 100 standards which can be customized according to needs of countries or regions within them. • The WHO Indicator Metadata Registry (IMR) is a central source of metadata of health-related indicators used by WHO and other organizations • WHO registry uses a Standard set of 100 indicators prioritized by the global community to provide concise information on the health situation and trends, including responses at national and global levels

14. Classification of Health Standards • Health Status Indicators :The list includes about 30 indicators such as life expectancy, fertility rate, neonatal mortality, MMR, suicide rates, rates pertaining to diseases like HIV, TB, Malaria, Hepatitis, NCDs including Cancer • Risk factors indicators : These include about 25 indicators such as birth weight, breast feeding and its initiation, anemia, child hood obesity, stunted/ malnourished children under five, tobacco and alcohol consumption, salt intake, BP/ Blood sugar levels in selected population groups, access to safe drinking water, air pollution levels etc. • Service coverage indicators : These include data about antenatal, delivery and postpartum services, immunization, care seeking and provision for management of pneumonia, diarrhea, special supplementations, HIV, TB and other services. • Health Systems : Access and utilization; bed density; human resources; training; expenditure on health by Government (% GDP); head counts pertaining to out of pocket expenditure, catastrophic expenditure, impoverishing expenditure etc.

15. Strategies to Improve Access to Services • Adequate infrastructure and Human Resources : Availability and proper deployment important are limitations. • Improve the access to appropriate technologies and expertise in the periphery and at other levels. • Innovation and adaptation of relevant technologies (preventive, promotive and curative) as well as appropriate strategies to make them available to all categories of Indian masses living under different geographical settings. • Rapid development and deployment of many a point of care technologies for mother and child care, infectious diseases and various non-communicable diseases can improve the situation very fast. • Strategies will need to address the issue of selection methods like through Health Technology Assessment System(s), financing, deployment, impact assessment and evidence based changes.

16. Point of Care (POC) Technologies – Some Examples

17. POC for India – Rural Centric and Geographically Sensitive POCs are relevant to • provide access to health monitoring and assessment technologies to people with limited or no healthcare facilities, • geographically distant or difficult to physically access facilities. • While developed countries may find POC technologies an effective means for reducing healthcare costs and improving efficiency, these are critical in the provision of diagnostic and monitoring healthcare needs in countries with large populations or rural areas. ( Dhawan et al 2015) POCs are thus very important in the forward march of India towards achieving excellence.

18. Point of Care (POC) Technologies • POC healthcare technologies (including sensor- and biomarkers-based POC diagnostic technologies; therapeutic and rehabilitation devices; and information and communication technology (ICT) with mHealth, eHealth, and health monitoring with POC decision support systems) are expected to impact patients, support staff, community center workers, and nurses, among others. • The users of POC need to become comfortable, to varying degrees, with technology usage and local decision-making. • Physicians, other users, public health people and administrators will also need to become conversant in the broad spectrum of data integration, mining and interpretation.  (Current and Future Challenges in Point-of-Care Technologies: A Paradigm-Shift in Affordable Global Healthcare With Personalized and Preventive Medicine Dhawan et al. IEEE J TranslEng Health Med. 2015; 3: 2800110 Published online 2015 Mar 5. 

19. POC’S for Infectious Diseases • Synthetic biology-based approaches may overcome diagnostic obstacles in infectious disease and improve health outcomes. (Synthetic Biology-Based Point-of-Care Diagnostics for Infectious Disease. Wei TY1, Cheng CM. Cell Chem Biol:. 2016 Sep 22;23[9)]1056-66). • Portable, robust and inexpensive electrochemical magnetic microbeads-based biosensor (EMBIA) platform for PoC serodiagnosis of infectious diseases caused by different types of microorganisms (parasitic , protozoa, bacteria and viruses ). Electrochemical magnetic microbeads-based biosensor for point-of-care serodiagnosis of  infectious diseases. Cortina et al.Biosens Bioelectron :.2016 Jun e15;80:24-33. • eNose : Rapid detection of the most relevant bacteria causing wound infections, differentiating MRSA from MSSA utilizing gaseous headspace sampling with an eNose. (Electronic Nose in the Detection of Wound Infection Bacteria from Bacterial Cultures: A Proof-of-Principle Study. Saviauk et al. Eur Surg Res.2018 Jan 10;59(1-2):1-11.)

