Medistat Outlook, India Q2 2011[1]

India Medical Device Market

Intelligence Report

Quarter II 2011

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A World Medical Device Market Report

ISSN 2043-9792

© Copyright 2011 Espicom Business Intelligence

All rights reserved. No part of this publication may be reproduced or used in any form or by any means graphic, electronic or mechanical, including photocopying, recording, taping or storage in information retrieval systems without the express permission of the publisher.

Every care has been taken to ensure that the information contained in this report is correct. The publisher accepts no liability for decisions made on the basis of information contained herein.

British Library Cataloguing in Publication Data.

A catalogue record for this report is available from the British Library.



MEDICAL OUTLOOK INDIA

Medical Outlook © espicom BUSINESS INTELLIGENCE

Quarter II 2011 i

Contents EXECUTIVE SUMMARY .......................................................................................................................... 1

Introduction ............................................................................................................................................. 2

MEDICAL DEVICE MARKET ANALYSIS ................................................................................................ 3

Overview .................................................................................................................................................................... 3

The Market in 2011 .................................................................................................................................................... 4

Past Performance 2006-10 ........................................................................................................................................ 7

Future Performance 2011-16 ..................................................................................................................................... 8

The Indian Market For Consumables ....................................................................................................................... 12

The Indian Market For Diagnostic Imaging Apparatus ............................................................................................. 14

The Indian Market For Dental Products ................................................................................................................... 16

The Indian Market For Orthopaedic Products .......................................................................................................... 18

The Indian Market For Patient Aids ......................................................................................................................... 20

Imports ..................................................................................................................................................................... 22

Consumables ......................................................................................................................................................................... 23

Diagnostic Imaging ................................................................................................................................................................. 23

Dental Products ...................................................................................................................................................................... 23

Orthopaedic & Prosthetic Products ........................................................................................................................................ 23

Patient Aids ............................................................................................................................................................................ 23

Domestic Manufacturing .......................................................................................................................................... 33

Domestic Production .............................................................................................................................................................. 33

Local Manufacturers ............................................................................................................................................................... 34

Anand Medicaids Pvt. Ltd. .............................................................................................................................. 34

ASCO ............................................................................................................................................................. 34

Atlas Surgical Company ................................................................................................................................. 34

Carewell Mediproducts ................................................................................................................................... 34

Dent-Eq .......................................................................................................................................................... 34

Eastern Medikit Ltd. ........................................................................................................................................ 34

Emdin India Pvt. Ltd. ...................................................................................................................................... 34

Endolite India Ltd ............................................................................................................................................ 35

Hindustan Syringes and Medical Devices Ltd. ............................................................................................... 35

Kay & Company .............................................................................................................................................. 35

Kiran Medical Systems ................................................................................................................................... 35

Lifeline Systems ............................................................................................................................................. 35

Narang Medical .............................................................................................................................................. 35

New Life Surgical Works ................................................................................................................................ 36

Pace Devices .................................................................................................................................................. 36

Relisys Medical Devices Ltd. .......................................................................................................................... 36



INDIA MEDICAL OUTLOOK


ii Quarter II 2011

Ribbel International Ltd. .................................................................................................................................. 36

Sahajanand Medical Technologies ................................................................................................................. 36

South India Surgical Company (SISCO) ........................................................................................................ 37

SURU International ......................................................................................................................................... 37

Wadia Group (INOR Orthopaedics, Dental Products of India and Medical Microtechnology Ltd.) ................. 37

Multinational Manufacturers ................................................................................................................................................... 37

Bausch and Lomb ........................................................................................................................................... 37

Baxter International ........................................................................................................................................ 37

B. Braun .......................................................................................................................................................... 38

Becton Dickinson ............................................................................................................................................ 38

Dräger ............................................................................................................................................................. 39

GE Healthcare ................................................................................................................................................ 39

GE BE ............................................................................................................................................................. 39

Johnson & Johnson ........................................................................................................................................ 40

Philips ............................................................................................................................................................. 40

Siemens .......................................................................................................................................................... 41

Terumo ........................................................................................................................................................... 42

Carl Zeiss Meditec .......................................................................................................................................... 43

Exports ..................................................................................................................................................................... 44

Consumables ......................................................................................................................................................................... 45

Diagnostic Imaging ................................................................................................................................................................. 45

Dental Products ...................................................................................................................................................................... 45

Orthopaedic Products ............................................................................................................................................................ 45

Patient Aids ............................................................................................................................................................................ 45

Accessing the Market ........................................................................................................................... 54

Distribution ............................................................................................................................................................... 54

Medical Device Regulation ...................................................................................................................................... 54

Healthcare Analysis .............................................................................................................................. 57

Demographics .......................................................................................................................................................... 57

Population .............................................................................................................................................................................. 57

Birth Rate ........................................................................................................................................................ 58

Death Rate ..................................................................................................................................................... 58

Infant Mortality ................................................................................................................................................ 58

Life Expectancy at Birth .................................................................................................................................. 58

Public Health .......................................................................................................................................................................... 59

Causes of Death ............................................................................................................................................. 59

Communicable and Non-communicable Diseases ......................................................................................... 59

National Rural Health Mission ........................................................................................................................ 60

Malaria ............................................................................................................................................................ 61

Filariasis ......................................................................................................................................................... 62





Quarter II 2011 iii

Kala-azar ........................................................................................................................................................ 62

Japanese Encephalitis .................................................................................................................................... 62

National Leprosy Eradication Programme ...................................................................................................... 63

National Tuberculosis Control Programme ..................................................................................................... 63

HIV/AIDS ........................................................................................................................................................ 64

Cancer ............................................................................................................................................................ 64

Healthcare System ................................................................................................................................................... 65

Department of Health and Family Welfare ............................................................................................................................. 66

The Department of AYUSH .................................................................................................................................................... 68

Health Insurance .................................................................................................................................................................... 68

Health Expenditure .................................................................................................................................................. 69

Healthcare Infrastructure ......................................................................................................................................... 70

All India Institute of Medical Sciences (AIIMS) ............................................................................................... 71

Safdarjung Hospital, New Delhi ...................................................................................................................... 72

Dr. Ram Manohar Lohia Hospital, New Delhi ................................................................................................. 72

JIPMER Hospital, Pondicherry ....................................................................................................................... 72

PGIMER Nehru Hospital, Chandigarh ............................................................................................................ 72

Lady Hardinge Medical College Associated Hospitals, New Delhi ................................................................. 73

Tata Memorial Centre ..................................................................................................................................... 73

Private Hospitals and Clinics.................................................................................................................................................. 73

Apollo Hospitals Group ................................................................................................................................... 74

Fortis Healthcare ............................................................................................................................................ 75

Global Hospitals ............................................................................................................................................. 75

Max Healthcare .............................................................................................................................................. 76

Medanta Medicity ........................................................................................................................................... 76

Yashoda Hospitals .......................................................................................................................................... 76

Other Commercial Providers .......................................................................................................................... 76

Primary Care .......................................................................................................................................................................... 77

First Aid and Disaster Relief................................................................................................................................................... 78

St. John Ambulance ....................................................................................................................................... 78

Indian Red Cross Society ............................................................................................................................... 78

Healthcare for the Underprivileged, Scheduled Castes and Scheduled Tribes ..................................................................... 78

Medical Care for Remote & Marginalised Tribal & Nomadic Communities .................................................... 79

Healthcare Personnel .............................................................................................................................................. 80

DIRECTORY ........................................................................................................................................... 81

Healthcare Organisations ........................................................................................................................................ 81

Trade Code Classifications .................................................................................................................. 82

Methodology.......................................................................................................................................... 84

Sources .................................................................................................................................................. 84





iv Quarter II 2011

List of Tables

Summary Key Data Projections, 2011-2016 .......................................................................................... 2

India Medical Device Market, Key Ratios, 2011 .................................................................................... 3

Espicom Analysis of the Indian Medical Market, 2011 ........................................................................ 5

SWOT Analysis of the Indian Medical Device Market, 2011 ................................................................ 6

Projected Medical Device Market, 2011-2016 ....................................................................................... 8

The Indian Medical Device Market, 2006-16 (US$ millions) ............................................................... 10

The Indian Medical Device Market, 2006-16 (US$ per capita) ........................................................... 10

The Indian Medical Device Market, 2006-16 (% of Total) ................................................................... 11

The Indian Medical Device Market, 2006-16 (% Change) ................................................................... 11

The Indian Consumables Market, 2006-16 (US$ millions) ................................................................. 12

The Indian Diagnostic Imaging Market, 2006-16 (US$ millions) ....................................................... 14

The Indian Dental Products Market, 2006-16 (US$ millions) ............................................................. 16

The Indian Orthopaedic & Prosthetic Devices Market, 2006-16 (US$ millions) ............................... 18

The Indian Patient Aids Market, 2006-16 (US$ millions) .................................................................... 20

Medical Equipment Imports by Product Area, 2005-09 (US$000s) ................................................... 24

Medical Equipment Imports by Product Area, 2005-09 (%) ............................................................... 24

Change in Medical Equipment Imports by Product Area, 2006-2009 (%) ........................................ 26

Leading Medical Equipment Suppliers by Product Area, 2009 (US$000s) ...................................... 27

Leading Medical Equipment Suppliers by Product Area, 2009 (%) .................................................. 27

Top 20 Suppliers to the Indian Market, 2009 ...................................................................................... 28

Imports of Medical Equipment, 2005-09 (US$000s) ........................................................................... 29

Medical Equipment Import Trends ...................................................................................................... 30

Leading Suppliers, 2009 ....................................................................................................................... 31

Leading Suppliers by Category, 2009 ................................................................................................. 32

Medical Equipment Exports by Product Area, 2005-09 (US$000s) ................................................... 46

Medical Equipment Exports by Product Area, 2005-09 (%)............................................................... 46

Medical Equipment Exports by Product Area, 2005-2009 (% of Total) ............................................. 47

Change in Medical Equipment Exports by Product Area, 2006-09 (%) ............................................ 47

Leading Medical Equipment Destinations by Product Area, 2009 (US$000s) ................................. 48

Leading Medical Equipment Destinations by Product Area, 2009 (%) ............................................. 48

Exports of Medical Equipment, 2005-09 (US$000s) ........................................................................... 50

Medical Equipment Export Trends ...................................................................................................... 51

Leading Destinations, 2009 .................................................................................................................. 52

Balance of Medical Trade, 2005-2009 (US$000s) ............................................................................... 53





Quarter II 2011 v

Summary of Demographic Data .......................................................................................................... 57

Projected Population, 2011-2016 ......................................................................................................... 57

Reported Incidence of Vaccine Preventable Diseases, 2009 ............................................................ 61

Reported Malaria Incidence & Deaths, 2009 ....................................................................................... 62

Reported Kala-azar Cases & Deaths, 2010 ......................................................................................... 62

Suspected Japanese Encephalitis Cases & Deaths, 2010 ................................................................ 62

Health Expenditure by Source, Fiscal 2008/09 ................................................................................... 69

Projected Health Expenditure, 2011-2016 ........................................................................................... 69

Hospitals & Beds, 2002 ........................................................................................................................ 70

Hospital Bed Projections, 2011-2016 .................................................................................................. 70

Beds in Selected Hospitals, 2007 ........................................................................................................ 71

AIIMS Hospital Activity, 2008/09 .......................................................................................................... 71

Projected Number of Physicians, 2011-2016 ...................................................................................... 80

HS Trade Codes Used in This Report ................................................................................................. 82

HS Trade Codes, Rearranged .............................................................................................................. 83





vi Quarter II 2011

List of Charts Indian Medical Device Market by Category, 2011 (%) .......................................................................... 4

Change in the Indian Medical Device Market, 2006-2010 (%) .............................................................. 7

CAGR of the Indian Medical Device Market by Product Area, 2006-2010 (%) ................................... 7

Market Projections, 2011-16 ................................................................................................................... 9

The Indian Market For Consumables, 2006-16 (US$ millions) .......................................................... 13

The Indian Market For Consumables, 2006-16 (CAGR) ..................................................................... 13

The Indian Market For Diagnostic Imaging Apparatus, 2006-16 (US$ millions) .............................. 15

The Indian Market For Diagnostic Imaging Apparatus, 2006-16 (CAGR) ......................................... 15

The Indian Market For Dental Products, 2006-16 (US$ millions) ...................................................... 17

The Indian Market For Dental Products, 2006-16 (CAGR) ................................................................. 17

The Indian Market For Orthopaedic Products, 2006-16 (US$ millions) ............................................ 19

The Indian Market For Orthopaedic Products, 2006-16 (CAGR) ....................................................... 19

The Indian Market For Patient Aids, 2006-16 (US$ millions) ............................................................. 21

The Indian Market For Patient Aids, 2006-16 (CAGR) ........................................................................ 21

Medical Equipment Imports, 1993-2009 (US$000s) ............................................................................ 22

Percentage Change in Imports, 1994-2009 ......................................................................................... 22

Medical Equipment Imports by Product Area, 2009 (%) .................................................................... 25

Medical Equipment Imports by Product Area, 2005-2009 (% of Total) ............................................. 25

CAGR of Medical Equipment Imports by Product Area, 2005-09 (%) ............................................... 26

Leading Medical Equipment Suppliers, 2009 (%) ............................................................................... 28

Exports of Medical Equipment & Supplies, 1993-2009 (US$000s) .................................................... 44

Change in Medical Exports, 1993-2009 (%) ........................................................................................ 44

Medical Equipment Exports by Product Area, 2009 (%) .................................................................... 46

CAGR of Medical Equipment Exports by Product Area, 2005-09 (%) ............................................... 48

Leading Medical Equipment Destinations, 2009 (%) ......................................................................... 49





Quarter II 2011 1

EXECUTIVE SUMMARY

India has a huge population in excess of one billion people and a growing middle class with access to high quality healthcare. Conversely, in this geographically vast country plagued by natural disasters, the majority of the population is both rural and poor.

The Indian market for medical equipment and supplies ranks among the world‟s top 20 but, despite strong growth rates, the market remains disproportionately small with per capita spending of US$2.

High quality, high tech products are sought after, particularly in the private sector.

Future increased demand for medical equipment and supplies will come mainly from private sector hospitals and medical centres.

Detailed regulation of medical devices is still under consideration. In October 2005, a number of in vivo medical devices were added to the Drugs and Cosmetics Act, bringing them into regulatory control. New guidelines for sterile medical devices came into force on 1st March 2006. In March 2009, clarification was published, which provided a list of additional sterile medical devices to be included under the provisions of the Drugs and Cosmetics Act and Rules.





2 Quarter II 2011

Introduction

Located in South Asia, India covers a total area of 3,287,590 square kilometres, making it just over one third of the size of the USA. The country‟s 7,000 kilometres of coastline borders the Arabian Sea and the Bay of Bengal, and land boundaries are shared with Bangladesh, Bhutan, Burma, China, Nepal and Pakistan. The largest democracy in the world, India is a federal republic, consisting of 25 self-governing states, six Union Territories and the National Capital Territory.

India has a huge population in excess of one billion people. In 2009, the population was officially estimated at 1.1 billion, of whom around 61.6 million were aged 65 years and over. By 2016, the population will likely to have grown to almost 1.3 billion, of whom 81.7 million will be aged 65 years or more.

India has made particular progress in areas like information technology. The country also has one of the world‟s largest film industries, based in Mumbai (Bombay).

In 2011, India‟s GDP is estimated to be US$1,869 billion, equivalent to around US$1,555 per capita with an annual real growth rate of 9.0%.

Summary Key Data Projections, 2011-2016

2011 2012 2013 2014 2015 2016

Medical Equipment Market (Rs. millions) 120,664.9 135,036.8 151,145.8 169,307.5 189,762.5 212,393.6

Medical Equipment Market (US$ millions) 2,642.7 3,000.2 3,478.6 3,965.0 4,518.2 4,957.8

Per capita (US$) 2.2 2.5 2.8 3.2 3.5 3.8

As % of Health Expenditure 4.5 4.5 4.4 4.4 4.3 4.3

% Supplied by Imports 77.8 77.8 77.8 77.8 77.8 77.8

Population (millions) * 1,202.0 1,220.0 1,238.0 1,256.0 1,274.0 1,291.0

Growth (%) * 1.5 1.5 1.5 1.4 1.4 1.4

Number Aged 65+ (millions) * 67.3 69.5 73.0 75.4 79.0 81.7

Aged 65+ (%) * 5.6 5.7 5.9 6.0 6.2 6.3

Health Expenditure (US$ billions) 58.3 66.9 78.5 90.4 104.0 115.4

Per Capita (US$) 48.5 54.8 63.4 72.0 81.6 89.4

As % of GDP 3.1 3.1 3.1 3.1 3.0 3.0

Private (%) 77.4 77.4 77.4 77.4 77.4 77.4

Hospital Beds (000s) 841.4 854.0 866.6 879.2 891.8 903.7

Private (%) 38.0 38.0 38.0 38.0 38.0 38.0

Rate/000 0.7 0.7 0.7 0.7 0.7 0.7

Physicians (000s) 781.3 793.0 804.7 816.4 828.1 839.2

Private (%) n/a n/a n/a n/a n/a n/a

Rate/000 0.65 0.65 0.65 0.65 0.65 0.65

GDP (US$ billions) * 1,869.0 2,169.0 2,549.0 2,958.0 3,413.0 3,814.0

Per Capita (US$) * 1,554.9 1,777.9 2,059.0 2,355.1 2,679.0 2,954.3

Real Growth (%) * 9.0 8.7 8.5 8.6 8.6 7.6

Source: Department of Health, *Economist Intelligence Unit (EIU), Espicom estimates.





Quarter II 2011 3

MEDICAL DEVICE MARKET ANALYSIS

Overview

One of the world‟s fastest growing medical markets

Growing middle class population fuelling demand for high quality private healthcare

Among the top 15 largest markets by overall size but tiny in per capita terms

Local domestic producers focus mainly on low-tech medical devices; higher end devices tend to be manufactured by multinationals

Demand and growth for imports remain very strong; imports supply around 78% of the market

As the country develops, India has a growing middle class population with access to high quality healthcare in some of the best private healthcare facilities in the world. Leading business and healthcare providers are also striving to make India an international health resort, with an airport to airport concept of health tourism.

But, India is a country of extremes and developments at the top of the market are unlikely to filter through to the public health system. The vast majority of the Indian population is both rural and poor, although urban poverty is also a problem. Modern healthcare technology and western style pharmaceuticals are not even an issue for millions of people. On a national level, the Indian health system is ill-equipped to cope with the rising number of elderly and the changing disease patterns, with an average of just 0.7 hospital beds and 0.7 physicians per thousand population. India faces the continuing challenge of fighting infectious diseases like malaria, tuberculosis and leprosy alongside increases in lifestyle related problems faced by the developed world, such as cancer, cardiovascular disease and diabetes.

Imports are mainly through Indian distributors, or the subsidiaries of multinational companies. Import policies for medical equipment vary greatly depending on the product and the end-user. The Department of Health is responsible for regulating imports, as well as the domestic industry, so products which are manufactured outside India usually face higher import tariffs in addition to other obstacles. Government and charitable hospitals and healthcare institutions do not have to pay import duties, whilst there may be high import duties on products imported by the private sector.

In general, there is no import duty for specified lifesaving or sight saving equipment. Import duty of 10% is payable for specified medical equipment which is not manufactured in India, while other medical equipment is subject to duty of 20%. Imports of electromedical equipment qualify for a reduced 15% rate of duty.

India Medical Device Market, Key Ratios, 2011

2011

Market size (US$ millions) 2,642.7 as % of total health expenditure 4.5 as % of GDP 0.1 as % of world market 1.0 Supplied by imports (%) 77.8 Growth rate (%) 13.4 Per capita (US$) 2.2

Source: Espicom estimates.





4 Quarter II 2011

The Market in 2011

The Indian market for medical equipment and supplies is valued at around US$2,642.7 million in 2011. Despite strong growth rates, the market remains disproportionately small, ranking among the top 15 in the world but with per capita spending of just US$2. High quality products are sought after, particularly in the private sector, and the high-tech end of the medical device market is dominated by multinationals with extensive service networks. Indian manufacturers of good quality mid-tech products struggle with a stigma for unreliability. Indian purchasers are, however, price-sensitive and seek value for money. The market for medical supplies and disposable equipment is dominated by domestic manufacturers.

Indian Medical Device Market by Category, 2011

US$ Millions As % of Total Market Per Capita (US$)

Consumables 519.1 19.6 0.4 Diagnostic imaging 968.1 36.6 0.8 Dental products 75.9 2.9 0.1 Orthopaedic & prosthetic products 152.3 5.8 0.1 Patient aids 204.6 7.7 0.2 Others 722.6 27.3 0.6

Total 2,642.7 100.0 2.2


Indian Medical Device Market by Category, 2011 (%)

Others

27.3%

Orthopaedic &

prosthetic devices

5.8%

Patient aids

7.7%

Consumables

19.6%

Diagnostic imaging

36.6%

Dental products

2.9%






Quarter II 2011 5

Espicom Analysis of the Indian Medical Market, 2011

Demographics Rating Very Strong Trend + Comment India is the second most populous country in the world, accounting for around one sixth of

the global population.

Economic performance Rating Below Average Trend ++ Comment India is one of the world‟s fastest growing economies and is attracting increasing foreign

investment, one of its largest investors being the USA.

Healthcare expenditure Rating Poor Trend + Comment Despite increased investment in healthcare in recent years, India‟s per capita spending

remains comparatively low and healthcare insurance remains out of the reach of all but the richest sectors of society.

Healthcare system Rating Poor Trend + Comment Healthcare provision in India ranges from the most basic public sector care in rural areas

to world class private hospitals in the country‟s major urban conglomerates, attracting „health tourists‟ with high standards and relatively low prices.

Import performance Rating Strong Trend + Comment Average year on year growth between 2005 and 2009 was 13.9%, with overall growth

during the period of 68.4%. Total imports reached US$1,496.5 million in 2009.

Domestic manufacturing Rating Fair Trend / Comment India‟s medical devices industry is extremely fragmented and limited mainly to the

production of low to mid tech medical equipment and supplies.

Health policies Rating Fair Trend + Comment India‟s overall aim is for „health for the underprivileged‟. While there is still some way to

go, the government has made significant progress in recent years with help from the World Bank and other international agencies, through various health projects and infrastructure investment, particularly at the primary care level.

Source: Espicom. Ratings go from: „Poor‟, „Below average‟, „Fair‟, „Strong‟, „Very Strong‟. Trends run from „- -„, to „-„, „/‟, „+‟, „+ +‟.





6 Quarter II 2011

SWOT Analysis of the Indian Medical Device Market, 2011

Strengths Weaknesses

Potentially huge market with a growing middle class

Low per capita expenditure

Growing private hospital sector aiming to attract health tourists

Healthcare infrastructure remains underdeveloped, particularly in rural areas

Opportunities Threats

High quality, high tech products are sought after by the private sector

Lack of regulation for medical devices

Overseas aid assisted projects to improve the healthcare infrastructure

Source: Espicom.





Quarter II 2011 7

Past Performance 2006-10

The Indian medical device market continued to perform strongly, backed by solid demand, especially from the private sector, in recent years. The market size in US$ terms dipped in 2009, but this was largely due to the weakened average exchange rate for the year resulting in a dip in import value; in local currency terms however, imports have recorded positive growth each year. Much of spending is out-of-pocket, health insurance uptake remained low and the country‟s growing middle class, along with the country being a highly lucrative medical tourism destination, have been the main drivers of growth in recent years. Some of India‟s best private hospitals are of world class standard, offering modern equipment and highly trained staff, at a fraction of the cost compared to more developed countries and this has resulted in the strong rise in medical tourism.

Change in the Indian Medical Device Market, 2006-2010 (%)

-10

0

10

20

30

2006 2007 2008 2009 2010

CAGR of the Indian Medical Device Market by Product Area, 2006-2010 (%)

13.912.3

15.1

35.5

25.3

9.9

13.6

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Consumables Diagnostic

imaging

apparatus

Dental

products

Orthopaedic &

prosthetic

products

Patient aids Others Total





8 Quarter II 2011

Future Performance 2011-16

Private sector investment in healthcare has been increasing since the mid 1980s and it is expected that future increased demand for medical equipment and supplies will come from private sector hospitals and medical centres. India has a growing middle-class of around 300 million people with disposable income and increasing healthcare expectations. Around one third of these can afford to pay for good quality private healthcare and this number is growing. Companies such as Apollo Hospitals Group, Fortis Healthcare and Max India have been building hospitals equipped to a very high standard and capable of undertaking complex procedures.

The best of India‟s private hospitals aim to attract an increasing number of „health tourists‟; private patients from overseas who are able to take advantage of India‟s high standards and relatively low prices. There is certainly an opportunity in the private sector for manufacturers of high quality products that represent value for money, although competition is fierce and the high-tech end of the market is dominated by multinationals with extensive service networks.

At the other end of the scale, India has a vast rural population, for whom all but basic healthcare provision will remain out of reach for the foreseeable future. There are a number of ongoing World Bank assisted projects that aim to improve the healthcare infrastructure. While there will be some opportunity for foreign manufacturers to provide equipment, however, the low to mid-tech end of the market will be met mainly by the domestic industry.

The best opportunities for foreign manufacturers are in the private sector, particularly for high quality products that represent value for money, although competition is fierce and the high tech-end of the market is dominated by multinationals with extensive service networks. At the other end of the scale, the low to mid tech end of the market will be met mainly by the domestic industry.

Projected Medical Device Market, 2011-2016

Market (US$ millions)

Per Capita (US$)

2011 2,642.7 2.2 2012 3,000.2 2.5 2013 3,478.6 2.8 2014 3,965.0 3.2 2015 4,518.2 3.5 2016 4,957.8 3.8

Source: Espicom projections.





Quarter II 2011 9

Market Projections, 2011-16

2,642.7

3,000.2

3,478.6

3,965.0

4,518.2

4,957.8

0

2,000

4,000

6,000

2011 2012 2013 2014 2015 2016





10 Quarter II 2011

The Indian Medical Device Market, 2006-16 (US$ millions)

US$ millions 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

CONSUMABLES 274.4 327.5 345.1 387.6 461.2 519.1 591.7 688.6 787.4 899.8 989.7

Woundcare Products 70.2 84.7 82.6 119.1 142.6 161.5 185.1 216.5 248.9 285.9 316.0

Syringes, Needles & Catheters 195.0 229.5 244.3 238.2 281.1 313.8 354.7 409.2 463.8 525.3 572.5

Others 9.2 13.3 18.2 30.3 37.4 43.8 51.9 62.8 74.6 88.6 101.3

DIAGNOSTIC IMAGING 542.9 633.6 783.1 730.2 864.5 968.1 1,097.8 1,270.8 1,445.6 1,643.3 1,798.0

Electrodiagnostic Apparatus 226.4 267.1 334.2 316.7 370.1 409.0 457.7 522.8 586.6 657.7 709.7

Radiation Apparatus 134.4 154.3 175.3 156.3 185.1 207.3 235.0 271.9 309.2 351.2 384.0

Imaging Parts & Accessories 182.1 212.2 273.6 257.2 309.3 351.8 405.1 476.1 549.8 634.3 704.4

DENTAL PRODUCTS 38.0 49.2 58.2 55.5 66.7 75.9 87.5 103.0 119.3 138.0 153.8

Dental Capital Equipment 11.7 12.6 13.6 9.6 10.8 11.6 12.5 13.9 15.1 16.3 17.0

Dental Instruments & Supplies 26.3 36.6 44.5 45.9 55.9 64.3 75.0 89.2 104.2 121.7 136.8

ORTHOPAEDIC PRODUCTS 38.6 57.1 88.2 105.6 130.4 152.3 180.2 217.8 258.7 307.1 351.0

Splints & Other Fracture Apps 5.7 10.5 13.7 10.9 12.7 13.9 15.4 17.5 19.5 21.7 23.3

Artificial Joints 18.8 25.9 33.2 43.6 53.8 62.8 74.3 89.7 106.3 126.0 143.7

Other Artificial Body Parts 14.1 20.7 41.3 51.1 63.9 75.6 90.5 110.6 132.9 159.4 184.1

PATIENT AIDS 71.0 92.7 104.9 141.4 174.9 204.6 242.4 293.1 348.3 413.5 472.6

Portable Aids 48.7 59.7 59.6 87.4 107.4 125.0 147.2 176.9 208.9 246.5 280.0

Therapeutic Appliances 22.3 33.1 45.3 54.0 67.4 79.7 95.2 116.2 139.4 167.0 192.6

OTHERS 451.9 559.8 649.7 570.7 660.3 722.6 800.5 905.3 1,005.8 1,116.5 1,192.7

TOTAL 1,416.9 1,719.9 2,029.2 1,991.0 2,357.9 2,642.7 3,000.2 3,478.6 3,965.0 4,518.2 4,957.8

The Indian Medical Device Market, 2006-16 (US$ per capita)

US$ 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

CONSUMABLES 0.2 0.3 0.3 0.3 0.4 0.4 0.5 0.6 0.6 0.7 0.8



Others 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.1 0.1 0.1

DIAGNOSTIC IMAGING 0.5 0.6 0.7 0.6 0.7 0.8 0.9 1.0 1.2 1.3 1.4




DENTAL PRODUCTS 0.0 0.0 0.1 0.0 0.1 0.1 0.1 0.1 0.1 0.1 0.1







PATIENT AIDS 0.1 0.1 0.1 0.1 0.1 0.2 0.2 0.2 0.3 0.3 0.4

Portable Aids 0.0 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.2 0.2 0.2


OTHERS 0.4 0.5 0.6 0.5 0.6 0.6 0.7 0.7 0.8 0.9 0.9

TOTAL 1.3 1.5 1.8 1.7 2.0 2.2 2.5 2.8 3.2 3.5 3.8





Quarter II 2011 11

The Indian Medical Device Market, 2006-16 (% of Total)

% of Total 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

CONSUMABLES 19.4 19.0 17.0 19.5 19.6 19.6 19.7 19.8 19.9 19.9 20.0



Others 0.6 0.8 0.9 1.5 1.6 1.7 1.7 1.8 1.9 2.0 2.0

DIAGNOSTIC IMAGING 38.3 36.8 38.6 36.7 36.7 36.6 36.6 36.5 36.5 36.4 36.3




DENTAL PRODUCTS 2.7 2.9 2.9 2.8 2.8 2.9 2.9 3.0 3.0 3.1 3.1







PATIENT AIDS 5.0 5.4 5.2 7.1 7.4 7.7 8.1 8.4 8.8 9.2 9.5

Portable Aids 3.4 3.5 2.9 4.4 4.6 4.7 4.9 5.1 5.3 5.5 5.6


OTHERS 31.9 32.5 32.0 28.7 28.0 27.3 26.7 26.0 25.4 24.7 24.1

TOTAL 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

The Indian Medical Device Market, 2006-16 (% Change)

% Change 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

CONSUMABLES 36.1 19.4 5.4 12.3 19.0 12.6 14.0 16.4 14.4 14.3 10.0

Woundcare Products -0.6 20.7 -2.5 44.2 19.7 13.2 14.6 17.0 15.0 14.9 10.5

Syringes, Needles & Catheters 56.5 17.7 6.5 -2.5 18.0 11.6 13.0 15.4 13.3 13.2 9.0

Others 44.7 45.1 36.5 66.2 23.7 17.0 18.5 21.0 18.8 18.7 14.3

DIAGNOSTIC IMAGING 18.4 16.7 23.6 -6.8 18.4 12.0 13.4 15.8 13.8 13.7 9.4

Electrodiagnostic Apparatus 12.7 18.0 25.1 -5.2 16.9 10.5 11.9 14.2 12.2 12.1 7.9

Radiation Apparatus 24.4 14.8 13.6 -10.8 18.4 12.0 13.4 15.7 13.7 13.6 9.3

Imaging Parts & Accessories 21.6 16.5 29.0 -6.0 20.2 13.7 15.1 17.5 15.5 15.4 11.0

DENTAL PRODUCTS 31.3 29.5 18.2 -4.6 20.2 13.8 15.3 17.7 15.8 15.7 11.4

Dental Capital Equipment 26.0 7.8 8.5 -29.7 13.1 6.9 8.3 10.5 8.6 8.5 4.4



Splints & Other Fracture Apps -30.7 84.6 31.2 -20.6 16.0 9.8 11.1 13.4 11.4 11.3 7.1


Other Artificial Body Parts -27.5 46.4 99.6 23.8 25.0 18.3 19.7 22.2 20.1 20.0 15.5

PATIENT AIDS 33.2 30.6 13.1 34.7 23.7 17.0 18.5 20.9 18.8 18.7 14.3

Portable Aids 29.6 22.5 -0.1 46.6 23.0 16.3 17.8 20.2 18.1 18.0 13.6


OTHERS 9.9 23.9 16.0 -12.2 15.7 9.4 10.8 13.1 11.1 11.0 6.8

TOTAL 19.2 21.4 18.0 -1.9 18.4 12.1 13.5 15.9 14.0 13.9 9.7





12 Quarter II 2011

The Indian Market For Consumables

The Indian market for consumables is estimated at US$519.1 million in 2011, equal to just US$0.4 per capita and 19.6% of the market as a whole. This sector has performed strongly in recent years and this trend is expected to continue relatively unchanged over the next five years.

The market for woundcare products is estimated at US$161.5 million in 2011, equal to US$0.1 per capita. Around 19.6% is supplied via imports. The leading suppliers are USA, China and Singapore.

The market for syringes, needles & catheters is estimated at US$313.8 million in 2011, equal to US$0.3 per capita. Around 75.4% is imported, from the USA and Spain.

The market for other consumable products, such as blood grouping reagents, ostomy appliances and surgical gloves, is estimated at US$43.8 million in 2011, equal to less than US$0.1 per capita. Around 23.2% is imported, principally from Malaysia, Austria, Germany and the USA.

The Indian Consumables Market, 2006-16 (US$ millions)

US$ millions 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

CAGR 06-10

CAGR 11-16

CONSUMABLES 274.4 327.5 345.1 387.6 461.2 519.1 591.7 688.6 787.4 899.8 989.7 13.9 13.8

Woundcare products 70.2 84.7 82.6 119.1 142.6 161.5 185.1 216.5 248.9 285.9 316.0 19.4 14.4 Syringes, needles, catheters 195.0 229.5 244.3 238.2 281.1 313.8 354.7 409.2 463.8 525.3 572.5 9.6 12.8

Others 9.2 13.3 18.2 30.3 37.4 43.8 51.9 62.8 74.6 88.6 101.3 42.1 18.2






Quarter II 2011 13

The Indian Market For Consumables, 2006-16 (US$ millions)

0

100

200

300

400

500

600

700

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Woundcare Products Syringes, Needles & Catheters Others

The Indian Market For Consumables, 2006-16 (CAGR)

13.9

19.4

9.6

42.1

13.8 14.412.8

18.2

0

5

10

15

20

25

30

35

40

45

Woundcare Syringes, Needles &

Catheters

Others Overall

2006-10 2011-16





14 Quarter II 2011

The Indian Market For Diagnostic Imaging Apparatus

In 2011, the diagnostic imaging market is estimated at US$968.1 million, equal to US$0.8 per capita and 36.6% of the total market.

The market for electrodiagnostic apparatus is estimated at US$409.0 million in 2011, equal to US$0.3 per capita. An estimated 81.7% is imported, with the USA, Germany and China the principal supplier countries.

The market for X-ray and other radiation apparatus is estimated at US$207.3 million in 2011, equal to US$0.2 per capita. An estimated 64.1% is imported, mainly from USA and Germany.

The market for imaging parts & accessories is estimated at US$351.8 million, equal to US$0.3 per capita. An estimated 76.0% is imported, mainly from the USA, Germany and Japan with Ireland holding a niche in the supply of contrast media.

The Indian Diagnostic Imaging Market, 2006-16 (US$ millions)

US$ millions 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 CAGR 06-10

CAGR 11-

16

DIAGNOSTIC IMAGING 542.9 633.6 783.1 730.2 864.5 968.1 1,097.8 1,270.8 1,445.6 1,643.3 1,798.0 12.3 13.2

Electrodiagnostic apparatus 226.4 267.1 334.2 316.7 370.1 409.0 457.7 522.8 586.6 657.7 709.7 13.1 11.6

Radiation apparatus 134.4 154.3 175.3 156.3 185.1 207.3 235.0 271.9 309.2 351.2 384.0 8.3 13.1

Imaging parts & accessories 182.1 212.2 273.6 257.2 309.3 351.8 405.1 476.1 549.8 634.3 704.4 14.2 14.9






Quarter II 2011 15

The Indian Market For Diagnostic Imaging Apparatus, 2006-16 (US$ millions)

0

100

200

300

400

500

600

700

800

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Electrodiagnostic Apparatus Radiation Apparatus Imaging Parts & Accessories

The Indian Market For Diagnostic Imaging Apparatus, 2006-16 (CAGR)

12.313.1

8.3

14.2

13.2

11.6

13.1

14.9

0

2

4

6

8

10

12

14

16

Electrodiagnostic

Apparatus

Radiation Apparatus Imaging Parts &

Accessories

Overall

2006-10 2011-16





16 Quarter II 2011

The Indian Market For Dental Products

The Indian market for dental products is estimated at US$75.9 million in 2011, equal to US$0.1 per capita and 2.9% of the total market. An estimated 82.0% of the market is imported.

The market for capital equipment – drills, chairs & X-rays – is estimated at US$11.6 million in 2011, equal to less than US$0.1 per capita. An estimated 72.8% of the market is supplied by imports. In terms of principal suppliers, dental drill engines were primarily sourced from South Korea, X-ray apparatus from Italy and dental chairs from China.

The market for instrument & supplies is estimated at US$64.3 million in 2011, equal to US$0.1 per capita and 2.4% of the total market. An estimated 83.9% of the market is supplied by imports with the USA and Germany being the main suppliers.

The Indian Dental Products Market, 2006-16 (US$ millions)

US$ millions 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 CAGR 06-10

CAGR 11-16

DENTAL PRODUCTS 38.0 49.2 58.2 55.5 66.7 75.9 87.5 103.0 119.3 138.0 153.8 15.1 15.2

Dental capital equipment 11.7 12.6 13.6 9.6 10.8 11.6 12.5 13.9 15.1 16.3 17.0 -1.8 8.0

Dental instruments, supplies 26.3 36.6 44.5 45.9 55.9 64.3 75.0 89.2 104.2 121.7 136.8 20.7 16.3






Quarter II 2011 17

The Indian Market For Dental Products, 2006-16 (US$ millions)

0

20

40

60

80

100

120

140

160

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Dental Capital Equipment Dental Instruments & Supplies

The Indian Market For Dental Products, 2006-16 (CAGR)

15.1

-1.8

20.7

15.2

8.0

16.3

-5

0

5

10

15

20

25

Dental Capital Equipment Dental Instruments & Supplies Overall

2006-10 2011-16





18 Quarter II 2011

The Indian Market For Orthopaedic Products

The market for orthopaedic and prosthetic products is estimated at US$152.3 million in 2011, equal to US$0.1 per capita and 5.8% of the total market. While India does have manufacturers of orthopaedic products, the bulk or around 92% of this market‟s value consists of imports. The market for artificial joints is estimated at US$62.8 million in 2011, with the USA being the main supplier.

The Indian Orthopaedic & Prosthetic Devices Market, 2006-16 (US$ millions)

US$ millions 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 CAGR 06-10

CAGR 11-16

ORTHOPAEDIC/PROSTHETIC 38.6 57.1 88.2 105.6 130.4 152.3 180.2 217.8 258.7 307.1 351.0 35.5 18.2

Orthopaedic appliances 5.7 10.5 13.7 10.9 12.7 13.9 15.4 17.5 19.5 21.7 23.3 22.2 10.9

Artificial joints 18.8 25.9 33.2 43.6 53.8 62.8 74.3 89.7 106.3 126.0 143.7 30.0 18.0

Artificial body parts 14.1 20.7 41.3 51.1 63.9 75.6 90.5 110.6 132.9 159.4 184.1 45.8 19.5






Quarter II 2011 19

The Indian Market For Orthopaedic Products, 2006-16 (US$ millions)

0

20

40

60

80

100

120

140

160

180

200

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Splints & other fracture appliances Artificial joints Other artificial body parts

The Indian Market For Orthopaedic Products, 2006-16 (CAGR)

35.5

22.2

30.0

45.8

18.2

10.9

18.019.5

0

5

10

15

20

25

30

35

40

45

50

Splints & other fracture

appliances

Artificial joints Other artificial body parts Overall

2006-10 2011-16





20 Quarter II 2011

The Indian Market For Patient Aids

The market for patient aids is estimated at US$204.6 million in 2011, equal to US$0.2 per capita and 17.0% of the total market. Portable aids such as hearing aids and pacemakers amounted to US$125.0 million in 2011 equal to under US$0.1 per capita. Around 97% of these are imported, primarily from the USA and Singapore. The market for therapeutic appliances amounted to US$79.7 million in 2011. Around 92% is imported, mainly from the USA, South Korea and Germany.

The Indian Patient Aids Market, 2006-16 (US$ millions)

US$ millions 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 CAGR 06-10

CAGR 11-16

PATIENT AIDS 71.0 92.7 104.9 141.4 174.9 204.6 242.4 293.1 348.3 413.5 472.6 25.3 18.2

Portable aids 48.7 59.7 59.6 87.4 107.4 125.0 147.2 176.9 208.9 246.5 280.0 21.9 17.5

Therapeutic appliances 22.3 33.1 45.3 54.0 67.4 79.7 95.2 116.2 139.4 167.0 192.6 31.8 19.3






Quarter II 2011 21

The Indian Market For Patient Aids, 2006-16 (US$ millions)

0

50

100

150

200

250

300

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Portable aids Therapeutic appliances

The Indian Market For Patient Aids, 2006-16 (CAGR)

25.3

21.9

31.8

18.2 17.519.3

0

5

10

15

20

25

30

35

Portable aids Therapeutic appliances Overall

2006-10 2011-16





22 Quarter II 2011

Imports

In 2009, imports declined by 2.9% to US$1,496.5 million, largely due to a weakened average exchange rate against the dollar in 2009. This was the first time imports have declined since 1993. In local currency terms, imports actually posted an annual rise of 8.0% in 2009. In CAGR terms, imports grew at a CAGR of 13.9% from 2005-2009.

Medical Equipment Imports, 1993-2009 (US$000s)

121,

170

184,

669

230,

570

296,

869

321,

351

321,

484

341,

116

416,

876

511,

700

526,

125

597,

397

1,54

1,98

0

1,49

6,49

6

690,

047

888,

519

1,06

6,19

2 1,29

6,26

50

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Percentage Change in Imports, 1994-2009

-10

0

10

20

30

40

50

60

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009





Quarter II 2011 23

Consumables

Imports of consumable medical devices rose by 2.6% over the previous year to reach US$210.0 million in 2009. This category represented 14.0% of total imports and had a CAGR of 17.7% in the 2005-2009 period. Woundcare products and the sub-category of all other consumables recorded gains of 44.2% and 66.2% respectively to reach totals of US$23.4 million and US$7.0 million while the largest sub-category of syringes, needles & catheters declined by 2.5% to US$179.6 million in 2009.

Diagnostic Imaging

Diagnostic imaging apparatus was the largest category, accounting for 37.0% of total imports at a value of US$554.3 million in 2009. This category declined by 6.6% over the previous year but had an average annual growth rate of 12.4% from 2005 to 2009. All three sub-categories, electrodiagnostic apparatus, radiation apparatus and imaging parts & accessories, posted declines in 2009.

Dental Products

Dental product imports declined by 3.7% over the previous year to US$45.5 million in 2009. This was the smallest category, making up just 3.0% of the total and expanding at a CAGR of 18.3% in the 2005-2009 period. Instruments & supplies made up the bulk of this category at a value of US$38.5 million, an annual rise of 3.2%, while capital equipment imports fell by 29.7% to US$7.0 million in 2009.

Orthopaedic & Prosthetic Products

Orthopaedic & prosthetic products grew the fastest in the 2005 to 2009 period, expanding at a CAGR of 34.5%. This category, which made up 6.5% of the year‟s total, experienced annual growth of 23.1% to reach US$96.8 million in 2009. Artificial joints and other artificial body parts posted annual gains of 31.3% and 23.8% to US$42.1 million and US$49.4 million, while splints & other fracture appliances declined by 20.6% to US$5.3 million in 2009.

Patient Aids

Patient aids imports grew by 35.1% over the previous year to reach US$134.0 million in 2009. This category made up 9.0% of total imports and expanded at a CAGR of 27.5% from 2005 to 2009. Portable aids imports rose by 46.6% to US$84.4 million while therapeutic appliances grew by 19.2% over the previous year to US$49.6 million in 2009.





24 Quarter II 2011

Medical Equipment Imports by Product Area, 2005-09 (US$000s)

2005 2006 2007 2008 2009

Consumables 109,303 162,938 192,719 204,608 209,969 Diagnostic imaging 347,128 409,471 478,273 593,253 554,322 Dental products 23,253 30,591 39,901 47,295 45,525 Orthopaedic & prosthetic 29,612 34,594 50,128 78,612 96,784 Patient aids 50,751 67,546 88,000 99,186 133,977 Others 328,472 361,052 447,244 519,026 455,919

TOTAL 888,519 1,066,192 1,296,265 1,541,980 1,496,496

Medical Equipment Imports by Product Area, 2005-09 (%)

2005 2006 2007 2008 2009

Consumables 12.3 15.3 14.9 13.3 14.0 Diagnostic imaging 39.1 38.4 36.9 38.5 37.0 Dental products 2.6 2.9 3.1 3.1 3.0 Orthopaedic & prosthetic 3.3 3.2 3.9 5.1 6.5 Patient aids 5.7 6.3 6.8 6.4 9.0 Others 37.0 33.9 34.5 33.7 30.5

TOTAL 100.0 100.0 100.0 100.0 100.0





Quarter II 2011 25

Medical Equipment Imports by Product Area, 2009 (%)

Consumables

14.0%

Diagnostic imaging

apparatus

37.0%

Dental products

3.0%

Patient Aids

9.0%

Others

30.5%

Orthopaedic products

6.5%

Medical Equipment Imports by Product Area, 2005-2009 (% of Total)

0

10

20

30

40

50

60

70

80

90

100

2005 2006 2007 2008 2009

CONSUMABLES DIAGNOSTIC IMAGING DENTAL PRODUCTS

ORTHOPAEDIC PRODUCTS PATIENT AIDS OTHERS





26 Quarter II 2011

Change in Medical Equipment Imports by Product Area, 2006-2009 (%)

2006 2007 2008 2009 CAGR 05-09

Consumables 49.1 18.3 6.2 2.6 17.7 Diagnostic imaging 18.0 16.8 24.0 -6.6 12.4 Dental products 31.6 30.4 18.5 -3.7 18.3 Orthopaedic & prosthetic 16.8 44.9 56.8 23.1 34.5 Patient aids 33.1 30.3 12.7 35.1 27.5 Others 9.9 23.9 16.0 -12.2 8.5

TOTAL 20.0 21.6 19.0 -2.9 13.9

CAGR of Medical Equipment Imports by Product Area, 2005-09 (%)

17.7

12.4

27.5

8.5

13.9

34.5

18.3

0

5

10

15

20

25

30

35

40


imaging

apparatus

Dental

products

Orthopaedic

products

Patient Aids Others Total





Quarter II 2011 27

The USA was the leading supplier of medical devices to India with shipments worth US$490.1 million equal to 32.8% of the total in 2009. The USA was particularly strong in the supply of orthopaedic & prosthetic products where it commanded a share of 62.6% of the total in 2009. Germany, Japan, China and Singapore were the other leading suppliers with shares of 18.2%, 7.3%, 6.6% and 5.5% of the total respectively. The European Union as a whole shipped US$497.8 million or 33.3% of the year‟s total in 2009.