20. POC for Infectious Diseases with focus on Field Applications • Digital PCR (dPCR) is an emerging technology for genetic analysis and clinical diagnostics (Digital PCR using micro patterned superporous absorbent array chips. Wang et al. Analyst.2016 June 21 ; 141 (12) 3821-31). • Indigenous H1N1 reagents including a small portable real time PCR suitable for small settings developed (ICMR/DBT funded project) • The smart phone can concurrently monitor multiple amplification reactors and analyze the recorded data. Our smart cup's utility was demonstrated by amplifying and quantifying herpes simplex virus type 2 (HSV-2) with LAMP assay in our custom-made micro-fluidic diagnostic chip. (Smart Cup: A Minimally-Instrumented, Smartphone-Based Point-of-Care Molecular Diagnostic Device. Liao SC et al. . Sens Actuators B Chem.2016 Jun 28;229:232-238). Such platforms are available for many infectious diseases, and can be easily developed for others including emerging/ reemerging diseases like typhus fever.

21. Technologies to Improve Access in Infectious Diseases • Paper-based ELISA - an innovative point-of-care diagnostic tool to rapidly detect E. coli, and possibly other pathogens. Such systems can be customizedfor other pathogens. (Paper-based ELISA to rapidly detect Escherichia coli. Shih et al. Talanta. 2015 Dec 1;145:2-5. ) • Mobile phone based ELISA (MELISA). Zhdanov et al. Biosens Bioelectron.2018 Apr 30;103:138-142. doi: • Line probe assays being used drug resistance in TB, leprosy and other diseases. • TrueNat, an indigenous system developed from Bengaluru, tested in 100 districts and found to be robust for detection of tuberculosis and drug resistance, shown to be feasible at Microscopy Centres level. • Such systems for hepatitis, fevers, diarrhea etc can become easy to use tools for diagnosis and also to deal with outbreaks

22. Technologies for Nutrition related problems • Lab-on-a-chip (LOC) technologies are enabling an increasing number of biochemical reactions at the point-of-need (PON) settings, and can significantly improve the current predicament in nutrition diagnostics by allowing rapid evaluation of one's nutritional status and providing an easy feedback mechanism for tracking changes in diet or supplementation. ( (Personalized nutrition diagnostics at the point-of-need. Lee et al. Lab Chip. 2016 Jul 7;16(13):2408-17.) • A new test for detection of pathogens in food that is potentially useful for public health for screening of food for safety (diarrhea and food poisoning pathogens) – system developed by NIN-ICMR • Tests for vitamin A, ferritin, iodine etc which are applicable to field situations have also been developed by NIN-ICMR and can be part of public health interventions/ monitoring by state.

23. POC Technologies for NCD’s • Electrical biochips can be used to both manipulate and sense biological entities, as they can have several inherent advantages, including on-chip sample preparation. (Electrical Chips for Biological Point-of-Care Detection. Reddy et al. Annu Rev Biomed Eng.2016 ; 18 :329-55). • Arrays of chip-integrated silicon photonic sensors, are suitable for simultaneous detection of eight cancer biomarkers in serum in a relatively rapid (1 hour) and fully automated antibody-based sandwich assay. (Multiplexed cancer biomarker detection using chip-integrated silicon photonic sensor arrays. Washburn et al. Analyst. 2016 Sep 21;141(18):5358-65). • New versions of lateral-flow paper chromatography and microfluidic immunosensor, which are considered the most practical POCT biosensor platforms (Current Technologies of Electrochemical Immunosensors: Perspective on Signal Amplification. Cho et al. Sensors (Basel).2018 Jan 12;18(1). pii: E207. doi: 10.3390/s18010207.) • Lab-on-a-chip (LoC)-based platforms developed for CVD and cancer biomarker sensing and analysis (Lab-on-a-Chip Platforms for Detection of Cardiovascular Disease and Cancer Biomarkers. Wu et al Sensors (Basel).2017 Dec 17;17(12). pii: E2934. doi: 10.3390/s17122934.)