Leading Medical Equipment Suppliers by Product Area, 2009 (US$000s)

USA Germany Japan China Singapore EU-27

Consumables 68,802 21,244 8,498 12,794 17,179 65,295 Diagnostic imaging 181,482 108,655 56,928 39,155 30,827 190,295 Dental products 7,949 8,159 3,091 4,479 2,237 16,070 Orthopaedic & prosthetic 60,553 3,867 50 503 0 15,123 Patient aids 48,585 9,038 1,513 9,220 10,685 36,632 Others 122,775 121,905 39,439 32,861 21,221 174,359

Total 490,146 272,868 109,519 99,012 82,149 497,774

Leading Medical Equipment Suppliers by Product Area, 2009 (%)

USA Germany Japan China Singapore EU-27

Consumables 32.8 10.1 4.0 6.1 8.2 31.1 Diagnostic imaging 32.7 19.6 10.3 7.1 5.6 34.3 Dental products 17.5 17.9 6.8 9.8 4.9 35.3 Orthopaedic & prosthetic 62.6 4.0 0.1 0.5 0.0 15.6 Patient aids 36.3 6.7 1.1 6.9 8.0 27.3 Others 26.9 26.7 8.7 7.2 4.7 38.2

Total 32.8 18.2 7.3 6.6 5.5 33.3





28 Quarter II 2011

Leading Medical Equipment Suppliers, 2009 (%)

USA

32.8%

Japan

7.3%

China

6.6%

Singapore

5.5%

Germany

18.2%

Other EU

15.1%

Others

14.5%

Top 20 Suppliers to the Indian Market, 2009

US$000s Percentage of Total

1 USA 490,146 32.8 2 Germany 272,868 18.2 3 Japan 109,519 7.3 4 China 99,012 6.6 5 Singapore 82,149 5.5 6 Switzerland 55,959 3.7 7 Ireland 36,091 2.4 8 France 35,117 2.3 9 South Korea 33,429 2.2 10 Netherlands 29,136 1.9 11 UK 28,164 1.9 12 Italy 24,375 1.6 13 Sweden 23,596 1.6 14 Hong Kong 19,295 1.3 15 Malaysia 18,253 1.2 16 Israel 15,729 1.1 17 Australia 13,096 0.9 18 Belgium 11,992 0.8 19 Denmark 10,916 0.7 20 Austria 10,567 0.7

Subtotal Top 20 1,419,409 94.8

Others 77,087 5.2

Total 1,496,496 100.0





Quarter II 2011 29

Imports of Medical Equipment, 2005-09 (US$000s)

2005 2006 2007 2008 2009

CONSUMABLES 109,303 162,938 192,719 204,608 209,969

Woundcare Products 13,861 13,778 16,632 16,213 23,386 Medical dressings (adhesive) 2,768 4,249 3,599 4,449 5,049 Medical dressings (non-adhesive) 7,570 5,769 8,793 7,403 11,957 Sutures, sterile, surgical & dental goods 3,523 3,760 4,240 4,361 6,380

Syringes, Needles & Catheters 93,966 147,024 172,988 184,164 179,550 Syringes (with/without needles) 14,669 27,948 28,432 13,207 16,003 Tubular metal needles/ needles for sutures 15,351 14,209 22,424 22,602 20,149 Other needles, catheters, cannulae etc 63,946 104,867 122,132 148,355 143,398

Others 1,476 2,136 3,099 4,231 7,033 Blood-grouping reagents 334 354 349 674 914 First-aid boxes & kits 23 30 177 251 91 Ostomy appliances 0 0 0 0 158 Surgical gloves 1,119 1,752 2,573 3,306 5,870

DIAGNOSTIC IMAGING 347,128 409,471 478,273 593,253 554,322

Electrodiagnostic Apparatus 164,060 184,962 218,220 273,022 258,716 Electrocardiographs 1,197 1,881 1,557 3,736 4,546 Ultrasonic scanning apparatus 43,378 59,756 57,030 70,711 75,051 Magnetic resonance imaging apparatus 29,594 33,174 66,536 67,764 69,483 Scintigraphic apparatus 877 798 571 4,058 107 Other electro-diagnostic apparatus 89,014 89,353 92,526 126,753 109,529

Radiation Apparatus 69,256 86,155 98,892 112,382 100,206 Computed tomography apparatus 37,254 46,327 47,828 62,689 43,529 Other medical X-ray apparatus 26,703 27,906 37,900 38,371 45,971 Medical alpha beta, gamma ray apparatus 5,299 11,922 13,164 11,322 10,706

Imaging Parts & Accessories 113,812 138,354 161,161 207,849 195,400 Contrast media 8,481 13,542 10,540 16,280 12,087 X-ray tubes 19,144 30,094 37,430 34,215 30,638 Parts & accessories for radiation apparatus 58,495 62,817 77,149 105,297 95,002 Medical X-ray film (flat) 10,314 15,270 16,498 21,878 22,556 Medical X-ray film (rolled) 17,378 16,631 19,544 30,179 35,117

DENTAL PRODUCTS 23,253 30,591 39,901 47,295 45,525

Dental Capital Equipment 6,736 8,488 9,151 9,925 6,977 Dental drill engines 225 297 59 65 165 Dental X-ray apparatus 561 1,162 1,754 1,708 959 Dental & similar chairs (inc. parts & accessories) 5,950 7,029 7,338 8,152 5,853

Dental Instruments & Supplies 16,517 22,103 30,750 37,370 38,548 Dental cements & other fillings 6,573 6,988 8,753 13,207 13,062 Other instruments & appliances used in dentistry 7,673 9,932 16,648 18,892 20,414 Artificial teeth 371 423 527 686 848 Other dental fittings 1,900 4,760 4,822 4,585 4,224

ORTHOPAEDIC & PROSTHETIC DEVICES 29,612 34,594 50,128 78,612 96,784

Splints & other fracture appliances

3,974 2,752 5,079 6,666 5,290 Artificial joints 6,798 18,189 25,063 32,060 42,102 Other artificial body parts 18,840 13,653 19,986 39,886 49,392

PATIENT AIDS 50,751 67,546 88,000 99,186 133,977

Portable aids 36,309 47,053 57,638 57,567 84,380 Hearing aids, except parts & accessories 7,657 9,739 12,328 16,967 19,789 Pacemakers, except parts & accessories 7,968 12,191 20,893 21,919 26,193 Other aids for the disabled 20,684 25,123 24,417 18,681 38,398

Therapeutic appliances 14,442 20,493 30,362 41,619 49,597 Mechano-therapy apparatus 4,257 6,150 10,056 14,180 15,060 Therapeutic respiration apparatus 9,649 12,688 19,441 26,464 33,859 Ultra-violet or infra-red ray apparatus 536 1,655 865 975 678

OTHERS 328,472 361,052 447,244 519,026 455,919

Wheelchairs, not mechanically propelled 313 402 542 1,091 1,183 Wheelchairs, mechanically propelled 344 399 1,006 1,239 1,380 Other medical, surgical, dental furniture 4,494 5,776 9,368 15,545 12,674 Medical, surgical sterilisers 6,270 8,777 18,415 29,862 11,467 Ophthalmic instruments & appliances 56,134 49,510 70,275 72,596 71,150 Other instruments & appliances 260,917 296,188 347,638 398,693 358,065

TOTAL 888,519 1,066,192 1,296,265 1,541,980 1,496,496





30 Quarter II 2011

Medical Equipment Import Trends

2008 2009

% of Total 2009

% Change 2009

CAGR 2005-09

CONSUMABLES 204,608 209,969 14.0 2.6 17.7

Woundcare Products 16,213 23,386 1.6 44.2 14.0 Medical dressings (adhesive) 4,449 5,049 0.3 13.5 16.2 Medical dressings (non-adhesive) 7,403 11,957 0.8 61.5 12.1 Sutures, sterile, surgical & dental goods 4,361 6,380 0.4 46.3 16.0

Syringes, Needles & Catheters 184,164 179,550 12.0 -2.5 17.6 Syringes (with/without needles) 13,207 16,003 1.1 21.2 2.2 Tubular metal needles/ needles for sutures 22,602 20,149 1.3 -10.9 7.0 Other needles, catheters, cannulae etc 148,355 143,398 9.6 -3.3 22.4

Others 4,231 7,033 0.5 66.2 47.7 Blood-grouping reagents 674 914 0.1 35.6 28.6 First-aid boxes & kits 251 91 0.0 -63.7 41.0 Ostomy appliances 0 158 0.0 ~ ~ Surgical gloves 3,306 5,870 0.4 77.6 51.3

DIAGNOSTIC IMAGING 593,253 554,322 37.0 -6.6 12.4

Electrodiagnostic Apparatus 273,022 258,716 17.3 -5.2 12.1 Electrocardiographs 3,736 4,546 0.3 21.7 39.6 Ultrasonic scanning apparatus 70,711 75,051 5.0 6.1 14.7 Magnetic resonance imaging apparatus 67,764 69,483 4.6 2.5 23.8 Scintigraphic apparatus 4,058 107 0.0 -97.4 -40.9 Other electro-diagnostic apparatus 126,753 109,529 7.3 -13.6 5.3

Radiation Apparatus 112,382 100,206 6.7 -10.8 9.7 Computed tomography apparatus 62,689 43,529 2.9 -30.6 4.0 Other medical X-ray apparatus 38,371 45,971 3.1 19.8 14.5 Medical alpha beta, gamma ray apparatus 11,322 10,706 0.7 -5.4 19.2

Imaging Parts & Accessories 207,849 195,400 13.1 -6.0 14.5 Contrast media 16,280 12,087 0.8 -25.8 9.3 X-ray tubes 34,215 30,638 2.0 -10.5 12.5 Parts & accessories for radiation apparatus 105,297 95,002 6.3 -9.8 12.9 Medical X-ray film (flat) 21,878 22,556 1.5 3.1 21.6 Medical X-ray film (rolled) 30,179 35,117 2.3 16.4 19.2

DENTAL PRODUCTS 47,295 45,525 3.0 -3.7 18.3

Dental Capital Equipment 9,925 6,977 0.5 -29.7 0.9 Dental drill engines 65 165 0.0 153.8 -7.5 Dental X-ray apparatus 1,708 959 0.1 -43.9 14.3 Dental & similar chairs (inc. parts & accessories) 8,152 5,853 0.4 -28.2 -0.4

Dental Instruments & Supplies 37,370 38,548 2.6 3.2 23.6 Dental cements & other fillings 13,207 13,062 0.9 -1.1 18.7 Other instruments & appliances used in dentistry 18,892 20,414 1.4 8.1 27.7 Artificial teeth 686 848 0.1 23.6 23.0 Other dental fittings 4,585 4,224 0.3 -7.9 22.1

ORTHOPAEDIC & PROSTHETIC DEVICES 78,612 96,784 6.5 23.1 34.5


6,666 5,290 0.4 -20.6 7.4 Artificial joints 32,060 42,102 2.8 31.3 57.8 Other artificial body parts 39,886 49,392 3.3 23.8 27.2

PATIENT AIDS 99,186 133,977 9.0 35.1 27.5

Portable aids 57,567 84,380 5.6 46.6 23.5 Hearing aids, except parts & accessories 16,967 19,789 1.3 16.6 26.8 Pacemakers, except parts & accessories 21,919 26,193 1.8 19.5 34.7 Other aids for the disabled 18,681 38,398 2.6 105.5 16.7

Therapeutic appliances 41,619 49,597 3.3 19.2 36.1 Mechano-therapy apparatus 14,180 15,060 1.0 6.2 37.1 Therapeutic respiration apparatus 26,464 33,859 2.3 27.9 36.9 Ultra-violet or infra-red ray apparatus 975 678 0.0 -30.5 6.1

OTHERS 519,026 455,919 30.5 -12.2 8.5

Wheelchairs, not mechanically propelled 1,091 1,183 0.1 8.4 39.4 Wheelchairs, mechanically propelled 1,239 1,380 0.1 11.4 41.5 Other medical, surgical, dental furniture 15,545 12,674 0.8 -18.5 29.6 Medical, surgical sterilisers 29,862 11,467 0.8 -61.6 16.3 Ophthalmic instruments & appliances 72,596 71,150 4.8 -2.0 6.1 Other instruments & appliances 398,693 358,065 23.9 -10.2 8.2

TOTAL 1,541,980 1,496,496 100.0 -2.9 13.9





Quarter II 2011 31

Leading Suppliers, 2009

USA Germany Japan China Sing. EU-27

CONSUMABLES 68,802 21,244 8,498 12,794 17,179 65,295

Woundcare Products 5,708 1,725 1,806 3,824 2,510 5,036 Medical dressings (adhesive) 460 335 0 790 2,378 767 Medical dressings (non-adhesive) 1,951 508 1,597 2,940 7 3,121 Sutures, sterile, surgical & dental goods 3,297 882 209 94 125 1,148

Syringes, Needles & Catheters 62,406 19,460 6,692 8,803 14,666 59,516 Syringes (with/without needles) 2,462 944 67 1,204 2,661 7,623 Tubular metal needles/ needles for sutures 3,352 364 2,665 1,422 2,207 3,459 Other needles, catheters, cannulae etc 56,592 18,152 3,960 6,177 9,798 48,434

Others 688 59 0 167 3 743 Blood-grouping reagents 292 0 0 0 0 617 First-aid boxes & kits 33 55 0 0 3 55 Ostomy appliances 72 4 0 0 0 21 Surgical gloves 291 0 0 167 0 50

DIAGNOSTIC IMAGING 181,482 108,655 56,928 39,155 30,827 190,295

Electrodiagnostic Apparatus 81,745 53,098 20,779 21,789 23,647 82,444 Electrocardiographs 1,503 159 34 429 5 549 Ultrasonic scanning apparatus 13,985 18,304 3,857 9,082 3,195 31,195 Magnetic resonance imaging apparatus 28,988 16,171 5,713 5,784 1,407 25,216 Scintigraphic apparatus 14 4 0 89 0 4 Other electro-diagnostic apparatus 37,255 18,460 11,175 6,405 19,040 25,480

Radiation Apparatus 27,380 21,731 8,361 12,642 5,468 40,029 Computed tomography apparatus 10,501 12,197 4,390 9,778 2,020 15,977 Other medical X-ray apparatus 15,106 7,818 2,841 2,805 3,422 19,571 Medical alpha beta, gamma ray apparatus 1,773 1,716 1,130 59 26 4,481

Imaging Parts & Accessories 72,357 33,826 27,788 4,724 1,712 67,822 Contrast media 457 85 0 0 0 11,242 X-ray tubes 23,448 777 1,398 1,528 132 2,840 Parts & accessories for radiation apparatus 23,763 31,722 4,817 3,046 1,580 45,743 Medical X-ray film (flat) 8,326 1,232 9,016 150 0 5,064 Medical X-ray film (rolled) 16,363 10 12,557 0 0 2,933

DENTAL PRODUCTS 7,949 8,159 3,091 4,479 2,237 16,070

Dental Capital Equipment 368 1,204 118 1,906 9 2,973 Dental drill engines 4 76 0 0 0 76 Dental X-ray apparatus 10 78 11 0 0 827 Dental & similar chairs (inc. parts & accessories) 354 1,050 107 1,906 9 2,070

Dental Instruments & Supplies 7,581 6,955 2,973 2,573 2,228 13,097 Dental cements & other fillings 2,717 3,709 223 338 2,212 4,913 Other instruments & appliances used in dentistry 2,473 3,026 2,678 2,039 16 6,611 Artificial teeth 319 56 72 122 0 298 Other dental fittings 2,072 164 0 74 0 1,275

ORTHOPAEDIC & PROSTHETIC DEVICES 60,553 3,867 50 503 0 15,123


3,219 778 0 292 0 948 Artificial joints 32,058 550 0 4 0 7,555 Other artificial body parts 25,276 2,539 50 207 0 6,620

PATIENT AIDS 48,585 9,038 1,513 9,220 10,685 36,632

Portable aids 36,167 5,615 550 1,816 10,284 24,177 Hearing aids, except parts & accessories 915 104 0 399 5,344 7,920 Pacemakers, except parts & accessories 17,685 1,742 0 0 0 6,083 Other aids for the disabled 17,567 3,769 550 1,417 4,940 10,174

Therapeutic appliances 12,418 3,423 963 7,404 401 12,455 Mechano-therapy apparatus 498 135 422 4,483 136 412 Therapeutic respiration apparatus 11,745 2,926 541 2,921 265 11,547 Ultra-violet or infra-red ray apparatus 175 362 0 0 0 496

OTHERS 122,775 121,905 39,439 32,861 21,221 174,359

Wheelchairs, not mechanically propelled 0 0 0 1,183 0 0 Wheelchairs, mechanically propelled 0 2 0 1,313 0 2 Other medical, surgical, dental furniture 1,493 1,966 129 2,937 24 5,379 Medical, surgical sterilisers 3,646 1,578 344 1,495 157 4,086 Ophthalmic instruments & appliances 21,177 18,731 12,323 2,863 2,178 22,863 Other instruments & appliances 96,459 99,628 26,643 23,070 18,862 142,029

TOTAL 490,146 272,868 109,519 99,012 82,149 497,774 Percentage of total 32.8 18.2 7.3 6.6 5.5 33.3





32 Quarter II 2011

Leading Suppliers by Category, 2009

Imports

US$000s

Leading Supplier Shipments US$000s

000s

% of Total

CONSUMABLES 209,969 USA 68,802 32.8

Woundcare Products 23,386 USA 5,708 24.4 Medical dressings (adhesive) 5,049 Singapore 2,378 47.1 Medical dressings (non-adhesive) 11,957 China 2,940 24.6 Sutures, sterile, surgical & dental goods 6,380 USA 3,297 51.7

Syringes, Needles & Catheters 179,550 USA 62,406 34.8 Syringes (with/without needles) 16,003 Spain 4,431 27.7 Tubular metal needles/ needles for sutures 20,149 USA 3,352 16.6 Other needles, catheters, cannulae etc 143,398 USA 56,592 39.5

Others 7,033 Malaysia 2,872 40.8 Blood-grouping reagents 914 Austria 424 46.4 First-aid boxes & kits 91 Germany 55 60.4 Ostomy appliances 158 USA 72 45.6 Surgical gloves 5,870 Malaysia 2,872 48.9

DIAGNOSTIC IMAGING 554,322 USA 181,482 32.7

Electrodiagnostic Apparatus 258,716 USA 81,745 31.6 Electrocardiographs 4,546 USA 1,503 33.1 Ultrasonic scanning apparatus 75,051 Germany 18,304 24.4 Magnetic resonance imaging apparatus 69,483 USA 28,988 41.7 Scintigraphic apparatus 107 China 89 83.2 Other electro-diagnostic apparatus 109,529 USA 37,255 34.0

Radiation Apparatus 100,206 USA 27,380 27.3 Computed tomography apparatus 43,529 Germany 12,197 28.0 Other medical X-ray apparatus 45,971 USA 15,106 32.9 Medical alpha beta, gamma ray apparatus 10,706 USA 1,773 16.6

Imaging Parts & Accessories 195,400 USA 72,357 37.0 Contrast media 12,087 Ireland 7,105 58.8 X-ray tubes 30,638 USA 23,448 76.5 Parts & accessories for radiation apparatus 95,002 Germany 31,722 33.4 Medical X-ray film (flat) 22,556 Japan 9,016 40.0 Medical X-ray film (rolled) 35,117 USA 16,363 46.6

DENTAL PRODUCTS 45,525 Germany 8,159 17.9

Dental Capital Equipment 6,977 China 1,906 27.3 Dental drill engines 165 South Korea 85 51.5 Dental X-ray apparatus 959 Italy 382 39.8 Dental & similar chairs (inc. parts & accessories) 5,853 China 1,906 32.6

Dental Instruments & Supplies 38,548 USA 7,581 19.7 Dental cements & other fillings 13,062 Germany 3,709 28.4 Other instruments & appliances used in dentistry 20,414 Germany 3,026 14.8 Artificial teeth 848 USA 319 37.6 Other dental fittings 4,224 USA 2,072 49.1

ORTHOPAEDIC & PROSTHETIC DEVICES 96,784 USA 60,553 62.6


5,290 USA 3,219 60.9 Artificial joints 42,102 USA 32,058 76.1 Other artificial body parts 49,392 USA 25,276 51.2

PATIENT AIDS 133,977 USA 48,585 36.3

Portable aids 84,380 USA 36,167 42.9 Hearing aids, except parts & accessories 19,789 Singapore 5,344 27.0 Pacemakers, except parts & accessories 26,193 USA 17,685 67.5 Other aids for the disabled 38,398 USA 17,567 45.7

Therapeutic appliances 49,597 USA 12,418 25.0 Mechano-therapy apparatus 15,060 South Korea 8,932 59.3 Therapeutic respiration apparatus 33,859 USA 11,745 34.7 Ultra-violet or infra-red ray apparatus 678 Germany 362 53.4

OTHERS 455,919 USA 122,775 26.9

Wheelchairs, not mechanically propelled 1,183 China 1,183 100.0 Wheelchairs, mechanically propelled 1,380 China 1,313 95.1 Other medical, surgical, dental furniture 12,674 China 2,937 23.2 Medical, surgical sterilisers 11,467 USA 3,646 31.8 Ophthalmic instruments & appliances 71,150 USA 21,177 29.8 Other instruments & appliances 358,065 Germany 99,628 27.8

TOTAL 1,496,496 USA 490,146 32.8





Quarter II 2011 33

Domestic Manufacturing

Domestic Production

Medical products are manufactured in India by both private companies and companies incorporated under the Ministry of Health and Family Welfare. A number of Indian manufacturers are either involved or interested in joint ventures with companies in the USA and Europe.

Domestic manufacturers dominate the low tech, disposable equipment and supplies end of the market. According to the Medical Disposables Manufacturer‟s Association, which was established in 1990, its members contribute approximately 60% of the country‟s production and requirements for medical disposable products such as IV sets.

A number of international companies have set up manufacturing facilities in India, including Bausch & Lomb, Baxter International, B. Braun, Becton Dickinson, Dräger, GE Medical Systems, Johnson & Johnson, Siemens, Terumo and Zeiss.

Domestic producers include the following:

Company Main product areas

Anand Medicaids Suction equipment, surgical disposables, UV sterilisers, foetal

dopplers, infection control systems Analytical Technologies Ltd Spectrophotometer ASCO Range of medical supplies and equipment Atlas Surgical Company Range of medical supplies and equipment Carewell Mediproducts Disposables Dent-Eq Sterilising equipment Dental Products of India Consumable dental products Eastern Medikit Ltd Range of medical and surgical disposable devices Emdin Dental products Endolite India Ltd Artificial limbs Ginni Consumer Products Absorbent cotton, dressings and adhesive and non-adhesive

bandages Hindustan Syringes and Medical Devices Disposable syringes, disposable needles, IV cannulae,

surgical blades and blood collection kits INOR Orthopaedics Orthopaedic instruments and implants Industrial Electronics Allied Products Blood pressure monitors Kayco Medical instruments, appliances and hospital furniture Kiran Medical Systems Medical imaging and X-ray accessories Lifeline Systems Medical and surgical disposables Medical Microtechnology Ltd High precision forceps, needle holders for ophthalmic surgery Narang Enterprises Range of medical and surgical equipment New Life Surgical Works Orthopaedic instruments and implants Pace Devices Endoscopy equipment Relisys Medical Devices Ltd Coronary stents, critical care products Ribbel International Disposable surgical instruments Sahajanand Medical Technologies Coronary stents SISCO Surgical instruments, disposable syringes, endotracheal

tubes and Foley catheters SURU International Disposable medical devices Surya Surgical Industries Steel surgical instruments





34 Quarter II 2011

Local Manufacturers

Anand Medicaids Pvt. Ltd.

Anand Medicaids Pvt. Ltd., based in New Delhi, manufactures suction units and related accessories, surgical disposables, UV sterilisers, foetal dopplers, infection control systems, infant care products and breast feeding products. Anand holds the Indian Standards Bureau‟s ISI certification and has ISO 9001:2000 certification. In addition to being a market leader in suction equipment in India, Anand exports its products to various countries in Europe, Asia, Africa and the Middle East. The company also offers contract manufacturing services.

ASCO

Apothecaries‟ Sundries Manufacturing Co. (ASCO) was established in New Delhi in 1948, having migrated from Sialkot, Pakistan. The company‟s product range includes hospital furniture, sterilisers, autoclaves, hospital hollowware, hospital rubber goods, diagnostic instruments, microscopes, scientific and optical glass products, orthopaedic instruments/implants, suction units, vacuum extractors, abortion sets, rehabilitation aids, surgical needles and surgical instruments. ASCO has ISO 9001 certification and exports products to more than 40 countries around the world, including the USA and Europe.

Atlas Surgical Company

Atlas Surgical Company, established in 1951, manufactures and exports medical supplies and equipment, hospital furniture, stainless steel hollowware, sterilising systems (sterilisers, hot air ovens, incubators, autoclaves), laboratory equipment, microscopes, suction machines, orthopaedic products, laryngoscopes, resuscitators, respiratory aids, diagnostic instruments and a range of disposables. The company holds ISO 9001 certification and is export oriented.

Carewell Mediproducts

Carewell Mediproducts Limited was established in 1985 using technical knowledge and plant purchased from Germany. The company‟s objective was to manufacture and market medical disposables of international quality under GMP standards. Carewell Mediproducts commenced production of its Careject range of disposable needles and syringes in January 1988 at its factory in Kashipur, Udham Singh Nagar District. The factory has the capacity to manufacture 60 million disposable syringes and 300 million disposable needles per year.

Dent-Eq

Dent-Eq is one of India's leading manufacturers and exporters of glass bead and hot air sterilising equipment. The company supplies the domestic market and exports to over 26 countries. Dent Eq‟s export market for glass bead sterilisers includes Australia, Sri Lanka, Hungary, Spain and the USA.

Eastern Medikit Ltd.

Eastern Medikit was established in 1988. The company manufactures and markets medical and surgical disposable devices at Gurgaon, near Delhi. Products include blood collection needles and tubes, blood bags, catheters, IV administration sets, arteriovenous fistula needles for haemodialysis, oxygen masks and nebuliser kits. The company exports its products to around 70 markets.

Emdin India Pvt. Ltd.

Emdin India is part of Emdin International Corporation of the USA. The company manufactures and distributes products for dentists including alginate impression materials, casting alloys and Starvest high heat crown and bridge casting investments. Emdin is also able to customise products to suit individual customers.





Quarter II 2011 35

Endolite India Ltd

Endolite India Ltd., an ISO 9001:2008 accredited organisation with headquarters in New Delhi, is a manufacturer of a wide range of artificial limb components. The company provides prosthetic & orthotic care at its centres nationwide.

Hindustan Syringes and Medical Devices Ltd.

Hindustan Syringes and Medical Devices Ltd. (HMD) was established in 1957. The company‟s major products are disposable syringes, disposable needles, IV cannulae, surgical blades and blood collection kits. HMD has manufacturing facitlities at Ballabgarh and Faridabad.

Products are manufactured to international standards and carry ISO 9001 and the CE Mark. HMD‟s products are marketed in India, the USA, Europe, the Middle East, South East Asia and South America, through an established national and international distribution network. The company claims a 65% share in the Indian market for disposable syringes and a 70% share of the disposable needle market. HMD group turnover is over Rs 25 billion (US$552 million).

As part of its export strategy, HMD has set up two subsidiaries: HMD Healthcare Ltd in the UK and HMD Healthcare (USA) Inc. in USA. Exports account for around 20% of HMD‟s turnover and the USA accounts for 50% of the total.

Kay & Company

Kay & Company (Kayco) manufactures and exports medical instruments and appliances, and hospital furniture. The company‟s product range includes surgical instruments, laryngoscopes, stethoscopes, suction units, autoclaves, orthopaedic implants, cannulae and hospital furniture. The company supplies healthcare institutions and clinical laboratories through a global network of direct importers. Kayco has been established for more than 50 years.

Kiran Medical Systems

Kiran Medical Systems, established in 1974, claims to be among the three largest manufacturers of medical imaging and X-ray accessories in the world. The company is headquartered in Mumbai, with manufacturing facilities in Navi Mumbai. Kiran's product range includes X-ray cassettes, intensifying screens and protective apparel, distributed in more than 120 countries worldwide under the LUMAX brand.

Lifeline Systems

Lifeline Systems Pvt Ltd was established in 1981 and currently claims to be India‟s leading manufacturer of medical and surgical disposables. The company has ISO 9001:2000 and CE certification and is WHO GMP compliant. Lifeline Systems manufactures disposable products used in anaesthesia, dialysis, transfusion, general surgery, gynaecology, urology, cardiology, cardiothoracic and vascular surgery, as well as general medical disposables.

Narang Medical

Narang Medical Limited, formerly Narang Enterprises, was established in 1989. The company manufactures and exports a wide range of medical and surgical equipment, anaesthesia equipment, diagnostic equipment, disposables, general surgical instruments, dental instrument, orthopaedic instruments and implants, surgical and medical rubber products, hospital hollowware, autoclaves and sterilisers, suction units, rehabilitation aids, laboratory equipment, hospital/medical furniture, gynaecology and obstetrics products, emergency medical products and cold chain equipment. The company exports to more than 80 countries.





36 Quarter II 2011

New Life Surgical Works

New Life Surgical Works, based in New Delhi, specialises in orthopaedic instruments and implants, including bone screws, bone plates, hip prostheses, bone cutting instruments, bone drill and wire instruments and various products used in bone fixation. The company, which was established in 1974, has ISO 9001-2000 certification and exports to around 60 countries.

Pace Devices

Established in 1992, Pace Devices was a distributor of surgical disposable instruments until 1996. In 1997, the company moved into the design and manufacture of endoscopy stone baskets and retrievals in the fields of urology, cardiology and gastroenterology to international quality standards. The company has its own manufacturing unit, an in-house R&D department and a distribution network. Pace Marketing products are manufactured under the „Xyster‟ brand name.

Relisys Medical Devices Ltd.

Relisys Medical Devices Ltd, based in Hyderabad, has taken a lead in India in the indigenous development of medical devices such as coronary stents, catheters, occlusive devices, cardiac surgery disposables and critical care products. The company‟s manufacturing facilities include a stent coating division and an integrated catheter manufacturing facility. In June 2007, the company‟s cardiac stent manufacturing facility was inaugurated by Dr.A.P.J.Abdul Kalam, the President of India.

In 2007, Relisys and Cinvention began a Corel drug-eluting stent (DES) trial, based on the paclitaxel-eluting Corel + C stent with a macro-porous nano-structured carbon-composite coating. Relisys‟ Corel + C drug-eluting stent comprises a cobalt-chromium stent that is coated with a macro-porous nano-structured carbon-composite matrix containing the active drug, paclitaxel. The coating, developed and provided by Cinvention, eliminates the use of polymers and provides a bioactive coating with less thrombogeneity and pro-endothelialisation surface design, therefore reducing tissue inflammation and reaction, but additionally enhancing engraftment and endothelialisation.

Ribbel International Ltd.

Ribbel International Ltd., based in New Delhi, is an established manufacturer and exporter of disposable surgical instruments, including blades, scalpels, stitch cutters and post mortem blade. The company manufactures sterile surgical blades from both carbon steel and stainless steel and a range of disposable scalpels with plastic handles. Ribbel International holds ISO-9001 certification and is entitled to use the CE mark. The company exports its products to more than 85 countries including the USA and Europe.

Sahajanand Medical Technologies

Established in 1997 and based in Surat, Sahajanand Medical Technologies (SMT) is one of the world's largest manufacturers of advanced coronary stents. SMT uses high-precision laser technology and makes both drug-eluting and non-drug-eluting stents. SMT is the largest privately-held producer of coronary drug-eluting stents outside North America, with its stents sold in more than 33 countries and over 25,000 implants.

Among SMT‟s products are drug-eluting stents such as the Infinnium and Supralimus stents, as well as the bare metal Matrix stent. Since 1998, SMT-India has been focused on drug-eluting stents and, in 2002 the Infinnium paclitaxel-eluting stent was commercially launched in the Indian market, with the Supralimus stent following in 2004.

In March 2005, Canadian based research and development company, MIV Therapeutics, signed a letter of intent to acquire SMT, but this was later cancelled by mutual consent. In February 2006, an agreement was formed between MIVT and SMT which focused upon the development of future drug-eluting stent technologies.





Quarter II 2011 37

South India Surgical Company (SISCO)

South India Surgical Company Ltd (SISCO), based in Chennai, has been manufacturing surgical instruments for 60 years. The company manufactures a range of surgical instruments, disposable syringes, endotracheal tubes and Foley catheters. The company boasts ISO and CE certification for its products. SISCO‟s Foley catheters are exported to 30 countries worldwide, including the USA, the UK, Germany, the Netherlands, Denmark, Spain and Australia.

SURU International

SURU International Pvt. Ltd is a medium sized company established in 1991 and based in Mumbai. The company's core business is supplying quality disposable medical devices to customers in over 40 countries. SURU International‟s product range includes sutures and disposable products for infusion therapy, anaesthesia, urology, gastroenterology, blood management and surgery. SURU has ISO 9001:2000 and ISO 13485:2003 certification and a number of products carry the CE mark.

Wadia Group (INOR Orthopaedics, Dental Products of India and Medical Microtechnology Ltd.)

The Wadia Group is a broadly diversified group of companies in India, encompassing the Bombay Burmah Trading Corporation Ltd., the second oldest publicly listed company in the country. Three medical companies operate within the group: Instruments Orthopaedics (INOR), Dental Products of India (DPI) and Medical Microtechnology Ltd.

INOR was set up by an orthopaedic surgeon and has been established for more than 30 years. INOR claims to be the leading orthopaedic company in India today, manufacturing orthopaedic instruments and implants. INOR was the first Indian company to manufacture hip and knee joints, and consequently received an award from the government. The market for these implants had previously been dominated by foreign manufacturers. The company currently exports to several south-east Asian and European countries, and is establishing itself in the international market. INOR also represents Corin Medical Ltd. (orthopaedic implants and instruments) and CMW Laboratories Ltd. (bone cement and accessories) of the UK; Stierlen Maquet AG (operating tables) and Maves (battery operated surgical instruments) of Germany; and Micro Aire Surgical Instruments of the USA (pneumatic equipment).

DPI was established at around the same time as INOR. The company claims to be the only dental company in India that has the BIS (ISI) mark of quality for its major products.

Medical Microtechnology Ltd. was set up in collaboration with Micro Titanium Ltd. of the UK, and is the youngest of HCD‟s three companies. Medical Microtechnology range of products includes high precision forceps and needle holders for ophthalmic surgery, which are exported worldwide through the company‟s UK partners. In India, the products are marketed by a separate trading division, INOR Ophthalmics.

Multinational Manufacturers

Bausch and Lomb

Through a joint venture, Bausch and Lomb manufactures soft contact lenses and various accessories in a facility based in Bhiwadi in the northern state of Rajasthan. The joint venture was set up with the Indian Mohan Singh group at an estimated cost of US$13 million, with each partner contributing 39.9% and the rest being raised through private shareholders. Inaugurated in 1992, the plant represented the first entrance of ready-to-wear soft contact lenses onto the Indian market. Bausch & Lomb also claims to have pioneered lasik surgery in India and to have set new benchmarks in cataract surgery.

Baxter International

Baxter International‟s subsidiary in India was set up in 1997 to provide critical therapies for people with life threatening conditions. Baxter India is headquartered in Gurgaon and has offices across the country.





38 Quarter II 2011

In July 2002, Baxter India acquired Wockhardt Life Sciences‟ IV fluids business for an overall consideration of US$40 million. The acquisition pushed Baxter into a leadership position in the Indian IV fluid market.

India is a strategic market for Baxter's expansion plans in Asia and the acquisition provided the company with a significant position in the critical care market in India. In addition to market leadership, Baxter gained Wockhardt's customer franchise, a country-wide marketing organisation of 165 people and two manufacturing units at Aurangabad and Chennai with a combined capacity of 100 million bottles a year. The IV fluids market in India is valued at Rs. 3.2 billion, growing at over 12% per year.

Baxter (India) Pvt Ltd is a 100% subsidiary of Baxter. It was established in 1997 and markets products used in renal failure, blood and blood component collection and storage, anaesthesia gases and pain management products. The company is a supplier of continuous ambulatory peritoneal dialysis (CAPD) therapy in the country and operates a CAPD Fluid system manufacturing plant at Manesar, near Delhi.

B. Braun

B. Braun‟s India subsidiary was incorporated in 1994. In February 2007, B. Braun India inaugurated a new production facility at Mahindra World City, Chengalpattu, Chennai. The manufacturing plant is a development and production centre for Braun‟s blue-chip products, including Right Heart Catheters, previously manufactured in the US. The company invested over US$3 million in the factory. India would become one of Braun‟s main global production bases and the plant would also be a centre of excellence for R&D.

In 2004, B. Braun Medical (India) launched an OEM/industrial division in India. The division helps industrial customers to design, manufacture, package, sterilise and private-label medical products, and will focus on providing local companies with medical components for the development of customised kits and novel drug delivery systems for formulations manufactured by pharmaceutical companies. The three main areas are chemotherapy drug-delivery systems, medical disposable components for cardiology and critical care, and pharmacy admixture products mainly required for R&D labs & biotechnology.

The division is working with pharmaceutical companies in India manufacturing chemotherapeutic drugs to bundle specialised medical disposables along with the formulations. The OEM/Industrial division also plans to closely work with local Indian medical disposable manufacturers to develop customised kits with a combination of components manufactured locally and imported from different manufacturing sites of Braun.

In 2001, B. Braun India established a manufacturing plant in Ponda, Goa, for surgical sutures. The company has approximately 231 employees. In 2002, B. Braun India entered a distribution agreement with USV Ltd, a leader in diabetes management, under which USV markets Braun‟s Quicktest blood glucose monitoring system in India. In 2003, B. Braun India opened new offices in Mumbai and Delhi, followed by one in Chennai which acts as the regional sales office for the whole of south India.

Becton Dickinson

Becton Dickinson (BD) has had a presence in India since 1989 and established a fully-owned subsidiary in 1996. BD has a major manufacturing facility at Bawal near Rewari in Haryana. This facility is amongst the largest syringe and medical device manufacturing plants in Asia.

In December 2004, BD and Hindustan Latex Ltd (HLL), a Government of India enterprise, entered into an agreement to promote injection safety in India through the introduction of auto-disable syringes; education and training of healthcare workers; and the implementation of advocacy programmes with the Government of India.





Quarter II 2011 39

Dräger

Having overcome a legal technicality on the termination of its former joint venture in India, and following approval by the Indian government‟s Foreign Investment Promotion Board, a new, wholly-owned subsidiary, Dräger Medical (India) Pvt. Ltd., was set up in Mumbai in 2005. It serves as Dräger‟s sales outlet in India, as well as providing consultancy, after sales, logistics and technical services.

GE Healthcare

GE Healthcare Technologies South Asia comprises Wipro GE Healthcare (Wipro GE Medical Systems Pvt Ltd), GE Medical Systems (India) Pvt Ltd, GE BE and Datex Ohmeda India Pvt Ltd. The company also has an Integrated Development Center, at Manipal Hospital in Bangalore. GE Healthcare has over 2,100 employees in India.

GE BE

GE BE Pvt Ltd is a joint venture between GE and Bharat Electronics Ltd, 26% owned by Bharat Electronics. The company was established in 1997. It operates a facility in Whitefield, Bangalore, which manufactures X-ray tubes for R&F and CT systems, as well as components such as high voltage tanks and detector modules for CT systems. The products are exported globally and meet the safety and regulatory standards specified by the FDA, CE, MHW, AERB. The facility has been accredited with ISO 9001 certification. In addition to manufacturing, an engineering team works on the development of new tube technologies to meet global needs. GE BE also markets the conventional X-ray tubes made at Bharat Electronics‟ Pune unit.

In the fiscal year ended 31st March 2006, GE BE achieved turnover of INR 4.2 billion (approximately US$94 million), compared with INR 4.7 billion (approximately US$104.5 million) in 2005 and INR 4.1 billion (US$89.8 million) in 2004. Net profit totalled INR 349 million (approximately US$9.3 million) in 2006, INR 297.3 million (approximately US$6.7 million) in 2005, and INR 488.44 million (approximately US$10.6 million) in 2004.

Wipro GE Healthcare

Based in Bangalore, Wipro GE Healthcare is a joint venture between GE Healthcare and Wipro Corporation. GE owns 51% of the company. A US$165 million company, it claims to be India's largest medical systems sales and service provider and the market leader, with the widest distribution and service reach in South Asia. Wipro GE, which manufactures and exports products for global markets, pioneered the manufacture of ultrasound and CT scanners systems in India for global and regional markets, respectively. Its business activities include the design and manufacture of ultrasound scanners, cardiology products like ECG, foetal monitors for the global market and software services and technology solutions for GE products manufactured worldwide.

Wipro GE Healthcare is also one of the region‟s three GE R&D centres, with responsibilities for software and ultrasound product development.

IDC Bangalore

In June 2006, GE opened its first Integrated Development Center (IDC) at Manipal Hospital in Bangalore. IDC in Bangalore is expected to conduct around 1,000 scans annually as part of clinical trials and will be part of a series of global multi-country clinical studies in the US, the EU and several other countries. Over time, GE will create more IDCs in key strategic locations globally.

Information obtained from the site will be combined with data from other centres and contribute towards the development of new contrast and MI agents or new indications for existing agents. The first studies will focus on Visipaque (iodixanol) an isosmolar contrast agent that was launched by GE in 1996. Future studies will be extended to cover the company's entire diagnostic imaging portfolio.





40 Quarter II 2011

Physicians at Manipal Hospital act as study investigators and provide clinical and imaging services and administration in the hospital. Manipal Hospital will conduct clinical research trials using a range of GE diagnostic imaging technologies, including its LightSpeed VCT, Discovery STe 16 slice PET/CT scanner, Dual Head Gamma Camera with CT (SPECT/CT) and TwinSpeed High Definition Magnetic Resonance (HDMR) imaging system.

Global Technology Operations - India (GTO)

The GE Healthcare Global Technology Operations at the Bangalore John F Welch Technology Centre is a centre of excellence for software development, tables and power components for medical systems. The unit delivers medical system products and services for modalities like CT, MR, MI, vascular, ultrasound, nuclear, X-ray, healthcare and patient monitoring. The engineering R&D team comprises 650 employees and works with all GE‟s medical engineering teams located in France, the US, Japan, Hungary, Israel and China.

Johnson & Johnson

Johnson & Johnson Medical India (JJMI), a division of Johnson & Johnson Limited, is one of the largest and most comprehensive medical devices companies in India. JJMI encompasses well-known franchises in India, including Ethicon, Cordis, J&J Hospital Supplies and DePuy.

Ethicon India claims to be the largest producer of absorbable and non-absorbable surgical sutures in India and a market leader in the wound closure business. Ethicon‟s suture finishing plant, which is based in Aurangabad, is certified to ISO13485.

Ethicon India has introduced Vicryl Plus, which it claims is the world‟s first antibacterial suture, offering protection against bacterial colonisation.

Philips

In 2008, Philips reached an agreement to acquire India-based Meditronics, a manufacturer of general X-ray systems. Upon closing of this transaction early in 2009, Meditronics became part of the Imaging Systems business within Philips‟ Healthcare sector. Financial details of this agreement were not disclosed.

Philips said that the transaction highlighted its growing presence in high-growth healthcare markets in emerging economies, and followed the earlier acquisitions of healthcare companies in India, China and Brazil. The transaction underscored the company‟s accelerating efforts to expand its healthcare business in emerging markets and India in particular. This, Philips said, underlined its initiative to step up investments in these high-growth areas while also delivering on its commitment to supply affordable healthcare solutions in emerging markets.

The company said that Meditronics‟ high-quality proven economy segment product portfolio would complement its existing high-end General X-Ray range and further strengthen its leading position in India‟s high-growth imaging and monitoring equipment market. The company quoted analysts‟ estimates that the General X-Ray segment of the Indian market will show annual growth rates of 10% or higher. Philips said it would invest to expand sales in the local Indian market and would use its global distribution network to expand its offering of economy X-ray products in other emerging and, importantly, mature markets.

The agreement marked Philips‟ growing presence in high-growth healthcare markets in emerging economies. The Meditronics acquisition strengthened the company‟s position in India‟s high-growth imaging and monitoring equipment market.

In July 2005, Philips India, the Indian Space Research Organisation (ISRO), part of the Department of Space under the Ministry of Science and Technology, Apollo Telemedicine Networking Foundation (ATNF) and Development of Humane Action (DHAN), a Madurai-based NGO, became jointly involved in DISHA (Distance Healthcare Advancement), a project aimed at meeting the healthcare needs of the less privileged in India.





Quarter II 2011 41

DISHA is a telemedicine initiative conceived by Philips India for providing distance healthcare to under-served people. This strategic partnership between a government agency (ISRO), the largest healthcare service provider in Asia (Apollo), an NGO in the country (Dhan) and a global leader in imaging and medical diagnostics (Philips) is the first of its kind in India. The DISHA initiative is being piloted in Theni district in Tamil Nadu and was formally inaugurated in Madurai.

Philips has custom-built a tele-clinical van complete with diagnostic equipment, including ultrasound, X-ray, a defibrillator and an ECG machine. ISRO is providing connectivity through VSAT and allocating the required bandwidth on its INSAT satellite, while Apollo Specialty Hospitals in Madurai is the referral hospital for the DISHA mobile tele-clinical van and provides staff for the van. DHAN provides the link to the local community and advice on nutrition and hygiene.

The DISHA tele-clinical van travels to identified locations once a week and is expected to cover a population of 500,000. This pilot project will be evaluated and the results will be used to build a business model for a healthcare delivery system, including the pricing for such a facility. The support of additional NGOs will also be sought to strengthen the interaction between the patients, doctors and the facilities.

Siemens

Siemens began to manufacture medical products in India in 1954. In 1996, the company opened a facility in Goa to manufacture mobile X-ray units for Siemens‟s worldwide requirements. Siemens claims to have been the first medical engineering company to achieve ISO 9001 Certification in India, in 1998.

In September 1999, Siemens established Siemens Hearing Instruments Pvt. Ltd. (SHI) to market and distribute hearing instruments in India. The company is a 100% subsidiary of Siemens Audiologische Technik GmbH. Headquartered in Bangalore, SHI has seven representative offices; in Bangalore, Chennai, Secunderabad, Mumbai, Delhi, Chandigarh and Kolkata, with a national network of 315 dispensing centres in 115 major cities in the country. In addition, SHI has set up ITE labs in Bangalore and Mumbai for customised products and repair services.

Siemens Medical Solutions has over 1,500 employees in India, including 360 working in sales and services. The company also had around 110 sales and service partners. It operates offices in 16 locations, including the following:

Head office and Uptime Service Centre – Mumbai;

Regional sales offices - Bangalore, Chennai, Delhi, Hyderabad, Kolkata and Mumbai;

Branch Offices - Ahmedabad, Bhopal, Chandigarh, Ciombatore, Jaipur, Kochi, Lucknow, Nagpur, Patna and Pune.

Siemens claims to have the leading market share in India for the medical products which it offers. With the Indian medical market growing by around 11% annually, Siemens‟ orders for medical products rose by 9% to Rs.5.3 billion in fiscal 2006, or EUR 98 million.

Sales grew by 12.4% to Rs.4.1 billion during the year, driven by expansion and modernisation undertaken by major hospitals and rising demand for new equipment and technology from the public and private sectors. In key segments such as CT and angiography, Siemens believes its sales in India grew at a significantly higher rate than the market, with over 35% growth for angiography and over 25% for CT scanners. For MRI and ultrasound, the company believes its sales rose in-line with market growth.

In March 2008, Siemens announced plans to build its first molecular imaging biomarker production facility in Chennai, India. The new facility will enable the healthcare providers in and around Chennai to access the positron emission tomography-computed tomography (PET-CT) technology to diagnose patients with life-threatening diseases, such as cancer and cardiac and neurological ailments.





42 Quarter II 2011

PETNET Solutions, a subsidiary of Siemens Medical Solutions USA, operates the largest PET radiopharmacy network with 49 radiopharmacies and distribution centres in the US, South Korea and the UK that produce and distribute PET radiopharmaceuticals to hospitals, clinics and research facilities for PET imaging. The new facility in Chennai will produce and supply the required radiopharmaceuticals to hospitals that have PET-CT facilities, which will help ease the burden of healthcare providers to produce their own radiopharmaceuticals. As a result, the new facility will also help reduce the cost of nuclear medicine and expand its reach to a wider community.

The new location will feature a Siemens Eclipse HP cyclotron and will be Siemens' first molecular imaging biomarker production facility in India. The Eclipse cyclotron will be deployed to manufacture fluorodeoxyglucose (FDG), the imaging biomarker used in PET-CT facilities to assist with diagnosis and staging of disease processes and to monitor cellular response to treatments, such as chemotherapy and radiotherapy. Currently, there is no PET-CT in the Indian state of Tamil Nadu due to a critical lack of F18-FDG, which has a half-life of only 110 minutes (losing half of its radioactivity every 110 minutes) and, hence, cannot be imported or transported long distances. The new cyclotron will guarantee reliable delivery of PET radiopharmaceuticals and will vastly increase availability of FDG, which means that many more patients in Chennai and nearby areas will have access to world-class PET-CT imaging. For cancer patients, this will allow for earlier lesion detection and differential diagnosis of primary cancers, which is important for treatment and disease management.

SISL Bangalore

AT SISL Bangalore, Siemens is focused on developing new medical software, including syngo post-processing applications for oncology care, ultrasound, CT, MRI and molecular imaging; developing new healthcare information systems; on-going research into software for clinical imaging; and research into the deployment of RFID technology for healthcare. The company currently employs around 1,100 software engineers.

Goa Works

The Goa works encompasses around 86,200 square metres of engineering and production space. It has 74 employees, with 70% of its activities outsourced. The site is a global competency centre for the Multimobil 2.5/10 mobile X-ray generator and the Multimobil 5C image intensifier, manufactures X-ray generators and is a RAD components centre for radiological tables. It is also responsible for a portfolio of products for the Indian market. R&D for medical hardware products is also conducted in Goa.

Between 2003 and 2005, the factory generated sales growth of 45% and increased its export share from 14% to 40%, according to Siemens. The company aims to increase factory sales by 115% from 2005 to 2007, with the export share rising from 40% to 65%. During fiscal 2006, exports from the Goa works increased by over 44%.

Telemedicine

In India, Siemens expects growth to come from the strong increase in the number of hospital chains such as Apollo, Wockhardt and Fortis, the move towards setting up healthcare facilities with government institutions and the expansion of telemedicine, connecting distant healthcare providers to specialty centres and creating mobile hospitals for rural areas.

Currently, there are several Siemens-made mobile hospitals serving rural India which were developed in co-operation with partners such as Nargis Dutt Foundation in Mumbai, Bhagwan Mahaveer Cancer Hospital in Jaipur, the Government of Delhi and the Government of Uttaranchal.

Terumo

Headquartered in Trivandrum, Kerala, Terumo Penpol Ltd. manufactures blood bags and offers a range of medical electronic products for use in blood transfusion centres and blood banks. The company claims to be the largest producer of blood bags in India, and has 465 employees.





Quarter II 2011 43

Terumo Penpol also operates the Metabolic Disorders Research Center which was inaugurated in November 1998 and is located in Jagathy, Trivandrum City. The centre aims to promote research into metabolic and genetic disorders which are more prevalent in Kerala than other parts of India, including chronic calcific pancreatitis, multinodular goitre, endomyocardial fibrosis and mucoid vasculopathy. It is the only facility which screens newborns for genetic disorders in the state.

The facilities at the centre are made available to medical professionals and the public. They are focused on research into the following areas:

Screening new born for genetic disorders

Screening healthy individuals for unconventional risk factors for coronary disease and stroke

Evaluation of metabolic disorders

Screening of amniotic fluid

Maternal serum screening for the prenatal diagnosis of genetic disorders

Carl Zeiss Meditec

Carl Zeiss began direct operations in India in January 1998 through the establishment of a subsidiary in Bangalore and branch offices in New Delhi, Mumbai, Kolkata, Chennai, Ahmedabad and Hyderabad. The company has over 75 employees working around the country.

In December 2002, together with the Aravind Eye Hospital in Madurai, Carl Zeiss set up the Carl Zeiss Center of Excellence in Glaucoma, a joint project aimed at combating preventable blindness caused by glaucoma. The centre aims to provide improved patient care and advanced training for ophthalmologists for the early diagnosis and therapy of the disease. The Aravind Hospital numbers among the most productive in the world, according to the company.





44 Quarter II 2011

Exports

Exports reached a new record high of US$590.0 million, a rise of 5.9% over the previous year, in 2009. In CAGR terms, exports expanded by 9.4% in the 2005-2009 period. Exports have grown every year since 1998.

Exports of Medical Equipment & Supplies, 1993-2009 (US$000s)

33,0

05

37,0

87 78,0

15

71,1

19 130,

498

170,

123

202,

501

232,

838

288,

915

341,

801

411,

721

477,

653

489,

293

557,

145

589,

969

45,9

63

66,4

61

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Change in Medical Exports, 1993-2009 (%)

-20

0

20

40

60

80

100

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009





Quarter II 2011 45

Consumables

Exports of consumables rose by 17.4% over the previous year to US$152.2 million in 2009. This category made up 25.8% of the total and had a CAGR of 11.0% in the 2005-2009 period. Syringes, needles & catheters, the largest sub-category, grew by 9.1% to reach US$81.0 million in 2009 but woundcare products fell by 0.6% to US$39.1 million.

Diagnostic Imaging

Diagnostic imaging products was the largest category accounting for 41.2% of the total at a value of US$243.1 million in 2009. This category fell by 11.7% over the previous year but this was largely due to a spike in exports in 2008; this category has been fairly stagnant over the five year period, expanding at a CAGR of 1.5%. All three sub-categories, electrodiagnostic apparatus, radiation apparatus and imaging parts & accessories, fell in 2009.