24. Women Health Related Issues Screening for Cervical Cancer • Magni-visualizer as a visual screening tool for cervical cancer screening in the field. This equipment developed by Parashari et al at ICPO –ICMR is a low cost and useful light as well as magnification equipment. • VIAM can be used in place of colposcopy as it has a higher sensitivity (95 vs. 85%) and comparable specificity (78 vs. 79%) to colposcopy for detecting high-grade CIN. The same holds true for all grades of CIN (93 vs. 84% sensitivity and 83 vs. 83% specificity) as well ( Aggarwal et al Arch Gynecol Obstet (2011) 284:397–403 ). • Sensitivity to detect CIN-II and higher lesions was 88.3% vs 86.7% that of colposcopy ( Singh et al J Gynocol Oncol 2014;25:282–6. • Sensitivity and specificity of visual inspection by Magnivisualizer comparable to cytology (Parashari et al. Low-cost technology for screening uterine cervical cancer. Bull World Health Organ 2000;78:964–7).

25. Other POC Technologies for Women’s Health • DNA-functionalized nanoparticles, paired with surface-enhanced Raman spectroscopy (SERS) for rapid detection of microRNA- MicroRNA-17 (miRNA-17) as a potential epigenetic indicator of preeclampsia ( Development of a miRNA surface-enhanced Raman scattering assay using benchtop and handheld Raman systems. Schechinger et al J Biomed Opt. 2018 Jan;23(1):1-11.) • Microchip ELISA that detects HE4, an ovarian cancer biomarker, from urine using a cell phone integrated with a mobile application for imaging and data (Microchip ELISA coupled with cell phone to detect ovarian cancer HE4 biomarker in urine. Wang et al analysisMethods Mol Biol. 2015;1256:111-21. • A simple diagnosis system for screening cancer by way of a blood test utilizing a miRNA 21 based biomarker with a complementary molecular beacon probe. (Microfluidic device for novel breast cancer screening by blood test using miRNA beacon probe. Salim B et al. Biomed Microdevices.2017 Sep 30;19(4):89. doi: 10.1007/s10544-017-0230-z.)

26. Technologies relevant for Child Health : perinatal, neonatal problems • Electrochemical POC devices can measure fetal lactate reliably. StatStrip Lactate showed a closer correlation and concordance with laboratory reference method. (Suitability of POC lactate methods for fetal and perinatal lactate testing: considerations for accuracy, specificity and decision making criteria. Orsonneau JL et al. Clin Chem Lab Med. 2013 Feb ; 51 (2):397-404). • StatStrip Lactate and Lactate Pro can be used as a lactate POCT device for obstetric use. (Comparison of two point-of-care testing (POCT) devices for fetal lactate during labor. Heinis AM et al Clin Chem Lab Med.2011 Sep 29;50(1):89-93) • Medical device to address neonatal hypothermia (AIIMS , IIT and Stanford University collaboration ) – Balram Bhargava and others • ICMR funded development of solar battery operated baby warmer • Therapeutic hypothermia (TH) service and a related cooling register established ( Establishing a hypothermia service for infants with suspected hypoxic-ischemic encephalopathy. Saliba E et al Semin Fetal Neonatal Med. 2015 Apr;20(2):80-6).

27. Geriatric Health • India has a increasing aging population. • Because of migration of younger generation for careers and also changing norms of family ties, we need to find solutions so that aging/ aged people remain self –reliant to the maximum extent. • Tools should be available at subcentre/ PHC level to detect and guide management for various nutritional problems, Osteoporosis, NCDs, mental health problems and other problems associated with aging. • Nursing home/ specialized hospitals approach has been found to be wanting on many counts – morbidity and mortality due to infections very high in the west.