Dental Products

Exports of dental products accounted for 2.3% of the total at a value of US$13.8 million in 2009. This category grew by 21.5% over the previous year and had a CAGR of 30.2% in the 2005-2009 period. Much of this category was in instruments & supplies, valued at US$10.2 million, while capital equipment exports made up the remainder worth US$3.6 million in 2009.

Orthopaedic Products

Orthopaedic & prosthetic product devices exports rose by 27.8% over the previous year to reach US$12.1 million in 2009. This category, which made up 2.1% of the total, had a CAGR of 33.5% in the 2005-2009.

Patient Aids

The smallest category, patient aids made up just 1.7% of total exports at a value of US$10.2 million in 2009. This category declined by 16.1% over the previous year and had a CAGR of 10.4% in the 2005-2009 period.





46 Quarter II 2011

Medical Equipment Exports by Product Area, 2005-09 (US$000s)

2005 2006 2007 2008 2009

Consumables 100,210 114,484 119,031 129,657 152,193 Diagnostic imaging 228,563 242,830 231,200 275,127 243,058 Dental products 4,803 8,690 11,444 11,360 13,801 Orthopaedic & prosthetic 3,821 4,741 6,175 9,507 12,146 Patient aids 6,868 19,390 13,626 12,157 10,205 Others 67,456 87,518 107,817 119,337 158,566

TOTAL 411,721 477,653 489,293 557,145 589,969

Medical Equipment Exports by Product Area, 2005-09 (%)

2005 2006 2007 2008 2009

Consumables 24.3 24.0 24.3 23.3 25.8 Diagnostic imaging 55.5 50.8 47.3 49.4 41.2 Dental products 1.2 1.8 2.3 2.0 2.3 Orthopaedic & prosthetic 0.9 1.0 1.3 1.7 2.1 Patient aids 1.7 4.1 2.8 2.2 1.7 Others 16.4 18.3 22.0 21.4 26.9

TOTAL 100.0 100.0 100.0 100.0 100.0

Medical Equipment Exports by Product Area, 2009 (%)

Consumables

25.8%Others

26.9%

Patient Aids

1.7%

Orthopaedic

products

2.1%Dental products

2.3%

Diagnostic imaging

apparatus

41.2%





Quarter II 2011 47

Medical Equipment Exports by Product Area, 2005-2009 (% of Total)

0

10

20

30

40

50

60

70

80

90

100

2005 2006 2007 2008 2009

CONSUMABLES DIAGNOSTIC IMAGING DENTAL PRODUCTS

ORTHOPAEDIC PRODUCTS PATIENT AIDS OTHERS

Change in Medical Equipment Exports by Product Area, 2006-09 (%)

2006 2007 2008 2009 CAGR 05-09

Consumables 14.2 4.0 8.9 17.4 11.0 Diagnostic imaging 6.2 -4.8 19.0 -11.7 1.5 Dental products 80.9 31.7 -0.7 21.5 30.2 Orthopaedic & prosthetic 24.1 30.2 54.0 27.8 33.5 Patient aids 182.3 -29.7 -10.8 -16.1 10.4 Others 29.7 23.2 10.7 32.9 23.8

TOTAL 16.0 2.4 13.9 5.9 9.4





48 Quarter II 2011

CAGR of Medical Equipment Exports by Product Area, 2005-09 (%)

11.0 10.4

23.8

9.4

1.5

33.5

30.2

0

5

10

15

20

25

30

35

40


imaging

apparatus

Dental

products

Orthopaedic

products

Patient Aids Others Total

The USA was the leading destination for medical devices from India with US$114.3 million worth shipped, equal to 19.4% of the total, in 2009. Singapore, Germany, Japan and China were the other leading destinations with shares of 11.7%, 6.9%, 5.3% and 4.4% of the total respectively. The European Union was the destination for 18.4% of the total at a value of US$108.4 million in 2009.

Leading Medical Equipment Destinations by Product Area, 2009 (US$000s)

USA Singapore Germany Japan China EU-27

Consumables 9,965 2,401 7,500 470 1,673 36,556 Diagnostic imaging 62,649 47,752 23,888 30,237 22,869 36,748 Dental products 4,315 271 764 0 0 3,907 Orthopaedic & prosthetic 1,827 391 548 0 0 1,508 Patient aids 1,116 58 1,885 0 19 2,546 Others 34,419 18,114 5,960 733 1,217 27,120

TOTAL 114,291 68,987 40,545 31,440 25,778 108,385

Leading Medical Equipment Destinations by Product Area, 2009 (%)

USA Singapore Germany Japan China EU-27

Consumables 6.5 1.6 4.9 0.3 1.1 24.0 Diagnostic imaging 25.8 19.6 9.8 12.4 9.4 15.1 Dental products 31.3 2.0 5.5 0.0 0.0 28.3 Orthopaedic & prosthetic 15.0 3.2 4.5 0.0 0.0 12.4 Patient aids 10.9 0.6 18.5 0.0 0.2 24.9 Others 21.7 11.4 3.8 0.5 0.8 17.1

TOTAL 19.4 11.7 6.9 5.3 4.4 18.4





Quarter II 2011 49

Leading Medical Equipment Destinations, 2009 (%)

USA

19.4%

Other EU

11.5%

Others

40.8%

China

4.4%

Singapore

11.7%

Japan

5.3%

Germany

6.9%





50 Quarter II 2011

Exports of Medical Equipment, 2005-09 (US$000s)

2005 2006 2007 2008 2009

CONSUMABLES 100,210 114,484 119,031 129,657 152,193

Woundcare Products 24,660 29,169 35,413 39,374 39,120 Medical dressings (adhesive) 4,428 5,761 7,256 6,569 3,578 Medical dressings (non-adhesive) 15,269 18,057 21,024 26,198 27,121 Sutures, sterile, surgical & dental goods 4,963 5,351 7,133 6,607 8,421

Syringes, Needles & Catheters 62,432 70,542 69,980 74,212 80,981 Syringes (with/without needles) 8,783 10,256 10,494 10,974 8,165 Tubular metal needles/ needles for sutures 9,109 13,484 9,167 12,859 17,439 Other needles, catheters, cannulae etc 44,540 46,802 50,319 50,379 55,377

Others 13,118 14,773 13,638 16,071 32,092 Blood-grouping reagents 25 17 296 307 472 First-aid boxes & kits 727 926 593 1,047 9,483 Ostomy appliances 0 0 0 0 0 Surgical gloves 12,366 13,830 12,749 14,717 22,137


Electrodiagnostic Apparatus 37,934 47,852 66,741 88,028 80,097 Electrocardiographs 5,945 521 2,655 1,395 9,798 Ultrasonic scanning apparatus 19,472 14,985 10,802 20,343 23,997 Magnetic resonance imaging apparatus 1,485 33 223 1,486 7,025 Scintigraphic apparatus 0 51 53 62 6 Other electro-diagnostic apparatus 11,032 32,262 53,008 64,742 39,271

Radiation Apparatus 77,129 96,429 64,558 86,068 77,512 Computed tomography apparatus 759 250 549 1,038 438 Other medical X-ray apparatus 72,138 81,251 49,810 76,750 75,180 Medical alpha beta, gamma ray apparatus 4,232 14,928 14,199 8,280 1,894

Imaging Parts & Accessories 113,500 98,549 99,901 101,031 85,449 Contrast media 32 108 137 350 1,209 X-ray tubes 44,533 38,261 46,971 58,401 62,420 Parts & accessories for radiation apparatus 66,548 57,556 50,497 40,097 21,226 Medical X-ray film (flat) 1,074 1,630 1,298 1,418 448 Medical X-ray film (rolled) 1,313 994 998 765 146

DENTAL PRODUCTS 4,803 8,690 11,444 11,360 13,801

Dental Capital Equipment 959 1,710 4,625 3,521 3,606 Dental drill engines 46 138 308 1 11 Dental X-ray apparatus 275 127 234 396 324 Dental & similar chairs (inc. parts & accessories) 638 1,445 4,083 3,124 3,271

Dental Instruments & Supplies 3,844 6,980 6,819 7,839 10,195 Dental cements & other fillings 2,464 4,098 4,294 5,397 4,801 Other instruments & appliances used in dentistry 796 1,440 1,191 1,473 1,681 Artificial teeth 16 142 166 233 1,747 Other dental fittings 568 1,300 1,168 736 1,966

ORTHOPAEDIC & PROSTHETIC DEVICES 3,821 4,741 6,175 9,507 12,146


2,849 3,300 4,813 7,530 7,761 Artificial joints 130 326 204 670 2,002 Other artificial body parts 842 1,115 1,158 1,307 2,383

PATIENT AIDS 6,868 19,390 13,626 12,157 10,205

Portable aids 5,053 7,445 5,382 6,840 4,107 Hearing aids, except parts & accessories 317 748 209 414 303 Pacemakers, except parts & accessories 192 1,104 506 749 533 Other aids for the disabled 4,544 5,593 4,667 5,677 3,271

Therapeutic appliances 1,815 11,945 8,244 5,317 6,098 Mechano-therapy apparatus 138 330 79 141 140 Therapeutic respiration apparatus 405 1,285 507 746 4,128 Ultra-violet or infra-red ray apparatus 1,272 10,330 7,658 4,430 1,830

OTHERS 67,456 87,518 107,817 119,337 158,566

Wheelchairs, not mechanically propelled 30 2,244 2,832 2,467 4,144 Wheelchairs, mechanically propelled 9 64 316 8 0 Other medical, surgical, dental furniture 2,116 1,556 2,200 2,380 8,944 Medical, surgical sterilisers 1,372 3,754 3,296 4,918 5,803 Ophthalmic instruments & appliances 3,029 3,145 4,662 7,372 8,755 Other instruments & appliances 60,900 76,755 94,511 102,192 130,920

TOTAL 411,721 477,653 489,293 557,145 589,969





Quarter II 2011 51

Medical Equipment Export Trends

2008 2009

% of Total 2009

% Change 2009 CAGR

CONSUMABLES 129,657 152,193 25.8 17.4 11.0

Woundcare Products 39,374 39,120 6.6 -0.6 12.2 Medical dressings (adhesive) 6,569 3,578 0.6 -45.5 -5.2 Medical dressings (non-adhesive) 26,198 27,121 4.6 3.5 15.4 Sutures, sterile, surgical & dental goods 6,607 8,421 1.4 27.5 14.1

Syringes, Needles & Catheters 74,212 80,981 13.7 9.1 6.7 Syringes (with/without needles) 10,974 8,165 1.4 -25.6 -1.8 Tubular metal needles/ needles for sutures 12,859 17,439 3.0 35.6 17.6 Other needles, catheters, cannulae etc 50,379 55,377 9.4 9.9 5.6

Others 16,071 32,092 5.4 99.7 25.1 Blood-grouping reagents 307 472 0.1 53.7 108.4 First-aid boxes & kits 1,047 9,483 1.6 805.7 90.0 Ostomy appliances 0 0 0.0 ~ ~ Surgical gloves 14,717 22,137 3.8 50.4 15.7

DIAGNOSTIC IMAGING 275,127 243,058 41.2 -11.7 1.5

Electrodiagnostic Apparatus 88,028 80,097 13.6 -9.0 20.5 Electrocardiographs 1,395 9,798 1.7 602.4 13.3 Ultrasonic scanning apparatus 20,343 23,997 4.1 18.0 5.4 Magnetic resonance imaging apparatus 1,486 7,025 1.2 372.7 47.5 Scintigraphic apparatus 62 6 0.0 -90.3 ~ Other electro-diagnostic apparatus 64,742 39,271 6.7 -39.3 37.4

Radiation Apparatus 86,068 77,512 13.1 -9.9 0.1 Computed tomography apparatus 1,038 438 0.1 -57.8 -12.8 Other medical X-ray apparatus 76,750 75,180 12.7 -2.0 1.0 Medical alpha beta, gamma ray apparatus 8,280 1,894 0.3 -77.1 -18.2

Imaging Parts & Accessories 101,031 85,449 14.5 -15.4 -6.9 Contrast media 350 1,209 0.2 245.4 147.9 X-ray tubes 58,401 62,420 10.6 6.9 8.8 Parts & accessories for radiation apparatus 40,097 21,226 3.6 -47.1 -24.8 Medical X-ray film (flat) 1,418 448 0.1 -68.4 -19.6 Medical X-ray film (rolled) 765 146 0.0 -80.9 -42.3

DENTAL PRODUCTS 11,360 13,801 2.3 21.5 30.2

Dental Capital Equipment 3,521 3,606 0.6 2.4 39.3 Dental drill engines 1 11 0.0 1,000.0 -30.1 Dental X-ray apparatus 396 324 0.1 -18.2 4.2 Dental & similar chairs (inc. parts & accessories) 3,124 3,271 0.6 4.7 50.5

Dental Instruments & Supplies 7,839 10,195 1.7 30.1 27.6 Dental cements & other fillings 5,397 4,801 0.8 -11.0 18.1 Other instruments & appliances used in dentistry 1,473 1,681 0.3 14.1 20.5 Artificial teeth 233 1,747 0.3 649.8 223.3 Other dental fittings 736 1,966 0.3 167.1 36.4

ORTHOPAEDIC & PROSTHETIC DEVICES 9,507 12,146 2.1 27.8 33.5


7,530 7,761 1.3 3.1 28.5 Artificial joints 670 2,002 0.3 198.8 98.1 Other artificial body parts 1,307 2,383 0.4 82.3 29.7

PATIENT AIDS 12,157 10,205 1.7 -16.1 10.4

Portable aids 6,840 4,107 0.7 -40.0 -5.1 Hearing aids, except parts & accessories 414 303 0.1 -26.8 -1.1 Pacemakers, except parts & accessories 749 533 0.1 -28.8 29.1 Other aids for the disabled 5,677 3,271 0.6 -42.4 -7.9

Therapeutic appliances 5,317 6,098 1.0 14.7 35.4 Mechano-therapy apparatus 141 140 0.0 -0.7 0.4 Therapeutic respiration apparatus 746 4,128 0.7 453.4 78.7 Ultra-violet or infra-red ray apparatus 4,430 1,830 0.3 -58.7 9.5

OTHERS 119,337 158,566 26.9 32.9 23.8

Wheelchairs, not mechanically propelled 2,467 4,144 0.7 68.0 242.8 Wheelchairs, mechanically propelled 8 0 0.0 -100.0 -100.0 Other medical, surgical, dental furniture 2,380 8,944 1.5 275.8 43.4 Medical, surgical sterilisers 4,918 5,803 1.0 18.0 43.4 Ophthalmic instruments & appliances 7,372 8,755 1.5 18.8 30.4 Other instruments & appliances 102,192 130,920 22.2 28.1 21.1

TOTAL 557,145 589,969 100.0 5.9 9.4





52 Quarter II 2011

Leading Destinations, 2009

USA Singapore Germany Japan China

CONSUMABLES 9,965 2,401 7,500 470 1,673

Woundcare Products 4,073 273 2,954 374 387 Medical dressings (adhesive) 29 0 233 42 179 Medical dressings (non-adhesive) 3,941 31 2,556 332 106 Sutures, sterile, surgical & dental goods 103 242 165 0 102

Syringes, Needles & Catheters 3,775 1,974 4,176 96 1,286 Syringes (with/without needles) 381 0 453 0 74 Tubular metal needles/ needles for sutures 1,260 759 441 96 660 Other needles, catheters, cannulae etc 2,134 1,215 3,282 0 552

Others 2,117 154 370 0 0 Blood-grouping reagents 109 0 0 0 0 First-aid boxes & kits 536 76 0 0 0 Ostomy appliances 0 0 0 0 0 Surgical gloves 1,472 78 370 0 0


Electrodiagnostic Apparatus 33,317 10,954 4,238 857 5,728 Electrocardiographs 140 297 126 0 53 Ultrasonic scanning apparatus 4,564 3,753 702 233 4,832 Magnetic resonance imaging apparatus 4,726 1,807 0 492 0 Scintigraphic apparatus 0 0 0 0 0 Other electro-diagnostic apparatus 23,887 5,097 3,410 132 843

Radiation Apparatus 6,012 8,400 16,716 28,107 7,100 Computed tomography apparatus 158 12 248 0 0 Other medical X-ray apparatus 5,629 8,370 16,465 28,101 7,096 Medical alpha beta, gamma ray apparatus 225 18 3 6 4

Imaging Parts & Accessories 23,320 28,398 2,934 1,273 10,041 Contrast media 313 0 0 0 0 X-ray tubes 15,261 26,851 270 248 9,561 Parts & accessories for radiation apparatus 7,731 1,547 2,664 1,025 480 Medical X-ray film (flat) 15 0 0 0 0 Medical X-ray film (rolled) 0 0 0 0 0

DENTAL PRODUCTS 4,315 271 764 0 0

Dental Capital Equipment 805 148 51 0 0 Dental drill engines 11 0 0 0 0 Dental X-ray apparatus 126 148 0 0 0 Dental & similar chairs (inc. parts & accessories) 668 0 51 0 0

Dental Instruments & Supplies 3,510 123 713 0 0 Dental cements & other fillings 1,461 0 546 0 0 Other instruments & appliances used in dentistry 519 123 114 0 0 Artificial teeth 792 0 0 0 0 Other dental fittings 738 0 53 0 0

ORTHOPAEDIC & PROSTHETIC DEVICES 1,827 391 548 0 0


1,144 318 223 0 0 Artificial joints 194 0 0 0 0 Other artificial body parts 489 73 325 0 0

PATIENT AIDS 1,116 58 1,885 0 19

Portable aids 951 43 177 0 19 Hearing aids, except parts & accessories 88 0 32 0 0 Pacemakers, except parts & accessories 99 0 0 0 0 Other aids for the disabled 764 43 145 0 19

Therapeutic appliances 165 15 1,708 0 0 Mechano-therapy apparatus 41 8 1 0 0 Therapeutic respiration apparatus 120 0 81 0 0 Ultra-violet or infra-red ray apparatus 4 7 1,626 0 0

OTHERS 34,419 18,114 5,960 733 1,217

Wheelchairs, not mechanically propelled 0 0 387 0 0 Wheelchairs, mechanically propelled 0 0 0 0 0 Other medical, surgical, dental furniture 331 44 0 0 117 Medical, surgical sterilisers 1,807 9 205 0 0 Ophthalmic instruments & appliances 815 244 724 37 43 Other instruments & appliances 31,466 17,817 4,644 696 1,057

TOTAL 114,291 68,987 40,545 31,440 25,778

Percentage of Total 19.4 11.7 6.9 5.3 4.4





Quarter II 2011 53

Balance of Medical Trade, 2005-2009 (US$000s)

2005 2006 2007 2008 2009

CONSUMABLES -9,093 -48,454 -73,688 -74,951 -57,776

Woundcare Products 10,799 15,391 18,781 23,161 15,734 Medical dressings (adhesive) 1,660 1,512 3,657 2,120 -1,471 Medical dressings (non-adhesive) 7,699 12,288 12,231 18,795 15,164 Sutures, sterile, surgical & dental goods 1,440 1,591 2,893 2,246 2,041

Syringes, Needles & Catheters -31,534 -76,482 -103,008 -109,952 -98,569 Syringes (with/without needles) -5,886 -17,692 -17,938 -2,233 -7,838 Tubular metal needles/ needles for sutures -6,242 -725 -13,257 -9,743 -2,710 Other needles, catheters, cannulae etc -19,406 -58,065 -71,813 -97,976 -88,021

Others 11,642 12,637 10,539 11,840 25,059 Blood-grouping reagents -309 -337 -53 -367 -442 First-aid boxes & kits 704 896 416 796 9,392 Ostomy appliances 0 0 0 0 -158 Surgical gloves 11,247 12,078 10,176 11,411 16,267

DIAGNOSTIC IMAGING -118,565 -166,641 -247,073 -318,126 -311,264

Electrodiagnostic Apparatus -126,126 -137,110 -151,479 -184,994 -178,619 Electrocardiographs 4,748 -1,360 1,098 -2,341 5,252 Ultrasonic scanning apparatus -23,906 -44,771 -46,228 -50,368 -51,054 Magnetic resonance imaging apparatus -28,109 -33,141 -66,313 -66,278 -62,458 Scintigraphic apparatus -877 -747 -518 -3,996 -101 Other electro-diagnostic apparatus -77,982 -57,091 -39,518 -62,011 -70,258

Radiation Apparatus 7,873 10,274 -34,334 -26,314 -22,694 Computed tomography apparatus -36,495 -46,077 -47,279 -61,651 -43,091 Other medical X-ray apparatus 45,435 53,345 11,910 38,379 29,209 Medical alpha beta, gamma ray apparatus -1,067 3,006 1,035 -3,042 -8,812

Imaging Parts & Accessories -312 -39,805 -61,260 -106,818 -109,951 Contrast media -8,449 -13,434 -10,403 -15,930 -10,878 X-ray tubes 25,389 8,167 9,541 24,186 31,782 Parts & accessories for radiation apparatus 8,053 -5,261 -26,652 -65,200 -73,776 Medical X-ray film (flat) -9,240 -13,640 -15,200 -20,460 -22,108 Medical X-ray film (rolled) -16,065 -15,637 -18,546 -29,414 -34,971

DENTAL PRODUCTS -18,450 -21,901 -28,457 -35,935 -31,724

Dental Capital Equipment -5,777 -6,778 -4,526 -6,404 -3,371 Dental drill engines -179 -159 249 -64 -154 Dental X-ray apparatus -286 -1,035 -1,520 -1,312 -635 Dental & similar chairs (inc. parts & accessories) -5,312 -5,584 -3,255 -5,028 -2,582

Dental Instruments & Supplies -12,673 -15,123 -23,931 -29,531 -28,353 Dental cements & other fillings -4,109 -2,890 -4,459 -7,810 -8,261 Other instruments & appliances used in dentistry -6,877 -8,492 -15,457 -17,419 -18,733 Artificial teeth -355 -281 -361 -453 899 Other dental fittings -1,332 -3,460 -3,654 -3,849 -2,258

ORTHOPAEDIC & PROSTHETIC DEVICES -25,791 -29,853 -43,953 -69,105 -84,638


-1,125 548 -266 864 2,471 Artificial joints -6,668 -17,863 -24,859 -31,390 -40,100 Other artificial body parts -17,998 -12,538 -18,828 -38,579 -47,009

PATIENT AIDS -43,883 -48,156 -74,374 -87,029 -123,772

Portable aids -31,256 -39,608 -52,256 -50,727 -80,273 Hearing aids, except parts & accessories -7,340 -8,991 -12,119 -16,553 -19,486 Pacemakers, except parts & accessories -7,776 -11,087 -20,387 -21,170 -25,660 Other aids for the disabled -16,140 -19,530 -19,750 -13,004 -35,127

Therapeutic appliances -12,627 -8,548 -22,118 -36,302 -43,499 Mechano-therapy apparatus -4,119 -5,820 -9,977 -14,039 -14,920 Therapeutic respiration apparatus -9,244 -11,403 -18,934 -25,718 -29,731 Ultra-violet or infra-red ray apparatus 736 8,675 6,793 3,455 1,152

OTHERS -261,016 -273,534 -339,427 -399,689 -297,353

Wheelchairs, not mechanically propelled -283 1,842 2,290 1,376 2,961 Wheelchairs, mechanically propelled -335 -335 -690 -1,231 -1,380 Other medical, surgical, dental furniture -2,378 -4,220 -7,168 -13,165 -3,730 Medical, surgical sterilisers -4,898 -5,023 -15,119 -24,944 -5,664 Ophthalmic instruments & appliances -53,105 -46,365 -65,613 -65,224 -62,395 Other instruments & appliances -200,017 -219,433 -253,127 -296,501 -227,145

TOTAL -476,798 -588,539 -806,972 -984,835 -906,527





54 Quarter II 2011

Accessing the Market

Distribution

Potential exporters to India need to appoint a local agent, or indeed several, dependent on the areas they intend to cover. Private hospitals and medical laboratories do not directly import medical equipment, but source it through agents or distributors. The distributor or agent benefits hospitals by acting as a single contact for numerous items and can provide information from various countries.

Details of a number of distributors are available in a separate document.

Medical Device Regulation

While the Department of Health has nominal jurisdiction over medical devices, detailed medical device regulation is still under consideration and the sale of medical devices has yet to be fully regulated. The limited regulation that has been introduced to date covers sterile medical devices under the Drugs and Cosmetics Act 1940 and subsequent amendments.

The Drugs Consultative Committee decided to bring all sterile medical devices under Section 3 (b) (iv) of the Drugs and Cosmetics Act. New guidelines covering the import, manufacture and sale of sterile medical devices were published in the Gazette notification S.O. 1468 (E) on 6th October 2005 and became effective from 1st March 2006. Subsequently, in March 2009, clarification was published, which provided a list of additional sterile medical devices to be included under the provisions of the Drugs and Cosmetics Act and Rules. With the addition of the new items, the list includes the following:

Cardiac stents;

Drug eluting stents;

Catheters;

Intra-ocular lenses;

IV cannulae;

Bone cements;

Heart valves;

Scalp vein set;

Orthopaedic implants;

Internal prosthetic replacements;

Spinal needles;

Insulin syringes;

Three way stop cock as an accessory of IV cannula/catheter/perfusion set;

Endotracheal tubes;

Introducer sheath;

Annuloplasty ring;

Cardiac patch;

Cochlear implant;

Extension tube;

Close wound drainage set;

Tracheostomy tube with/without cuff;

AV fistula needle;

Extension line as a accessory of infusion set;

ANGO kit/PTCA/cath lab kit;

Heart lung pack;

Measure volume set;

Flow regulator as a accessory of infusion set;

Haemodialysis tubing set/blood tubing set/arterial venous tubing set;

Dialysis catheter.





Quarter II 2011 55

The devices must now be licensed by an approved central licensing authority for manufacture, sale or distribution. Committees will also be set up to evaluate and monitor quality of devices and to ensure GMP compliance.

The guidelines require the procedure for registration and import licence as set out in the Drugs and Cosmetics Rules to be followed. A licence is also required for the manufacture of sterile devices, as per the Rules. In addition, importers and retailers are required to obtain appropriate sale licences from the State Licensing Authorities.

Since the publication of the guidelines, additional clarification has been provided on a number of issues, including the classification of groups of medical devices, such as catheters, which may be grouped together according to end use and the material used in manufacture, thereby requiring a single registration fee for the „family‟ of products.

At the end of August 2006, specific guidance was issued concerning orthopaedic implants, which are commonly imported as non-sterile devices and subsequently sterilised by the hospital. An expert committee concluded that if the end use of a notified device is as a sterile product, then it falls under the ambit of the guidelines and requires registration and import licence under the Drug and Cosmetics Rules.

In September 2007, additional clarification of the guidelines for the import registration and manufacture of medical devices was published. The clarification states that a pre-requisite for the registration of medical devices under the provisions of the Drugs and Cosmetics Rules is a Free Sale Certificate in the country of origin, issued by the Ministry of Health/National Regulatory Authority.

Clarification with regard to the requirement of regulatory status of a medical device to be registered in India is as follows:

For medical devices manufactured in the USA, USFDA approval for the manufacture and free sale of the device in USA is to be submitted;

For medical devices manufactured in Australia, Japan and Canada, approval for the manufacture and free sale in the respective country of origin is to be submitted;

For medical devices manufactured in European Countries, CE certification along with approval for manufacture and the Free Sale Certificate from the respective country of origin is to be submitted;

For medical devices manufactured in countries other than those specified above, approval for the manufacture and free sale in the respective country of origin is to be submitted, together with approval from any one of the following: US FDA, TGA Australia, Health Canada, Ministry of Health, Labour and Welfare Japan or CE Certification.

The clarification additionally states that:

All peripheral stents are covered under the provisions of the Drugs and Cosmetics Rules and, as such need to be registered for import and licences must be approved by the Central License Approving Authority (CLAA) for indigenous manufacture.

All “Cardiac Patches” and “Occluders” used in interventional cardiology or for closing holes in the cardiovascular system are to be considered as an “Internal Prosthetic Replacement” (Medical Devices) and must be registered under the provisions of the Drugs and Cosmetics Rules. The import of any cardiac patches and occluders requires a valid Registration Certificate and a Form 10 Licence with immediate effect.

The clarification also details the requirements for clinical trials with regard to the importation of stents. Where manufacturers wish to import stents that are currently in use in countries outside India, a six month clinical trial is required on 100 patients. In the case of new stents that are not already in use outside India, a 12 month clinical trial on 100 patients is required.

Further information on the guidelines can be found on the Central Drugs Standards Control website at http://cdsco.nic.in



http://cdsco.nic.in/



56 Quarter II 2011

Background to Device Regulation

In 2004, a government advisory body, the Mashelkar Committee, called for the creation of a specific medical devices division within the Central Drugs Standard Control Organisation to address the management of the approval, certification and quality assurance of medical devices. This would involve making suitable provision in the Drugs and Cosmetics Act 1940 and its subsequent amendments, under which medical devices are defined as “drug”:

“such devices intended for internal or external use in the diagnosis, treatment, mitigation or prevention of disease or disorder in human beings or animals, as may be specified from time to time by the Central Government by notification in the Official Gazette, after consultation with the Board”.

Under the Drugs and Cosmetics (2nd Amendment) Rules, 1994, a new schedule M-III (Requirements of factory premises for manufacture of medical devices) was inserted. The schedule covers the following:

General requirements: location and surroundings, buildings, water supply, waste disposal, health, clothing and sanitation of workers, medical services;

Requirements of manufacture of medical devices;

Raw materials;

Storage areas

Washing, drying and sealing areas;

Sterilisation;

Testing facilities; and

Records





Quarter II 2011 57

Healthcare Analysis

Demographics

More detailed figures on demographics in India can be found in Tables 1-13 of the accompanying Health Statistics document.

Population

India was the second country in the world after China to officially cross the one billion mark. The final calculation of the Census of India 2001 put the population at 1,028,610,328, comprising 532,156,772 males and 496,453,556 females. In 2001, population growth was estimated to be around 1.93%.

According to official estimates, the population of India was around 1,176,742,000 in 2010 with a growth rate of 1.4%.

India has a comparatively young population. According to the Census, around 35.3% of the population was aged less than 15 years in 2001, while only around 4.8% of people were aged 65 and over. Despite this comparatively low proportion, India‟s elderly population is vast, at around 49.1 million according to the 2001 census.

As in most other countries around the world, the Indian population is gradually ageing. In 2010, the over 65 age group is estimated at 5.4%. This proportion has been forecast to increase to 6.2% by 2016 and 8.3% by 2026.

The most populous state is Uttar Pradesh, accounting for 16.8% of India‟s inhabitants in 2010. Maharashtra accounts for around 9.4%, Bihar for 8.2%, West Bengal for 7.5% and Andhra Pradesh for 7.1%. Average population density in India in 2010 was 358 inhabitants per square kilometre.

The urban population in Delhi in 2001 was 9.8 million. According to the 2001 census, there were 27 cities in India with populations in excess of one million. In addition to Delhi, principal municipalities include Greater Mumbai (Bombay) (11.9 million inhabitants), Kolkota (Calcutta) (4.6 million), Bangalore (4.3 million) and Chennai (formerly Madras) (4.2 million). In 2001, 27.8% of the population lived in urban developments, whilst 72.2% lived in rural areas. The country has approximately 638,356 villages.

Summary of Demographic Data

Number Year

Population size (millions) 1,176.7 2010

Growth rate (%) 1.4 2010

Aged 65+ (%) 5.4 2010

Birth rate/000 population 22.8 2008

Death rate/000 population 7.4 2008

IMR/000 live births 53.0 2008

Life expectancy at birth (male) 62.6 2006

Life expectancy at birth (female) 64.2 2006

Source: National Health Profile of India, Central Bureau of Health Intelligence, EIU.

Projected Population, 2011-2016

2011 2012 2013 2014 2015 2016

Population (millions) 1,202.0 1,220.0 1,238.0 1,256.0 1,274.0 1,291.0

% Growth 1.5 1.5 1.5 1.4 1.4 1.4

Number Aged 65+ (millions) 67.3 69.5 73.0 75.4 79.0 81.7 % Aged 65+ 5.6 5.7 5.9 6.0 6.2 6.3

Source: EIU.





58 Quarter II 2011

Birth Rate

India launched its National Family Welfare Programme in 1952. Among the country‟s achievements since that time is a reduction in the total fertility rate, from 6.0 in 1951 to around 2.7 in 2007 according to the Central Bureau of Health Intelligence. The crude birth rate has been reduced from 40.8 in 1951 to 22.8 in 2008.

Despite progress over the years, the birth rate remains very high by world standards, ranked amongst the top 10. The birth rate remains higher in rural areas, at a rate of 24.4 per thousand population, compared to urban areas, where it was 18.5 per thousand population in 2008.

India‟s demographic indicators vary greatly between states. In 2008, the birth rate per thousand population varied from 29.1 per thousand population in Uttar Pradesh to 14.3 in Lakshadweep.

Death Rate

The crude mortality rate has been reduced, from around 25 deaths per thousand population in 1951, to 7.4 in 2008. The rate remains higher in rural areas, at 8.0 per thousand population in 2008, compared with 5.9 in urban areas. The lowest crude mortality rate was in Nagaland, at 4.6 deaths per thousand population; the highest was in Orissa, at 9.0 deaths per thousand population, in 2008.

Infant Mortality

While still high compared with developed countries, the national infant mortality rate in India has been significantly reduced, from 72.0 deaths per thousand births in 1996 to 53.0 in 2008. The rate remains higher in rural areas, at 58.0 deaths per thousand births, compared with 36.0 in urban areas.

Infant mortality rates also vary widely across the States and Union Territories, from 10 deaths per thousand live births in Goa to 70 per thousand live births in Madhya Pradesh in 2006.

Life Expectancy at Birth

Average life expectancy in India has been projected at around 65.8 years for males and 68.1 years for females between 2006 and 2010. Although still low by global standards, life expectancy has been increasing since the 1950s, due to medical advances and improved sanitary conditions. In 1951, average life expectancy was just 37 years.





Quarter II 2011 59

Public Health

Causes of Death

Due to India‟s size and geography, detailed figures for causes of death are unavailable. There are systems in place for recording deaths by cause, although the coverage of these varies between states. At the national level, the Registrar General of India is responsible for collection, collation and publication of cause of death statistics. Causes of death for rural areas were collected under the Survey of Causes of Rural Death until December 1998. The scheme operated in Public Health Centres (PHCs) in around 1,000 sample villages, the selection criteria for which appeared to rely on the availability of medical personnel. The cause of death was classified by paramedical personnel, through an interview with a member of the deceased person‟s household using a structured questionnaire. This was then checked by the medical officer attached to the PHC.

In 1998, a total of 40,351 deaths were recorded under the Survey of Causes of Rural Death in India. Of these, 17.2% were attributed to respiratory conditions, 12.5% to circulatory disease and 9.6% to infectious and parasitic diseases.

In the same year, a study by the WHO regional office for South East Asia estimated that non-communicable diseases, including accidents, injuries and poisonings, accounted for 2,759,371 deaths, 32.0% of all deaths in 1998. The data for this study was compiled mainly from medical certification of deaths in urban areas, together with the rural Survey of Causes of Death. According to this data, cardiovascular diseases were responsible for more than one million deaths in 1998, 13.0% of the total. Around 8.7% were attributed to external causes, 6.7% were attributed to chronic respiratory disorders, and 3.4% were attributed to cancer.

Since January 1999, the Survey of Causes of Death has been integrated with the Sample Registration System (SRS). The SRS cause of death component is based on a list of causes and symptoms and their corresponding ICD 10 codes and eliminates the structured questionnaire. SRS covers both rural and urban areas. In urban areas, a Medical Certification of Cause of Death scheme also operates, whereby all medically attended deaths are expected to be registered and the cause recorded according to a national list, which is based on the ICD coding and guidelines.

In 2000, a total of 510,580 deaths were medically certified and recorded by cause, representing around 14.5% of the 3.5 million deaths registered for that year. Of these, 24.3% were attributed to circulatory diseases, 25.7% to infectious and parasitic diseases and 11.3% to external causes. Deaths during the first year of life accounted for 12.0% of the total reported, of which 64.7% were attributed to perinatal conditions.

The largest ever study of causes of death in India began in January 2004. The study is following a larger, enhanced SRS with a sample frame of 7.6 million people who will be followed until 2014. Around 600,000 deaths will be reviewed from this sample population for cause specific mortality data. The study relies on a system of verbal autopsy and, while substantial misclassification is anticipated, it is expected to result in considerably better cause of death data than has previously been available. In order to collect detailed information on neonatal, child, adult and maternal deaths, four different forms have been introduced to focus the verbal autopsy interview on causes of death specific to each group.

Communicable and Non-communicable Diseases

India‟s vast population, geography, and economic conditions combined make the control of infectious diseases a constant battle. With the help of international aid, the Government of India has set up a number of health projects to combat disease. The scale of the problem is indicated by the number of recorded cases of potentially life threatening diseases recorded annually. Each year there are around two million cases of malaria, and more than two million people develop active tuberculosis. India has an estimated one million leprosy sufferers, four million HIV carriers, and an estimated 45% of the population are at risk from filariasis. A number of successes were highlighted in the National Health Policy 2002, among them the eradication of smallpox in 1981, and of guinea worm in 2000.





60 Quarter II 2011

India‟s geography also makes it particularly prone to natural disasters, especially cyclones, and floods and landslides caused by heavy rain. Waterborne diseases are a major threat following floods, as drinking water becomes contaminated.

Although some infectious diseases are particularly prevalent in the rural states, with around half the population living in extreme poverty, the country‟s health problems are not confined to the rural poor. The health status of the urban poor is said to be as bad as, if not worse than, those living in rural areas.

Cardiovascular diseases in particular represent a major problem. According to the Central Bureau of Health Intelligence, there were 23,367,840 cases of ischaemic heart disease equal to an incidence rate of 2,080 per 100,000 population in 2004. The incidence rate of the disease has risen over the years, from 1,919 per 100,000 population in 1998, when there were 18,600,940 reported cases. There were 554,194 deaths from ischaemic heart diseases in 2004, compared to 463,562 cases in 1998. Incidences of stroke numbered 930,895, of which 693,455 were fatal, in 2004. Cancer is an increasing problem, and there were 819,354 cases and 259,814 deaths from the disease in 2004.

In 2008, there were 1,517,333 cases of pulmonary tuberculosis, equal to an incidence rate of 132.6 per 100,000 population. There were 66,204 deaths from the disease in 2008.

India has considerably more people suffering from diabetes than any other country in the world and this situation is not expected to change. The International Diabetes Federation estimates there are around 58.7 million people with the disease in 2010.

National Rural Health Mission

The National Rural Health Mission 2005-2012 was launched in April 2005 by the Government of India. The aim of the Mission is to provide effective healthcare to the rural population throughout the country, with particular focus on 18 states that have low public health indicators and/or inadequate infrastructure. These are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh.

The Mission is part of the government‟s commitment to increase public health spending to 2-3% of GDP.

Key components of the Mission include:

Provision of a female health activist in each village;

The preparation of a village health plan by a local team, headed by the Health & Sanitation Committee of the Panchayat;

Strengthening of rural hospitals for effective curative care, and accountability of these to the community through Indian Public Health Standards; and

Integration of vertical Health & Family Welfare Programmes and Funds for optimal utilisation of finances and infrastructure and strengthening delivery of primary healthcare.

Universal Immunisation Programme

Reported incidence of the main childhood diseases has declined as a direct result of the government‟s Universal Immunisation Programme (UIP), which was launched in 1985. The programme became part of the CSSM programme in 1992 and, subsequently, the RCH programme in 1997.

By 1993, 50.7% of urban children and 30.9% of rural children between the ages of 12 and 23 months had been vaccinated against the major childhood diseases, (e.g. diphtheria, tetanus, polio, measles). Immunisation coverage for tuberculosis (BCG) was 96% in 1997/98, and there was 79% coverage for tetanus toxoid for pregnant women. As a result of the programme, the incidence of vaccine preventable diseases has decreased by 73% since 1980.





Quarter II 2011 61

In 1998/99, a special campaign against measles in urban areas was begun with UNICEF assistance. The emphasis of the project was to cover unprotected children up to three years of age with a single dose of measles vaccine in 40 major cities across India. The impact on measles has been particularly effective; 40,840 cases were reported in 2009 compared with 160,216 in 1985.

The pulse polio immunisation scheme, which was launched in 1995, has had a significant impact of the number of reported cases of poliomyelitis. Under the scheme, all children under five years of age are given oral polio vaccine annually. In 2009, there were just 741 reported cases, compared with 8,675 in 1995.

Another major initiative under the UIP has been to reduce neonatal tetanus by immunising women with tetanus toxoid vaccine. The programme also provides a cold chain system for transportation and storage of vaccines. The incidence of neonatal tetanus has been reduced from 9,313 reported cases in 1990 to 889 in 2009. The number of pertussis cases has also been greatly reduced through immunisation, from 184,368 in 1985 less than 30,000 per year by 1995.

Reported Incidence of Vaccine Preventable Diseases, 2009

2009

Diphtheria 3,480 Pertussis n/a Neonatal tetanus 889 Other tetanus 2,051 Polio 741 Measles 40,840

Source: Ministry of Health & Family Welfare.

Malaria

Under the National Anti-Malaria Programme (NAMP), the incidence of malaria was reduced from around 6.5 million cases in 1976 to around 2.2 million cases in 1984 and subsequently contained to two to three million cases each year despite population growth. Under the Eighth Plan, a major intensification of efforts was directed towards the tribal areas in the north-eastern states (Andhra Pradesh, Madhya Pradesh, Gujarat, Maharashtra, Bihar, Rajasthan and Orissa), in which 64% of malaria cases and 77% of the more dangerous Plasmodium falciparum infections occur. Sikkim has been included in this support since 2003/04.

Under the enhanced Malaria Control Project, World Bank assistance was directed towards 1,045 PHCs in 100 rural districts of eight states: Andhra Pradesh, Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh, Maharashtra, Orissa and Rajasthan; and 19 urban areas since 1997. The World Bank commitment was US$164.8 million for the duration of the project, which ran until 31st December 2005.

In July 2005, a grant agreement was signed for the launch of an Intensified Malaria Control Project (IMCP) with assistance from the Global Fund to Fight AIDS, Tuberculosis and Malaria in 10 states (seven north-east states and selected high risk areas of Orissa, Jharkhand and West Bengal) to increase access to rapid diagnosis and treatment in remote and inaccessible areas, reduce malaria transmission risk through the use of insecticide treated bed nets (ITNs) and larvivorous fish, enhance community awareness about malaria control and promote community, NGO and private sector participation. The total grant approved was US$63.5 million in two phases.

In 2009, there were 1.56 million reported cases of malaria, of which around 0.84 million were Plasmodium falciparum, responsible for 1,144 deaths during the year.





62 Quarter II 2011

Reported Malaria Incidence & Deaths, 2009

2009

P. falciparum cases (million) 0.84 Malaria cases (million) 1.56 Deaths 1,144

Source: National Malaria Eradication Programme/Ministry of Health and Family Welfare.

Filariasis

Filariasis is a major health hazard in some parts of the country. In early 1996, public health experts in India called upon the government to prioritise prevention and control of lymphatic filariasis. Over 45% of the Indian population is at risk of infection, making the problem second only to malaria amongst vector borne diseases.

The revised strategy of the National Filaria Control Programme planned to cover the entire population and to be more cost effective and technically precise. The primary focus is a National Filaria Day, when the entire population is targeted for a single dose of diethlycarbamazine citrate (DEC). This dose is repeated annually for five years.

Kala-azar

Kala-azar, a form of leishmaniasis, is endemic in Bihar, Jharkhand, West Bengal and a few districts of Uttar Pradesh. The centrally sponsored Kala-azar Control Programme has been operative since 1990/91. The strategy for kala-azar includes indoor residual insecticide spraying, early diagnosis and treatment and education and communication. The number of cases and deaths have started to decline in recent years. In 2010, there were 39,178 reported cases and 70 deaths.

Reported Kala-azar Cases & Deaths, 2010

2010

Cases 39,178 Deaths 70

Source: Ministry of Health & Family Welfare. Provisional figures.

Japanese Encephalitis

Japanese Encephalitis (JE) largely affects children and sporadic outbreaks have caused concern. The disease has a high fatality rate and survivors have varying degrees of neurological complications. Identification of high risk groups and epidemiological monitoring of the disease for effective prevention and control have been major activities over the last few years. Priorities for controlling the disease include vaccination of children aged 1-15 years. In 2006, the government integrated JE vaccination with the Universal Immunisation Programme with single dose live attenuated JE vaccine in 11 endemic districts of Uttar Pradesh, Assam, West Bengal and Karnataka for children aged 1-15 years.

In 2010, there were 4,341 reported cases of suspected JE and 605 deaths in the 15 states that report viral activity.

Suspected Japanese Encephalitis Cases & Deaths, 2010

2010

Cases 4,341 Deaths 605

Source: Ministry of Health & Family Welfare. Provisional figures.





Quarter II 2011 63

National Leprosy Eradication Programme

The National Leprosy Eradication Programme is a major public health programme. An estimated 60% of the world‟s leprosy sufferers are in India, and around 15-20% of those are children. In 1981, India had an estimated four million leprosy cases from a world total of 12 million. The national programme has greatly reduced this number and, in December 2005, achieved the goal of elimination of leprosy as a public health problem, defined as less than one case per 10,000 population at the national level. On 31st December 2005, the prevalence rate was recorded at 0.95 cases per 10,000 population. By the end of April 2009, this number had been further reduced to 0.72 cases per 10,000.

Leprosy is treated by MDT (multi-drug therapy), which has been available since the early 1980s. MDT, a combination of refamicin, clofazimine and dapsone, is provided free for all leprosy patients by the WHO and is now available in all PHCs. By March 2001, around 9.53 million patients had been cured by MDT.

National Tuberculosis Control Programme

India accounts for around 20% of the global burden of tuberculosis (TB). In 2000, India had a total of 8.5 million cases, of which 3.8 million were bacillary pulmonary cases. Although the disease is not always fatal, the 1.8 million new cases of TB annually result in an estimated 370,000 deaths. Around 75% of TB cases in India occur in people between 15 and 45 years old; the most economically active and productive segment of society. The appearance of HIV/AIDS in India, which weakens resistance to TB, coupled with evidence of new drug-resistant strains of TB, means the country faces a public health hazard of potentially enormous costs.

The National Tuberculosis Programme was revised and extended in 1997, with the assistance of a World Bank credit of US$142.4 million. The loan has been supporting the largest intervention against TB ever undertaken by international donors, following a revised national strategy to reverse the high incidence of TB in India by focusing on curing more people. The initial National Tuberculosis Control Project ran until 31st March 2006. In August 2006, the World Bank approved funding of US$170 million for a second National Tuberculosis Control Project, which is expected to run until 31st March 2012. Additional funding is being provided by the Government of India.

The objective of the second National Tuberculosis Control project is to achieve global targets of 70% case detection and 85% cure rate in all districts, and for the zones where Directly Observed Treatment Short course (DOTS) has been under implementation for five or more years, to decrease the incidence of smear-positive tuberculosis.

The Revised National Tuberculosis Control Programme (RNTCP) includes DOTS and improved medical and management practices, including:

Diagnosing patients based on sputum analysis rather than X-rays;

Emphasising curing infected patients who come forward for treatment to reduce the risk of infection, and administering DOTS;

Registering, monitoring and following-up patients more rigorously;

Decentralising TB control services to reach remote areas.

Under the second national project, special emphasis will be given to improving laboratory services, supervision and monitoring, continuous operations research, advocacy, and health communication and strengthening institutional capacity to implement the programme.

In addition, the project aims to maximise the inclusion to tuberculosis patients under the DOTS strategy. Following the expansion of DOTS to all districts in the country, the programme will implement appropriate strategies to ensure that services reach the poor, tribes and other difficult to reach groups, as well as patients who consult non-RNTCP health service providers, children and adolescents, patients infected with HIV/AIDS and multi-drug resistant cases.





64 Quarter II 2011

HIV/AIDS

Between 1986 and 31st July 2007, 182,787 AIDS cases were reported to the National AIDS control Organisation (NACO). Of these, 86.3% of were sexually transmitted, 4.3% were perinatal transmission, 1.8% were injecting drug users and 1.9% were infected via blood products. For the remainder, the route of infection is unknown. Up to 2006, a total of 11,682 deaths due to AIDS had been reported.

In collaboration with the National Institute of Health and Family Welfare and the National Institute of Medical Statistics, NACO has published estimates of India‟s population living with HIV/AIDS each year since 1998. These official estimates rely on direct extrapolation of annual sentinel surveillance data from public sector antenatal and sexually transmitted infection clinics, as well as some high-risk groups.

This methodology has been criticised for potential over-estimation of the HIV/AIDS burden in India, for example by a population-based study of HIV in south India, published in BMC Medicine on 13th December 2006 (1741-7015-4-31).

The study sampled 13,838 people, aged 15-49 years, from 66 rural and urban clusters using a stratified random method to represent adults in Guntur district in Andhra Pradesh. Of these, 91.2% gave a blood sample which was tested for HIV. The study concluded that overall prevalence of HIV in adults in Guntur district, adjusted for age, sex and rural/urban distribution of the population was 1.72%. In comparison, the sentinel surveillance method resulted in an estimate of 4.38% of people in the 15-49 age range living in Guntur district with HIV, some 2.5 times higher than the population-based study estimate.

The study concluded that the perceived overestimation of the HIV burden by the official method, compared with the population-based estimate, was due to:

(i) The addition of substantial extra HIV estimates from STI clinics; (ii) The common practice of referral of HIV-positive and HIV-suspected people by private practitioners

to public hospitals, including antenatal clinics; and (iii) A preferential use of public hospitals by lower socioeconomic strata that had a higher HIV

prevalence in this study.

The study authors suggested that the potential major implications of their findings for the overall HIV estimate for India need to be examined.

In 2007, however, sentinel surveillance was expanded to 1,134 sites across India and is believed to provide the most accurate estimate to date. The official estimates for 2007 suggest that national adult HIV prevalence in India is approximately 0.34% (0.44% for males and 0.23% for females), affecting 1.8-2.9 million people.

Cancer

There are around 800,000 new cases of cancer each year in India and a total of around 2.5 million cases. Around 75-80% of cases are in an advanced stage at the time of detection. More than 50% of all cases are tobacco related cancers. Current national projections suggest that the prevalence of cancer for all sites will double by 2026. The Cancer Control Programme began in 1975. The programme was converted into a national programme in 1985 and re-named the National Cancer Control Programme (NCCP). The programme was revised in December 2004 in recognition of the growing need to bridge geographical gaps in the availability of cancer treatment facilities across the country. There are five schemes under the revised programme, each of which receives funding, including for the purchase of equipment for the diagnosis and treatment of cancer:

Recognition of new Regional Cancer Centres (RCCs). There are currently 25 RCCs in the country.





Quarter II 2011 65

Strengthening of existing RCCs. The main objective in establishing RCCs was to provide cancer prevention activities and comprehensive treatment facilities across the country. The revised scheme envisages enhancement of the capacity of cancer treatment facilities in existing RCCs to enable them to act as tertiary level referral centres.