28. Molecular Techniques

29. Strategies for Genetic Analysis • Single gene mutations – several methods including SSCP, PCR-RFLP, hybridization and sequencing • Sanger sequencing, an accurate and sensitive approach, allows for the identification of potential novel variants, it is however limited by the single amplicon being interrogated. • Both RT-PCR and microarrays are efficient approaches for quantitative and qualitative profiling of gene expression changes , but are limited to the genes present on the array or being assayed. • Next-generation sequencing (NGS) technologies – excellent for searching for therapeutic targets and genomic markers for novel clinical applications - hereditary disorders , risk screening for hereditary cancers and therapeutic decision-making for somatic cancers within affordable cost to middle class and above. Clinical Next Generation Sequencing for Precision Medicine in Cancer. Ling Dong et al. Curr Genomics 2015 Aug; 16(4):253-63

30. New Generation Sequencing Technologies • Whole Exome sequencing (WES) : The whole exome represents the complete coding region of the genome, estimated to encompass only approximately 1-2% of the genome, yet contain approximately 85% of disease-causing pathogenic variants, found to be quite useful in identifying new genes associated with rare diseases, cancers. • Whole-genome sequencing (WGS) : Complete elucidation of the genomic determinants of a patient’s heritable make-up, and thus is the most comprehensive tool for future clinical application. • A human genome can be sequenced at 30x coverage under $1000.

32. Mycobacterium chimerae: New pathogenic mycobacteria1st report from India Sequences producing significant alignments: Score (Bite) E Valuegi|90654487|gb|DQ437715.1|Mycobacterium sp. W 16S ribosomal RNA 511 4e-142 gi|88595998|gb|DQ381736.1| Mycobacterium sp. FI-05334 16S rib... 511 4e-142 gi|29150188|emb|AJ548480.2|MCH548480 Mycobacterium chimaera 511 4e-142 gi|57545018|gb|AY859025.1| Mycobacterium chimaera strain MAIS... 511 4e-142 gi|57545017|gb|AY859024.1| Mycobacterium chimaera strain MAIS... 511 4e-142 gi|57545016|gb|AY859023.1| Mycobacterium chimaera strain MAIS... 511 4e-142 gi|57545015|gb|AY859022.1| Mycobacterium chimaera strain MAIS... 511 4e-142 gi|57545013|gb|AY859020.1| Mycobacterium chimaera strain MAIS... 511 4e-142 gi|57545012|gb|AY859019.1| Mycobacterium chimaera strain MAIS... 511 4e-142 gi|27733763|gb|AF547939.1| Mycobacterium intracellulare strai.. . 511 4e-142 gi|27527618|emb|AJ536036.1|MIN536036 Mycobacterium intracellular 511 4e-142 1 2 3 4 5 M BLAST Search Results 500bp 439bp 400bp 200 150 100 50 Gene amplification – restriction analysis of mycobacterial isolates targeting hsp 65 gene region digested with Hae III Lane 1 Lane-M.avium (reference strain), Lane 2- M.chimerae (patient isolate), Lane 3-4 M.interaceluulare (reference strain), Lane5- Uncut (439 bp), Lane M- molecular weight marker

33. Use of Microarrays in Cancer : Historical perspective • High-throughput gene expression profiling (GEP) using microarray technology was developed about 20 years ago Schena et al.Science 270:467-470, 1995 ; Augenlicht et al. Proc NatlAcadSci USA 88:3286-3289, 1991 • GEP has helped to improve the classification and prognostication of non-Hodgkin lymphomas (NHL) as well as improved our understanding of their pathophysiology and response to new therapeutics. Gene expression profiling in non-Hodgkin lymphomas. Song JY et al. Cancer Treat Res. 2015;165:97-123). • Refinement of the technology and analytical approaches has enabled us to routinely evaluate practically the entire transcriptome at a time.

34. DNA chip for studying the genes encoding efflux pumps in M.tuberculosis *A microarray encoding efflux pumps of M.tuberculosis prepared at JALMA. *Ten efflux genes were found to be over expressed , eight identified for the first time. * Higher transcription levels, correlation with blocking the entry of drugs, observed with Isoniazid, Ethambutol, Aminoglycosides and Fluroquinolones Array of efflux pump genes

35. DNA Chip of M.tuberculosisconsisting of 62 genes of efflux pumps, membrane permeability & transcription in a MDR strain One reported for the first time from JALMA A: Labeled control, B: FQS resistance associated gene, C: ABC family efflux pump Unhybridized A B C Hybridized 2 genes found to be over-expressed with Ofloxacin, one reported for the 1st time from JALMA

36. Genomics as a guide to treatment of Lymphomas • In follicular lymphoma, gene expression profiling showed that the host immune response to tumors is an important determinant of outcome and can strongly predict survival at the time of diagnosis. • The application of immunologic therapies that modify the host immune response could have a major effect on survival in patients with follicular lymphoma. • Gene expression profiling and outcome prediction in non-Hodgkin lymphoma. Dave S, Blood Marrow Transplant.2006 Jan;12(1 Suppl 1):50-2).

37. Use of New Technology – Example of Gene Panels • The actionable gene panels are collections of well-studied actionable genes that are commonly involved in several diseases. Most of such panels interrogate somatic mutations to aid in • therapeutic decision -making. • risk of development of inherited diseases including cancers, • to diagnose suspected genetic diseases. • More than 332 cancer panels from 120 laboratories, one third of which are available in commercial set ups – mostly developed and being used in developed world. • Some panels for hereditary diseases available with Next Generation Sequencing (NGS) strategy are potentially useful in disease diagnosis and classification. • Manifestation of diseases is also known to be influenced by local genetic/ epigenetic influences – developing countries must assume role/ partnership for such discovery, innovation and translation.

38. Application of NGS to cytology specimens • NGS can be reliably applied on cytology specimens with high degree of sensitivity, specificity and reproducibility. • Colon and Lung Cancer panel has been applied for the detection of targeted gene mutations using 38 lung adeno carcinoma cytology specimens. (Molecular typing of lung adenocarcinoma on cytological samples using a multigene next generation sequencing panel. Scarpa et al  PLoS One . 2013;8(11):e80478. doi: 10.1371/journal.pone.0080478) • Thyroid Cancer : NGS sequencing on FNA samples successful in 98%, suggesting that the vast majority of FNA samples should be amenable to such analysis (Targeted next-generation sequencing panel (ThyroSeq) for detection of mutations in thyroid cancer.  Nikiforova et al J. Clin. Endocrinol. Metabol 2013;98(11):E1852–E1860) • Pancreatic Cancer : Excellent results with cytology specimens

39. Innovations in Technologies for Emergency Care Services

40. Emergency Care Services • POC echocardiography should be an important part of the algorithm in young patients presenting with chest pain and abnormal vital signs that do not improve with supportive measures .(Point of Care Echocardiography in an Acute Thoracic Dissection with Tamponade in a Young Man with Chest Pain, Tachycardia, and Fever.Carmody et alJ Emerg Med.2016 Aug 29. pii: S0736-4679(16)30374-2. doi: 10.1016/j.jemermed.2016.06.046. [Epub ahead of print] • Pocket-Echocardiography Integrated Mobile Health Device Assessments in Modern Structural Heart Disease Clinics. Bhavnani SP et al, JACC Cardiovasc Imaging.2017 Sep 9. pii: S1936-878X(17)30721-0. doi: 10.1016/j.jcmg.2017.06.019. • Transthoracic echocardiography (TTE) may detect thoracic aortic pathology. (Point-of-care focused cardiac ultrasound for the assessment of thoracic aortic dimensions, dilation, and aneurysmal disease. Taylor et al Acad Emerg Med.2012 Feb;19(2):244-7) • Point-of-care abdominal Ultrasound is a promising modality to improve patient care in emergency and critical care settings. (Overview of point-of-care abdominal ultrasound in emergency and critical care. Kameda T, Taniguchi N . J Intensive Care.2016 Aug 15;4:53. doi: 10.1186/s40560-016-0175-y. eCollection 2016).

41. Emergency services – cardiac, stroke, trauma • With minimal training, paramedics can use Ultrasound to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill. Pre-hospital assessment with ultrasound in emergencies: implementation in the field. Rooney KP et al World J Emerg Med.2016;7(2):117-23. • An ambulance equipped with a computed tomography (CT) scanner, point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit [MSU]) has been shown to enable delivery of thrombolysis to stroke patients at the emergency site, thereby significantly decreasing time to treatment, also useful in evaluation of head injury. (Prehospital Imaging-Based Triage of Head Trauma with a Mobile Stroke Unit: First Evidence and Literature Review. Schwindling L et al. J Neuroimaging.2016 Sep;26(5):489-93). • Thermal desorption electrospray ionization mass spectrometry, with informational support provided by an online mass spectral database, allows for early point-of-care identification of mis-swallowed oral medications in the evacuated gastric lavage contents. (Rapid point-of-care identification of oral medications in gastric lavage content by ambient mass spectrometry in the emergency room. Lee CW et al Rapid Commun Mass Spectrom. 2016 Jun 15;30(11):1295-303).