Development of an Oncology Wing. This scheme has been in operation under the national programme for more than a decade in order to proved government medical colleges with financial assistance to develop an oncology wing. The scheme has now been widened to include government hospitals that are not attached to medical colleges with the objective of reducing geographical gaps in cancer treatment facilities across India;

District Cancer Control Programme (DCCP). The DCCP was initiated in 1990/91 and focuses on cancer prevention, early detection, minimal treatment of common cancers and provision of supportive care in the district.

Decentralised NGO Scheme. This scheme aims to extend financial assistance to non-government organisations (NGOs) working for cancer and operates through a nodal agency, which is either an RCC, or a government medical college or hospital with radiotherapy facilities.

The Indian Council of Medical Research has been collecting data under the National Cancer Registry Programme since 1985. Under the Hospital Based Cancer Registries, data is collected from five regional centres:

Tata Memorial Hospital, Mumbai (Bombay);

Kidwai Memorial Institute of Oncology, Bangalore;

Cancer Institute, Chennai (Madras);

Regional Cancer Centre, Thiruvananthapuram;

Assam Medical College, Dibrugarh.

Between 1st January 2001 and 31st December 2003, a total of 122,273 cancer patients were diagnosed and registered at these five centres, of whom 63,444 were males and 58,829 were females. Overall, the leading cancer sites among males were the mouth (9.6% of total), lung (8.4%), tongue (6.3%) and oesophagus (6.2%). The leading sites among females were the breast (23.7%), cervix uteri (21.4%), mouth (6.5%) and ovary (5.3%). There are, however, regional variations, particular among males. In Chennai, for example, the leading site among males was the stomach, which accounted for 9.1% of cases; mouth cancer ranked 2nd at this centre (8.4%), while lung cancer ranked 3rd (6.9%).

In addition to the hospital based registry, the Indian Council of Medical Research runs a Population Based Cancer Registry (PBCR). Until recently, this involved six cities: Bangalore, Barshi, Bhopal, Chennai, Delhi and Mumbai, representing a total population of around 38.4 million. During the three year period, 2001-2003, a total of 88,613 new cases of cancer were registered in these cities, of whom 44,077 were male and 44,536 were female.

Healthcare System

The Ministry of Health and Family Welfare comprises the Department of Health and Family Welfare, the Department of AYUSH, and the Department of Health Research, each of which is headed by the Secretary to the Government of India. The Ministry of Health and Family welfare is responsible for the implementation of national health and family welfare programmes, such as the prevention and control of major communicable diseases, maternal and child health and family planning, as well as the promotion of traditional and indigenous systems of medicine, and the provision of technical assistance to the states in the prevention and control of seasonal disease outbreaks and epidemics.





66 Quarter II 2011

Department of Health and Family Welfare

Regulatory bodies for monitoring the standards of medical education, training and research activities operate under the Department of Health and Family Welfare at central level. These are:

The Medical Council of India,

The Dental Council of India,

The Indian Nursing Council,

The Pharmacy Council of India.

The Directorate General of Health Services (DGHS) is attached to the Department of Health and Family Welfare and has subordinate offices throughout the country. The DGHS renders technical advice on medical and public health matters and is involved in the implementation of various health schemes.

Various colleges, institutes, teaching hospitals and training centres operate under the DGHS, along with a variety of research establishments, as follows:

National Academy of Medical Sciences (India),

All India Institute of Medical Sciences, New Delhi,

Post-graduate Institute of Medical Education & Research, Chandigarh,

Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry,

Lady Hardinge Medical College and Associated Hospitals,

Mahatma Gandhi Institute of Medical Sciences, Sewagram,

Raj Kumari Amrit Kaur College of Nursing, New Delhi,

Rural Health Training Centre, Najafgarh,

Lady Reading Health School, Delhi,

National Institute of Communicable Diseases, Delhi,

Bio-Chemistry Division,

Epidemiology Division,

Helminthology Division,

Division of Medical Entomology & Vector Control,

Microbiology Division,

Zoonosis Division,

Pasteur Institute of India, Coonoor,

National Institute of Mental Health and Neuro Sciences, Bangalore,

All India Institute of Physical Medicine and Rehabilitation, Mumbai (Bombay),

All India Institute of Speech and Hearing, Mysore,

Central Institute of Psychiatry, Ranchi,

Central Research Institute, Kasauli,

Indian Council of Medical Research,

Chest Institute, University of Delhi,

Central Health Education Bureau,

Central Bureau of Health Intelligence,

North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong,

National Institute of Biologicals,

BCG Vaccine Laboratory, Guindy, Chennai (Madras),

All India Institute of Hygiene and Public Health, Kolkata,

Central Leprosy Teaching and Research Institute, Chengalpattu,

Regional Leprosy Teaching and Research Institute, Raipur (M.P.),

Regional Leprosy Training and Research Institute, Aska, Ganjam (Orissa),

Regional Leprosy Training and Research Institute, Gouripur, Bankura (West Bengal),

National Tuberculosis Institute, Bangalore,

National Medical Library.





Quarter II 2011 67

The Central Government Health Scheme (CGHS) was introduced in 1954, in Delhi, to provide comprehensive medical care facilities to central government employees and members of their families. Over the years, the scheme has expanded to cover Mumbai (Bombay), Kolkata (Calcutta), Patna, Chennai (Madras), Hyderabad, Bangalore, Pune, Nagpur, Ahmedabad, Jaipur, Kanpur, Allahabad, Meerut, Lucknow and Jabalpur. Besides the central government employees, CGHS facilities are available to: employees of autonomous organisations; retired central government servants; widows of central government employees in receipt of family pension; members of parliament; ex-governors; ex-vice presidents; retired judges of Supreme Court and High Court; freedom fighters and members of the general public (currently in 14 specified areas of Delhi only); workers of the Employees State Insurance Corporation, Kanpur; retired employees of the Indian Council of Agricultural Research (optees in Delhi/New Delhi only); employees of Kendriya Vidyalaya Sangathan stationed at Delhi/New Delhi, Calcutta, Chennai (Madras), Bangalore, Hyderabad and Secundrabad; employees of departmental canteens in cities where the scheme is functioning; press representatives; employees of Delhi High Court.

The facilities available under the scheme include; outpatient care supply of medicines; laboratory and X-ray investigations; domiciliary visits; emergency treatment; ante-natal care; confinement and post-natal care; advice on family welfare; specialist consultations and hospitalisation facilities in government hospitals and private hospitals recognised under CGHS.

Various organisations provide support to the Department of Health and Family Welfare, including:

The Medical Stores Organisation (MSO), which is responsible for the procurement and supply of medical stores to hospitals and dispensaries all over the country at economical rates. The MSO has seven depots in Mumbai (Bombay), Calcutta, Guwahati, Hyderabad, Karnal, Chennai (Madras) and New Delhi, with quality control testing laboratories in Mumbai (Bombay), Chennai (Madras) and (Kolkata) Calcutta.

The Central Drug Standard Control Organisation, whose main functions are quality control of imported drugs, new drug approval, acting as the Central Licence Approving Authority with respect to blood and blood products, sera and vaccine, and to co-ordinate the activities of State/Union Territories Drug Control Authorities.

The Drugs Consultative Committee, which advises for uniform implementation of the Drugs and Cosmetics Act.

The Central Licence Approving Authority (CLAA), which grants and renews licences with respect to blood banks, sera and vaccines, and intravenous fluids.

The National Institute of Health & Family Welfare, New Delhi, which pursues education, training, research and consultancy activities in the field of health and family welfare.

The International Institute for Population Sciences, Mumbai (Bombay), which works in the field of population studies, under the administrative control of the Ministry of Health and Family Welfare.

The Indian Medical Association (IMA), based in Delhi, which works in collaboration with the Ministry of Health and Family Welfare. The IMA is one of the largest voluntary organisations in India working for Public Health, Medical Education, and the Family Welfare Programme. The IMA has a network of 1,200 branches and a total membership of 85,000 doctors throughout the country.

Organisations providing medical relief and supplies under the auspices of the Department of Health and Family Welfare include the Indian Red Cross Society, St. John Ambulance and the Emergency Medical Relief Division of the Directorate General of Health Services (see Primary Care, First Aid and Disaster Relief for further details). The Emergency Medical Relief Division is responsible for providing support to State Governments in the event of natural disasters. Medical supplies are kept in readiness for emergencies and can be distributed to the population through the Indian Red Cross Society, as well as to other countries through the Ministry of External Affairs.





68 Quarter II 2011

The Department of AYUSH

The Department of Indian Systems of Medicine was established under the Ministry of Health and Family Welfare in 1995. In 2003, it was renamed the Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy (AYUSH). The Department is supported by various regulatory bodies, institutions and research councils, including the Central Council of Indian Medicine and the Central Council of Homeopathy.

The necessity to initiate organised measures to enable the Indian Systems of Medicine (Ayurveda, Siddha, Unani, Yoga, Naturopathy and Homeopathy) to develop and find a role in the overall healthcare delivery system for the benefit of the population was envisaged in the National Health Policy, 1983. The Indian people have faith in their traditional systems of medicine, which are cheaper, available in rural areas, and generally have no side effects.

The objectives of the Department of AYUSH are to upgrade educational standards in the country‟s Indian Systems of Medicines and Homeopathy colleges, to strengthen existing research institutions and ensure a time-bound research programme on identified diseases for which these systems have an effective treatment, to draw up schemes for the promotion, cultivation and regeneration of medicinal plants used in these systems, and to develop pharmacopoeia standards for AYUSH drugs.

Health Insurance

Although some form of health protection is provided by government and major private employers, not to mention private health insurance cover for those who can afford it, the health insurance schemes available to the public are generally basic and out of the reach of most people and coverage is less than 10% of the population, most of whom are in the upper income groups. Health related expenditure is a major cause of debt in the rural communities and out of pocket spending on hospital care is estimated to cause almost 25% of hospitalised Indians to fall below the poverty line.

The main provider is the government-run General Insurance Company (GIC), along with its four subsidiaries, The New India Assurance Co., Oriental Fire and Insurance Co., National Insurance Co., and The United India Insurance Co. GIC is able to obtain funds for underwriting from other countries, although foreigners are not allowed in the Indian insurance sector. The Indian Medical Association has also attempted to encourage individual participation in healthcare financing through its savings scheme, Medisave.

India‟s first ever medical insurance scheme for the poor was launched in the 1996-97 budget. „Janarogya Yojana‟ was expected to enrol more than four million policyholders in its first year of operation, although reports suggest this has not been the case.

The scheme is marketed by all four subsidiaries of GIC, and covers people between the ages of five and 70 years for pre and post hospitalisation expenses, for up to 30 and 60 days respectively. The insurance cover costs around Rs.5,000 (US$141) per annum.

Insurance is, however, on a reimbursement basis. Patients are required to pay for treatment out of their own pockets and then claim reimbursement; a process which, according to local reports, can take up to six months.

To address the inadequacies of existing schemes, the government promised to design a community based universal health insurance scheme during 2003/04. Premiums were proposed at Rs.1 per day for an individual, Rs.1.5 per day for a family of five and Rs.2 per day for a family of seven. This would cover reimbursement of medical expenses of up to Rs.30,000 towards hospitalisation, accidental death cover of Rs.25,000 and compensation for loss or earnings at a rate of Rs.50 per day for a maximum of 15 days. In order to make the scheme available to families below the poverty line (BPL), the government would contribute Rs.100 towards their annual premium.





Quarter II 2011 69

The Universal Health Scheme was launched in July 2003. While it was aimed at poor families, it quickly became clear that it was not reaching that targeted BPL population. By May 2004, just 11,408 BPL families had been covered. In the 2004/05 budget, the Finance Minister proposed changes to the scheme that would make it exclusive for BPL families. The annual premiums were revised to Rs.165 for individuals, Rs.248 for a family of five and Rs.330 for a family of seven, without any reduction in benefits. To offset the reduction in premiums, the subsidy was increased from Rs.100 to Rs.200 for an individual, Rs.300 for a family of five and Rs.400 for a family of seven. The government anticipated a subsequent increase in the number insured to around one million.

Health Expenditure

More detailed figures on healthcare expenditure in India can be found in Tables 14-18 of the accompanying Health Statistics document.

Total health expenditure in India was estimated at R2,197.8 billion (US$45,403.7 million) in fiscal 2008/2009. This was equal to 4.1% as a percentage of GDP. The majority of spending was in the private sector, which accounted for 71.6% of the total, at R1,573.9 billion (US$32,516.0 million), in fiscal 2008/09. Much of private spending, 91.1% of the total, was out-of-pocket, based on the latest year for which a more detailed breakdown is available, in fiscal 2004/05. Company health expenditure and insurance schemes accounted for just 7.3% and 1.4% of total private health expenditure.

Public health expenditure accounted for just 26.7% of total spending with a total R586.8 billion (US$12,123.0 million) in fiscal 2008/09. The public sector breakdown for spending was broadly split into central government (34.5%), State government (60.9%) and local bodies/other public sector spending (4.7%).

External funding accounted for R37,015 billion (US$764.7 million) or 1.7% of total spending in fiscal 2008/09.

Health Expenditure by Source, Fiscal 2008/09

Rupee 000s As % of Total

Public expenditure 586,813,788 26.7 Private expenditure 1,573,935,382 71.6 External funding 37,015,853 1.7

Total expenditure 2,197,765,023 100.0 Total expend. as % of GDP 4.13 ~

Source: National Health Profile of India, Central Bureau of Health Intelligence.

Health expenditure, estimated at US$58.3 billion in 2011, is projected to reach US$115.4 billion in 2016. In per capita terms, spending will rise from an estimated US$49 to US$89 during the period in question.

Projected Health Expenditure, 2011-2016

2011 2012 2013 2014 2015 2016

Total health expenditure (US$ billions) 58.3 66.9 78.5 90.4 104.0 115.4 Per capita (US$) 48.5 54.8 63.4 72.0 81.6 89.4 As % of GDP 3.1 3.1 3.1 3.1 3.0 3.0 Private (%) 77.4 77.4 77.4 77.4 77.4 77.4

Source: Espicom.





70 Quarter II 2011

Healthcare Infrastructure

More detailed figures on healthcare infrastructure in India can be found in Tables 19-29 of the accompanying Health Statistics document.

The majority of hospitals in India are run by the public sector, although the private sector has been growing for the last 15 years. Railway hospitals and those run by the large public sector undertakings (PSU) such as the Steel Authority and Nalco own a number of hospitals for their employees. These hospitals are generally well equipped, having generous budgets for equipment. In 2003/04, the railways ran 121 hospitals, 674 health units/dispensaries and 13,633 beds. Healthcare is also provided by the Armed Forces Medical Service, which operates entirely outside the civilian system.

In 2002, India had around 15,393 hospitals with a total of 683,495 beds, equivalent to around 0.7 beds per thousand population. The majority of hospitals are owned by private and voluntary organisations.

In 1998, India had a total bed capacity of 898,000, including beds in hospitals, dispensaries, Public Health Centres (PHC), clinics and sanatoriums. Overall, there are around 0.9 beds per thousand population in healthcare institutions.

Public hospitals are more widespread than private hospitals, but, with the exception of a few recognised centres of excellence, have a reputation for inefficiency, poorly maintained equipment and long waiting lists. India‟s growing middle classes are, therefore, increasingly becoming attracted to private healthcare providers.

Hospitals & Beds, 2002

Hospitals/Beds Year

Hospitals 15,393 2002

Public (%) 26 2002

Beds 683,495 2002

Rate/000 population 0.7 2002

Public (%) 62 2002

Source: Source: Directorate General of Health Services, Ministry of Health & Family Welfare.

Hospital Bed Projections, 2011-2016

2011 2012 2013 2014 2015 2016

Hospital beds (000s) 841.4 854.0 866.6 879.2 891.8 903.7

Private (%) 38.0 38.0 38.0 38.0 38.0 38.0

Rate/000 population 0.7 0.7 0.7 0.7 0.7 0.7

Source: Espicom.





Quarter II 2011 71

In January 2007, there were an estimated 7,663 government hospitals and CHCs with a combined total of some 492,698 beds. An average of 0.4 beds per thousand population were available in government facilities, although the ratio varied from less than 0.1 beds per thousand in Bihar and Jharkhand to 2.9 in Pondicherry. Rural areas were served by 4,256 hospitals and CHCs with 132,475 beds, while in urban areas there were 3,300 hospitals and CHCs with 340,308 beds.

The major government and quasi-government institutes and teaching hospitals had a total bed complement of around 10,145 in 2007. Most of these hospitals operate under the auspices of the Ministry of Health & Family Welfare, although the All India Institute of Medical Sciences is an autonomous institution.

Beds in Selected Hospitals, 2007

Beds

Safdarjung Hospital, New Delhi 1,531 Dr Ram Manohar Lohia Hospital, New Delhi 1,000 JIPMER Hospital, Pondicherry 1,012 PGIMER Nehru Hospital, Chandigarh 1,412 Smt. S.K. Hospital, New Delhi 877 Kalawati Saran Children‟s Hospital 370 Kasturba Hospital 648 Central Institute of Psychiatry, Ranchi 643 All India Institute of Physical Medicine & Rehabilitation, Mumbai 60 National Institute of Mental Health & Neuro-Sciences, Bangalore 805 All India Institute of Medical Sciences 1,803 Total 10,145

Source: MH&FW/AIIMS.

All India Institute of Medical Sciences (AIIMS)

The All India Institute of Medical Sciences (AIIMS) was established in 1956 as an autonomous national institution through an act of parliament and has comprehensive facilities for teaching, research and patient care. In 2008/09, the AIIMS had a total of 2,534 inpatient beds, of which 1,611 were at the main AIIMS Hospital in New Delhi. In addition, the AIIMS has six specialty centres, namely the Dr R. P. Centre for Opthalmic Sciences, Dr B.R. Ambedkar Institute Rotary Cancer Hospital, Cardiothoracic Sciences Centre, Neurosciences Centre, Centre for Community Medicine and the Jai Prakesh Narayan Apex Trauma Centre.

AIIMS Hospital Activity, 2008/09

General Beds Private Beds Admissions

Surgical Procedures

Main hospital 1,486 125 174,353 79,578 Dr R.P. Centre for Ophthalmic Sciences 280 21 29,642 29,276 Dr B. R. Ambedkar Institute Rotary Cancer Hospital 167 15 23,822 6,651 Cardiothoracic Sciences Centre 166 14 10,614 3,477 Neurosciences Centre 166 14 6,396 2,741 Centre for Community Medicine 50 0 29,033 0 Jai Prakesh Narayan Apex Trauma Centre 30 0 19,226 1,128

Total 2,345 189 293,086 122,851

Source: AIIMS.





72 Quarter II 2011

Safdarjung Hospital, New Delhi

Safdarjung Hospital is one of the largest hospitals under the Ministry of Health and Family Welfare, having all major disciplines and providing 24-hour emergency services. The hospital has 1,531 inpatient beds, including 174 cots for new-born infants. In 2009, a total of 128,175 inpatients were admitted to the Safdarjung Hospital. During the year, 23,354 major and 69,091 minor surgical procedures were performed. In addition, 248,211 X-ray examinations and 3,698,191 laboratory tests were undertaken. The Safdarjung Hospital has the largest burns unit in the country and is the regional centre for plastic surgery.

A six-storey outpatient complex, which can accommodate more than 3,000 patients at a time, was commissioned in 1992 and phase II of the project is currently in progress. An average of 6,300 outpatients attended the hospital daily.

The hospital provides services to the poor from Delhi and neighbouring states. All treatment facilities are provided free of charge, including more than 140 medicines, such as antibiotics, anti-epileptics and analgesics to outpatients.

Dr. Ram Manohar Lohia Hospital, New Delhi

The Dr. Ram Manohar Lohia Hospital is a teaching hospital with around 1,000 beds. In addition to providing its own post-graduate courses in various specialties, the hospital is a training centre for the Lady Hardinge Medical College. The hospital has specialty departments covering neurosurgery, burns and plastic surgery, cardiology, urology, gastroenterology, paediatrics and cardiothoracic surgery, as well as a range of diagnostic facilities and a hyperbaric oxygen chamber. The National Consultant in AIDS is based at this hospital. The Dr. Ram Manohar Lohia Hospital is the only government hospital to have a nursing home for CGHS members.

In 2006/07, the hospital provided services to 251,588 patients, of whom 49,174 were admitted as inpatients. The average length of stay for inpatients was 5.1 days. During the year, 9,270 major and 16,309 minor surgical procedures were performed. Around 10,303 CT scans, 1,609 MRIs, 1,523 colour Doppler scans, 24,776 ultrasound scans and 128,266 X-rays were performed and around 1,431,419 laboratory investigations were undertaken.

JIPMER Hospital, Pondicherry

The JIPMER hospital is attached to the Jawaharlal Institute of Post-graduate Research in Pondicherry. The 860-bed hospital provides treatment to patients free of charge. The hospital is able to perform complex procedures, such as open heart surgery, and cancer treatment is on a par with other major Indian cancer centres. A new, fully air-conditioned emergency medical services department was opened in January 2000. The hospital has around 4,285 outpatient visits per day from Pondicherry and surrounding states. In 2007, there were 1,269,201 outpatients, 56,210 inpatients and 36,876 surgical procedures were undertaken. Bed occupancy was around 100.5%.

PGIMER Nehru Hospital, Chandigarh

The Nehru Hospital is attached to the Post-graduate Institute of Medical Education & Research (PGIMER) in Chandigarh. The hospital is a referral centre for several northern states and offers specialised care including cardiac surgery, kidney dialysis and transplantation, neurosurgery, orthopaedic surgery, intensive burns care and plastic surgery, and radiotherapy. In 2008/09, the Nehru Hospital had 1,479 beds. During the year, a total of 58,496 inpatients were admitted to the hospital and there were 856,034 outpatient attendances.





Quarter II 2011 73

Lady Hardinge Medical College Associated Hospitals, New Delhi

The 877-bed Smt. Sucheta Kripalani Hospital and the 370-bed Kalawati Saran Hospital are attached to the Lady Hardinge Medical College in New Delhi. The hospitals and college were set up to provide higher education for women and medical care for women and children. The children‟s hospital exclusively provides paediatric services for children up to 12 years of age. The Smt. S. K. Hospital provides curative, preventive and rehabilitative services to handicapped patients. In addition to these hospitals, the training facilities of the Medical College include 70 medical, 60 surgical and 20 orthopaedic surgery beds at the Ram Manohar Lohia Hospital.

In 2006/07, Smt. Sucheta Kripalani Hospital had 562,972 outpatient attendances, 30,305 inpatient admissions and 12,636 deliveries. There were 7,195 major and 9,180 minor surgical procedures undertaken at the hospital during the year.

In 2006/07, the Kalawati Children‟s Hospital had 29,289 inpatient admissions and 295,992 outpatient attendances. During the year, 1,900 surgical procedures were undertaken, of which 1,600 were recorded as major operations. The hospital has been designated a „Centre of Excellence and Regional Referral Centre for Paediatric AIDS‟. A paediatric anti-retroviral facility was opened in November 2006.

Tata Memorial Centre

The Tata Memorial Centre (TMC) is the national cancer centre for the prevention, treatment, education and research in cancer and is recognised as one of the leading cancer centres in the region. The TMC comprises the Tata Memorial Hospital in Mumbai and the Indian Cancer Research Institute, which were merged under the auspices of the Department of Atomic Energy in 1966. The TMC treats around 43,000 new patients each year from clinics all over India and from neighbouring countries. More than 70% of patients are treated almost free of charge.

In the news in October 2008 were plans for the Tata Memorial Hospital to expand its programme of advanced whole-body radiosurgery with the acquisition of a Varian Medical Systems/BrainLAB Novalis Tx radiosurgery platform. Varian and BrainLAB joined forces late in 2007 to introduce the Novalis Tx, and Tata Memorial is the first hospital in India to order the tool. NovalisTx offers radiosurgery for malignant and benign lesions throughout the body, arteriovascular malformations and functional lesions. It features high-dose delivery rates, which means that treatments can be delivered rapidly. NovalisTx also offers dynamic ultra-fine beam shaping and frameless patient positioning for more rapid and comfortable treatments. The platform also includes an On-Board Imager device for pinpointing the tumour and positioning the patient with sub-millimetre precision.

Before this, the hospital already had three Varian Clinac linear accelerators and four telecobalt devices, and had been carrying out stereotactic radiotherapy on Clinac accelerators since 2000, mainly for brain tumour patients.

Private Hospitals and Clinics

The private sector in India is expanding through the promotion and construction of a number of hospitals by companies such as the Apollo Hospitals Group and Max India. These facilities are equipped to Western standards and capable of undertaking complex procedures. It is hoped that the best of India‟s private hospitals will attract an increasing number of private patients from overseas. The majority of private hospitals are run by profit making organisations, although there is a significant voluntary segment which provides mainly long stay facilities.

Private nursing homes serve as small hospitals with up to 40 beds. They are usually owned by successful doctors and provide private healthcare in smaller towns where there are no large private hospitals. In the big cities they tend to specialise in gynaecology and obstetrics, cardiac care, orthopaedics and minor surgery.