42. Enabling Systems/ Mechanisms

43. Enabling Mechanisms • Tele- ophthalmology (LV Prasad and other Institutes) • Patient screening • Appropriate referral to experts • Pediatric screening • Timely care for retinopathy of prematurity • Geriatric - Screening and referral for diabetic retinopathy (DR), glaucoma, age-related macular degeneration (ARMD), and other sight-threatening conditions. • Comprehensive vision screening and refractive error services. • Clinical Decision Support System (CDSS) for frontline workers who are technology oriented. Tablet-based CDSS implemented within primary health care systems has the potential to help improve CVD outcomes (Andhra Pradesh) • Various other telemedicine applications

44. Other Health Technologies • Mobile phone messaging (prenatal services and quitting smoking, mental health care investigated) • Short messages (SMS Short messaging services) • Multimedia messaging (MMS) • Chronic NCD’s (Diabetes and hypertension) • Innovations for diagnosis • Mobile phone messaging health care management • web-based registries • computer-based decision support systems and multifaceted health professionals in the care team

45. Knowledge Management Policy for Health • Department of Health Research, MoHFW held nation wide consultations during 2011-12 and developed a draft policy in 2013. • This policy envisages development of an efficient Health Knowledge management system for • Collection • Analysis • Dissemination • Utilization of knowledge for improving the quality of Health Services, Education and Research.

46. Knowledge Management Policy for Health • Regarding service delivery, the policy aims at empowering end user for better access by • Promoting awareness and making available updated information about services • Enriching health professionals with knowledge • Increasing accountability of health care professionals by developing a mandatory forward and back referral pathway, • Connecting remote areas by telemedicine • Efficient handling of health aspects of disasters • Efficient e-governance for records, data and analysis etc. • This Draft Policy has also guidance for strengthening education and research

47. Leadership at Medical Institutions level • Teaching and training of health professionals is key element for achieving the goals of achieving excellence and will be main expected role of medical colleges/ institutions located in different parts of the country. • These institutions need to focus on adaptation and implementation of technologies for patient care suited to different eco-systems. • Research : Innovation with focus to improve patient care, pilot testing of new technologies, generation of new knowledge for understanding the causes and disease dynamics for improving patient care and public health interventions – should be published and available in public domain. • Networking for improving academic and research standards within India and may be internationally as per felt needs.

48. Choice of Technologies • Innovations and their translation need to address true needs of people specially those with low paying capacity. • Affordable and efficient tools – for safe drinking water, air and environment, diagnostics, vaccines and therapeutics; targeting larger population segments make better business sense as well. • Vaccines, reagents, therapeutics : Have to be locally relevant –BCG protection against TB ranged from 0-80% in different parts of world. Other vaccines need to be developed & used which are relevant and effective locally, not necessarily globally. • Social behavioral research on users and providers needs top priority – there are examples of people in encephalitis affected areas not using water from deep tube wells – understanding peoples perspective, create tools for better communication as used effectively in elections.

49. Future – Key Messages • Health needs to move to central stage of expectations of people. • Health Services need to move from present chaotic style to assured care – organized referral system in which public and private players have defined roles. • For achieving excellence – we will have to go beyond – focus on testing, adaptation and incorporation of best technologies developed any where in the world, evaluated and decision taken based on cost benefit analysis by a neutral and objective system, HTAB (DHR) – NICE Model in UK etc. • For sustaining excellence – we have to be innovators of new methods (In POC -current 2.1% of global share) , new algorithms relevant for clinical and public health practices with optimum understanding of social aspects linked with health and disease. • Ultimate goal – we are healthy; world should start thinking about our innovations & models developed and our work is cited.

50. Acknowledgement • Talk dedicated to Sir Joseph Bhore and his team, many medical and public health people, scientists, administrators, persons in public and social sphere who have contributed and continue to serve the cause of public health in India