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Apollo Hospitals Group

In 1983, the Apollo Hospitals Group founded India‟s first corporate hospital in Chennai (Madras), with the aim of bringing international quality healthcare „within the reach of every individual‟. In 2000, the three companies which made up the Apollo Group: Apollo Hospital Enterprises Ltd (AHEL), Deccan Hospital Corporation Ltd (DHCL) and Indian Hospital Corporation Ltd merged, making Apollo the largest corporate healthcare provider in South Asia. The Apollo Hospitals Group offers a full range of healthcare services, including hospitals, diagnostic centres, pharmacies, health insurance, schools for nursing and paramedical training, preventive medicine and managed care. The Apollo Hospitals Group comprises a network of 43 hospitals, 7,500 hospital beds, over 100 clinics and a pharmacy network with more than 750 retail outets. Apollo claims to be the single largest healthcare provider in Asia and has treated over six million patients and performed over 750,000 major surgical procedures since it was established. Group aggregated turnover is around Rs5 billion (US$105 million).

The first to be established was the Apollo Hospital in Chennai in 1983. It has 500 beds in four centres: a multi-specialty tertiary hospital, a 200-bed specialty hospital that is mainly a cancer and neurology centre, and two day care centres. The specialty hospital was the first in India to be awarded ISO 9002 certification for quality systems.

Indrasprastha Apollo in New Delhi has been described by group as the „jewel in Apollo‟s crown‟. The 560-bed hospital offers over 50 medical specialities and has 140 ICU beds, the largest number of ICU beds in India. Indraprastha Apollo is the largest private hospital outside the US and the fourth largest corporate hospital in the world. The hospital has 14 operating theatres, five hi-tech cardiothoracic operating theatres, dialysis units and transplant facilities. It provides 24 hour emergency and trauma care and includes facilities for burns treatment, head injuries, acute cardiac emergencies, fractures and poisoning.

Apollo Hospital, Hyderabad is a 550 bedded, multi-speciality, tertiary care centre. The hospital has over 100,000 patients each year and is an important referral centre for patients from India and abroad. Facilities available in Hyderabad include the Apollo Cancer Hospital. The hospital claims to have been the first in India to install a PET-CT scanner, in January 2005. A nursing school and hospital management school are also located within the hospital campus.

The 400-bed multi-specialty Apollo Hospital, Ahmedabad opened in May 2003. It claims to be the largest corporate hospital in Gujarat and the only hospital in the state with a 1.5 Tesla MRI scanner. Specialties include cardiology and cardiothoracic surgery, radiology, neurology and neurosurgery, nephrology and urology, orthopaedics and trauma care, paediatrics and neonatology, respiratory medicine, maxillo-facial and cosmetic surgery, oncology, gastroenterology, ENT, general surgery and ophthalmology.

The Apollo Hospital in Madurai, a 200-bed multi-specialty hospital, was designed to be a major referral centre. Complete kidney care is included among this hospital‟s specialties, the first kidney transplant having been performed here in 1998. The hospital claims to be the first in India to perform laparoscopic renal transplantation.

The 290-bed Apollo Hospital in Bilaspur was established in October 2001. It was the first multi-specialty tertiary care hospital in the state of Chhattisgarh. The latest addition to the group is a multi-specialty hospital in Bangalore.

The Apollo Gleneagles Hospital in Kolkata is a 325-bed multi-speciality hospital. The hospital is a joint venture between Apollo Hospitals and the Parkway Group of Singapore. The hospital boasts seven super-specialty operating theatres and a 72-bed intensive care unit.

The Apollo Projects and Consultancy Division, formerly Indian Hospitals Corporation Ltd set up the heart hospital in Vishakapatnam and the Apollo-Ranchi hospital, otherwise known as the Abdur Razzaque Ansari Memorial Weavers Hospital, Ranchi, which was established in co-operation with the Chotanagpur Regional Handloom Weavers Co-operative Union.





Quarter II 2011 75

The Apollo Clinic in Mumbai, is specifically designed for managed healthcare and was the first of its kind in India, with healthcare programmes designed for the diagnosis and management of a variety of conditions.

Fortis Healthcare

Fortis Healthcare Ltd was founded in 1996 on the vision of the late Dr Parvinder Singh, formerly chairman of Ranbaxy Laboratories Ltd. The company claims to be India‟s fastest growing healthcare chain. Fortis aims to become a patient focused, integrated healthcare delivery organisation via a network of world-class super speciality hospitals at the hub of a larger network of multi-speciality and tertiary hospitals. The company‟s „hub and spoke‟ model provides patients with access to networked facilities. The acquisition of Escorts Healthcare brought with it four hospitals in the North of India. The company currently has 28 hospitals, including 12 specialty centres:

Fortis Hospital, Mohali – a 250-bed super-specialty cardiac hospital in Punjab;

Fortis Hospital, Noida – a 350-bed super-specialty hospital providing treatment in orthopaedics and neurosciences;

Fortis Jessa Ram Hospital, New Delhi – a 100-bed multi-specialty hospital established in 1952;

Fortis Rajan Dhall Hospital,Vasant Kunj, New Delhi – a 200-bed hospital with departments for five super specialties - The Fortis Heart Institute, Fortis Institute for Renal Sciences, Fortis Specialty Centre for Joints, Fortis Lung Centre and Fortis Centre for Diabetes;

Escorts Heart Institute and Research Centre (EHIRC) - The EHIRC is an internationally recognised 350-bed facility in New Delhi;

Fortis Escorts Hospital, Faridabad – a 250-bed multi-specialty facility in Faridabad;

Fortis Escorts Hospital, Amritsar- a 154-bed super-speciality cardiac care hospital in Amritsar which has been fully functional since January 2003;

Fortis Escorts Hospital, Raipur (EHC-R) – a 45-bed super-specialty cardiac centre which was a joint venture between Escorts and the government of Chhattisgarh;

Fortis La Femme, New Delhi – a specialist women‟s healthcare facility;

Fortis Escorts Hospital, Jaipur – a „multi super-specialty‟ hospital in Rajasthan;

Fortis Malar Hospital, Chennai – a 250-bed multi-specialty hospital.

Fortis International Oncology Centre – A joint venture between Fortis and International Oncology, this comprehensive cancer centre, aimed at providing advanced treatments for patients, was officially opened in Noida in June 2010. The centre is equipped with advanced radiotherapy equipment and software by Varian Medical Systems.

Global Hospitals

Founded in 1998, Global Hospitals is a fast growing super specialty care and multi-organ transplantation hospital group with branches in Hyderabad (two facilities), Bangalore, Chennai and Mumbai.

The Bangalore facility, BGS Global Hospitals, is a 500-bed state-of-the-art multi-disciplinary and tertiary care facility. It has 14 major operating rooms, advanced imaging/radiology facilities and 120 specialty ICU beds and one of the largest liver ICUs in India. The Global Hospitals and Healthcity (GHHC) is a 500-bed super specialty hospital with a proposed 1,000 bedded tertiary care facility located off the IT highway (OMR) at Chennai. This facility also uses advanced medical equipment to provide high quality tertiary healthcare services.

In Hyderabad, Global Hospitals Lakdi-ka-pul offers tertiary-level super specialty care and multi-organ transplantation services. The other hospital, Aware Global Hospital Hyderabad LB Nagar, is a 300-bed multi-specialty hospital with advanced medical equipment, ICUs and operation theatres.





76 Quarter II 2011

In November 2010, it was announced that Global Hospitals had purchased four Varian Medical Systems medical linear accelerators (three TrueBeam systems and one UNIQUE accellerator) for its hospitals in Bangalore, Chennai, Mumbai and Hyderabad.

Max Healthcare

Following the sale of his 40% share in Hutchison Max Telecom, Max India‟s chairman, Analjit Singh set aside Rs2 billion to set up world-class healthcare services in India. Max Healthcare‟s services are in three tiers, from primary to tertiary care. At the primary care level are Dr. Max clinics, located in prime locations in Delhi and staffed by general practitioners, paediatricians and specialists in gynaecology and chronic care for patients with diabetes, asthma, arthritis and hypertension. The clinics also offer physiotherapy, dentistry and basic radiology services, such as X-Ray, ECG and ultrasound. Also at primary care level, Dr Max Implants are replicas of Dr Max Clinics situated in various institutions.

The secondary care level comprises a number of hospitals and Max Medcentre, a comprehensive medical centre with a range of specialities, diagnostics and ambulatory surgery. Hospitals include the 150-bed Max Balaji Hospita, Patparganj, Delhi; the 100-bed Max Hospital, Pitampura, New Delhi, and the 40-bed Max Hospital, Noida.

At the tertiary level, the Max Devki Devi Heart & Vascular Institute in Saket, Delhi, is a 200-bed state-of-the-art cardiovascular facility. The neighbouring Max Super Specialty Hospital houses a number of specialised facilities, including the Max Institutes of Neuro Sciences, Orthopaedics, Obstetrics and Gynaecology, and Paediatrics, as well as Max Eye Care.

Medanta Medicity

Medanta Medicity, is one of India's largest multi-specialty institutes located in Gurgaon, Haryana, a satellite town near New Delhi. Spread across 43 acres, the institute includes a research centre, medical and nursing school. It has 1,250 beds and over 350 critical care beds with 45 operating theatres catering to over 20 specialties. The Medicity is designed to attract international patients and has nine institutes, namely a heart institute, institute of neurosciences, bone & joint institute, kidney & urology institute, cancer institute, institute of critical care & anaesthesiology, institute of digestive & hepatobiliary sciences, institute of minimally invasive surgery and institute of transplant & regenerative medicine.

The medical device equipment the Medicity has includes a 256 Slice CT scanner, brain suite intra-operative imaging operating theatre, Da Vinci Robot for minimally invasive surgery, Artis-Zeego Endovascular Surgical Cath Lab, four linear accelerators, integrated brachytherapy unit with remote controlled HDR, 3.0 Tesla MRI scanner, PET CT scanner, Gamma camera, X-ray equipment (digital X-rays, flouroscopy, bone densitometry), ultrasound equipment (3D and 4D) and digital mammography.

Yashoda Hospitals

Yashoda Hospitals started as a small clinic in Hyderabad in 1989, and has now grown into a business with three hospitals in Secunderabad, Malakpet and Somajiguda. Each hospital has a nursing school and college. In total, the group manages over 1,000 beds, 450 doctors, 1,500 nurses and 4,000 paramedical and other support staff. The group claims to treat around 300,000 people annually. Yashoda Hospitals claim to be ISO certified, its labs NABL (India) accredited and all facilities NABH (India) compliant. The hospitals also prides itself in providing the latest medical technology for treating patients. In 2010 for example, it was the hospital in Secunderabad upgraded its Varian medical linear accellerator with Rapid Arc technology, which promises to enable radiosurgery sessions to be performed in just 10 minutes, including patient set up and imaging.

Other Commercial Providers

The BM Birla Heart Research Centre in Kolkata, part of the GP-CK Birla Group, specialises exclusively in the diagnosis, treatment and research of cardiovascular diseases. The 165-bed centre has one of the largest intensive coronary care units in the country and has achieved ISO 9002 and ISO 14001 certification. BM Birla also offers a specialist diabetes centre.





Quarter II 2011 77

The Lifeline Group of Hospitals runs the 100-bed Rigid Hospital and the 225-bed Lifeline Multi-Specialty Hospital in Chennai, offering tertiary care, the 110-bed secondary care S & V Loga Lifeline Hospital in Karur and eleven primary care centres.

Some of the big industrial organisations in India provide hospital services, mainly for their employees. Tata Steel Ltd provides healthcare facilities for its staff, including the 830-bed Tata Main Hospital (TMH) in Jamshedpur. TMH caters its services to around 60,000 employees of Tata Steel and their families, and also extends its facilities to patients from in and around Jamshedspur, as well as associated and contractor companies.

The JK Organisation promotes the Pushpawati Singhania Research Institute in Delhi, a leading super-specialty hospital for liver, renal and digestive diseases, as well as hospitals in Jaipur, Kanpur and Kota.

Pharmaceutical company, Wockhardt Ltd, set up the Wockhardt Hospital & Heart Institute in 1989, since when it has become a renowned tertiary level heart centre. The institute‟s Center of Cardiology performs more than 500 angioplasties and 2,500 cardiac interventions each year, including paediatric catheterisations. The Center of Cardiovascular Surgery annually performs more than 1,200 cardiac procedures.

Primary Care

The vast majority of primary care is undertaken at government health centres and dispensaries. To cater for the needs of the growing private sector, however, a number of private general practitioners/clinics have been established.

The primary healthcare infrastructure is based on a three tier system, with sub-centres as the first point of contact with the community in rural areas, providing basic health and family welfare services. The Sub-centres are provided with basic drugs for minor ailments. Sub-centres are staffed by two health workers, under the supervision of a Lady Health Visitor. In 2007, there were 145,272 Sub-centres functioning, of which some 97,750 were funded by the Department of Family Welfare. The remainder are funded by the state governments.

The second tier comprises Primary Health Centres (PHCs), which act as a referral point for six Sub-centres and have 4-6 beds. PHCs are established and maintained by the states, under the Minimum Needs / Basic Minimum Service Programme. The PHC is staffed by a medical officer and 14 paramedical staff and is the first point of contact with a medical officer. In 2007, there were 22,370 PHCs providing preventive and curative healthcare.

Across the country, there are around 28,000 government dispensaries. In the tribal/hilly areas and Scheduled Castes Basties/villages, there are 78 mobile clinics, 2,108 allopathic dispensaries and 2,996 Indian Systems of Medicine and Homeopathy (ISM&H) dispensaries. In the village communities, primary healthcare and family planning advice may be available from the Village Health Guide (see Medical Personnel for more details).

Family planning advice, facilities and services are provided free of charge to eligible couples in all Sub-Centres, PHCs, Community Health Centres (CHCs), Rural Family Welfare Centres and District Hospitals. Services are provided through medical and paramedical staff.

Outpatient facilities are available exclusively to approximately 3.3 million central government employees and other entitled persons under the Central Government Health Scheme (CGHS). In 2007, there were 335 dispensaries, 17 polyclinics, 70 laboratories and 19 dental units operating under the scheme. While 247 dispensaries were allopathic, the remainder were dedicated to Indian systems of medicine. There were 37 homeopathic dispensaries, 35 ayurvedic dispensaries, 11 unani dispensaries, two dedicated to yoga and three to siddha.





78 Quarter II 2011

First Aid and Disaster Relief

St. John Ambulance

St. John Ambulance has over 52,000 trained personnel working across India, providing training and first aid. The organisation‟s facilities include 19 State Centres, eight Railway Centres, two Union Territory Centres, and 637 centres at regional, district and local level. St. John Ambulance trains around 700,000 people in first aid and allied subjects each year.

Indian Red Cross Society

The Indian Red Cross Society is a countrywide organisation, whose primary activities include disaster relief, blood collection and distribution, maternity and child welfare, community services and ambulance and nursing services. The organisation‟s national headquarters is in Delhi and it has 700 branches across the country. The Red Cross also has the largest voluntary blood bank in the country at its headquarters in Delhi.

Red Cross facilities include 33 mobile medical units, 94 static medical units, two general hospitals, two tuberculosis hospitals, 15 polyclinics, 75 blood banks and 57 drug stores.

Healthcare for the Underprivileged, Scheduled Castes and Scheduled Tribes

The Scheduled Castes and Scheduled Tribes of India have been given priority in the provision of health services to the tribal, hilly and backward areas, as well as to those affected by endemic diseases, and vulnerable sections of society. Under the chairmanship of the Secretary, Ministry of Welfare, a Central Planning Committee has been set up to review the health activities of backward tribal areas in the country. The committee has identified such areas in 52 districts of 13 states, as follows:

Andhra Pradesh (6 districts) Orissa (8 districts)

Bihar (6 districts) Uttar Pradesh (1 district)

Gujarat (3 districts) Rajasthan (2 districts)

Kerala (5 districts) Tamil Nadu (2 districts)

Madhya Pradesh (4 districts) Tripura (4 districts)

Maharashtra (6 districts) West Bengal (1 district)

Manipur (1 district)

In order to provide better healthcare and family welfare services to scheduled castes (SCs) and tribes, the population coverage norms of the establishment of rural infrastructure have been relaxed. Under the Minimum Needs Programme, the aim is to provide services through a network of PHCs, Sub-centres, CHCs, Rural Dispensaries, and Village Health Guides. Mobile dispensaries and camps are organised wherever feasible, to cater for the needs of the people „at their door-steps‟.

From the 258 Scheduled Tribe communities, 74 groups have been recognised as Primitive Tribal Groups (PTGs). These groups have low literacy rates, a pre-agricultural level of technology and a stagnant or diminishing population. As a result of recommendations put forward by the Working Group on Development Welfare of Scheduled Tribes, a scheme for improving healthcare for PTGs was drawn up for inclusion in the Eighth Plan.

The tribes and castes are particularly susceptible to the communicable diseases covered by the National Health Programmes and are being given priority under some schemes (e.g. Malaria eradication).





Quarter II 2011 79

Medical Care for Remote & Marginalised Tribal & Nomadic Communities

Introduced in the Ninth Plan (1997-2002), the Medical Care for Remote & Marginalised Tribal & Nomadic Communities scheme is implementing four projects submitted by the Indian Council of Medical Research (ICMR):

Intervention programme for nutritional anaemia and haemoglobinopathies among some of India‟s primitive tribal population. This project has been launched in Maharashtra, Gujarat, Tamil Nadu and Orissa.

Intervention programme for cholera intestinal parasites, Vitamin A deficiency disorders and scabies among primitive tribes in Orissa;

Intervention of hereditary common haemolytic disorders among the major tribes of Sundargarh district in Orissa;

Prevention and control of hepatitis B infection among the primitive tribes of Andaman & Nicober Islands.





80 Quarter II 2011

Healthcare Personnel

More detailed figures on healthcare personnel can be found in Tables 30-32 of the accompanying Health Statistics document.

In 2009, there were 757,377 doctors possessing recognised qualifications and registered with state medical councils in India, equivalent to around 0.65 per thousand population. Assuming this rate remains unchanged, there are around 769,700 doctors in 2010 Although the majority of the Indian population live in rural areas, most of the qualified medical personnel work in metropolitan and urban areas.

Projected Number of Physicians, 2011-2016

Physicians Rate/000 Population

2011 781.3 0.65 2012 793.0 0.65 2013 804.7 0.65 2014 816.4 0.65 2015 828.1 0.65 2016 839.2 0.65

Source: Espicom.





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DIRECTORY

Healthcare Organisations

Ministry of Health and Family Welfare, Nirman Bhavan, New Delhi - 110 011. Tel: +91 11 301 3968. Fax: +91 11 301 4252. Web: http://mohfw.nic.in

Indian Medical Association, IMA House, Indraprashtra Estate, New Delhi - 110 002. Tel: +91 11 2337 0009. Web: http://www.ima-india.org

Regional Director, Regional Office for Health and Family Welfare, 48/8 Hindustan Park, Calcutta - 700 029, West Bengal.

Regional Director, Regional Office for Health and Family Welfare, Danara House, Salimpur Ahara, (Behind RBI), Patna - 3, Bihar.

Regional Director, Regional Office for Health and Family Welfare, C-2, B-80, Mahanagar, Lucknow, Uttar Pradesh.

Regional Director, Regional Office for Health and Family Welfare, Kothi No. 3281, Sector-21-D, Chandigarh.

Regional Director, Regional Office for Health and Family Welfare, A11/256/B1, New Airport, Prakash Nagar, Hyderabad, Andhra Pradesh.

Regional Director, Regional Office for Health and Family Welfare, Anand Estate, Industrial Estate Corner, Bapunager, Ahmedabad - 380 024, Gujarat.

Regional Director, Regional Office for Health and Family Welfare, 25 Ramanathan Street, T. Nagar, Madras - 600 017, Tamil Nadu.

Regional Director, Regional Office for Health and Family Welfare, Ripon Hospital Compound, Shimla - 171 001, Himachal Pradesh.

Regional Director, Regional Office for Health and Family Welfare, F-711 Prem Nagar (New Plot), Jammu Tawi.

Regional Director, Regional Office for Health and Family Welfare, 140 Saheed Nagar, Bhubaneshwar - 751 007, Orissa.

Regional Director, Regional Office for Health and Family Welfare, 34/2 Parvati Darpan Building, 1st Floor, Shankar Nagar-II, Pune - 411 009, Maharashtra.

Regional Director, Regional Office for Health and Family Welfare, Navanesthan Building, TC.27/1460 (i) Statue Road, Chirakulam Lane, Thiruvananthapuram, Kerala.

Regional Director, Regional Office for Health and Family Welfare, Sangrilla Uriock Road, Imphal - 795 001, Manipur.

Regional Director, Regional Office for Health and Family Welfare, 131/16 Maharana Pratap Magar, Bhopal - 462 001, Madhya Pradesh.

Regional Director, Regional Office for Health and Family Welfare, 101 Sree Sanidhi Railway Parallel Road, Kumar Park West, Bangalore - 560 020, Karnataka.

Regional Director, Regional Office for Health and Family Welfare, K-10 Durga Das Path, Malviya Marg, Jaipur, Rajasthan.

Regional Director, Regional Office for Health and Family Welfare, Felli-Velle, Lumsohpoh, Shillong - 793 014, Meghalaya.

Serologist & Chemical Examiner to the Govt. of India, 3 Lyd Street, Calcutta - 700 016. (Manufactures diagnostic reagents)

Medical Store Depots

Govt. Medical Store Depot, Bombay - 400 008.

Govt. Medical Store Depot, 9 Clyde Rev: P.O. Hastings, Kolkata - 700 022.

Govt. Medical Store Depot, Post Box No. 8, Karnal - 132 001 (Haryana).

Govt. Medical Store Depot, No. 37 Naval Hospital Road, Madras - 600 003.

Govt. Medical Store Depot, Hyderabad.

Govt. Medical Store Depot, Post Box No. 84, Guwahati - 781.

Medical Stores Sub-Depot, Qutab Enclave, New Delhi.





82 Quarter II 2011

Trade Code Classifications

International trade is now universally classified according to the Harmonised System (HS). This began to be used in the 1990s, and is overseen by the World Customs Organisation (WCO).

Medical equipment is generally well-defined in the Harmonised System. There is one major code (HS9018) named Medical Equipment, but there are a number of other codes for products with a specifically medical use. These are listed in detail the table on this page. For the majority of countries, it is not possible to provide a more detailed breakdown than this.

Espicom has rearranged the data from its original code order, to create six major subcategories: Consumables, Diagnostic Imaging, Dental Products, Orthopaedic & Prosthetic Products, Patient Aids, and Others. Their relation to the trade codes is shown on the next page. These are the categories presented in the import/export sections of this report, and the categories used when estimating the overall medical equipment market.

HS Trade Codes Used in This Report

3005-3006 Medical Supplies 3005 Plasters, other adhesive dressings, dressings with pharmaceutical coatings, wadding, gauze, bandages, sterile surgical

catgut, laparotomy sponges 3006 Sterile tissue adhesives, blood grouping reagents, Contrast media, dental cements, bone reconstruction cements, first aid

boxes & kits, Ostomy appliances 3701-3702 Medical X-ray film

3701.1 Flat 3702.1 Rolled

4015.11 Gloves, surgical, of rubber 8419.2 Medical, surgical or laboratory sterilisers 8713 Wheelchairs

8713.1 Not mechanically propelled 8713.9 Mechanically propelled

9018 Medical equipment

9018.1 Electromedical ECGS, ultrasound, MRI, scintigraphic apparatus, patient monitoring systems, EEGs, EMGs

UV/IR apparatus (9018.2) 9018.3 Syringes, needles & catheters 9018.4 Dental instruments & appliances Dental drill engines, chairs, operating units, burs, hand instruments 9018.5 Ophthalmic instruments and appliances 9018.9 Other instruments and appliances used in medical or veterinary sciences

Surgical instruments, electromedical instruments, anaesthetic apparatus, forceps, knives, scissors, other hand tools, stethoscopes, sphygmomanometers, defibrillators, dialysis equipment

9019 Therapy apparatus Mechano therapy appliances, massage apparatus, therapeutic respiration apparatus 9021 Orthopaedic/prosthetic goods Artificial joints, other orthopaedic/fracture appliances, bone plates, nails, screws, artificial teeth, dental fittings, other artificial

body parts, hearing aids, pacemakers, other appliances for the disabled 9022 X-ray apparatus CT scanners, medical/dental X-ray apparatus, medical , , ray apparatus, X-ray tubes, parts & accessories 9402 Medical furniture Dentists‟ chairs, hospital furniture, other medical, surgical, dental furniture





Quarter II 2011 83

HS Trade Codes, Rearranged

CONSUMABLES

Note for readers of previous editions

This edition of the Medistat Outlook uses a revised method for reclassifying the trade data. This has been done to create a more meaningful and useful set of product categories. The changes made are as follows: One category has been added: Ostomy Appliances (3006.91). This is a new category which has only become available over the past year. One category has been removed: Contact Lenses (9001.3) A separate Imaging Parts & Accessories category has been created, in order to better emphasise the apparatus itself. The Orthopaedic & Prosthetic category has had a number of related products removed, in order to improve its focus. These have been moved to a new category, Portable Aids, within Patient Aids. Patient Aids is a new category, which also comprises Therapeutic Appliances. If you have any queries regarding the change, please do get in touch.

Woundcare Products Medical dressings (adhesive) 3005.1 Medical dressings (non-adhesive) 3005.9 Sutures, sterile, surgical & dental goods 3006.1 Syringes, Needles & Catheters Syringes (with/without needles) 9018.31 Tubular metal needles/ needles for sutures 9018.32 Other needles, catheters, cannulae etc 9018.39 Others Blood-grouping reagents 3006.2 First-aid boxes & kits 3006.5 Ostomy appliances 3006.91 Surgical gloves 4015.11

DIAGNOSTIC IMAGING

Electrodiagnostic Apparatus Electrocardiographs 9018.11 Ultrasonic scanning apparatus 9018.12 Magnetic resonance imaging apparatus 9018.13 Scintigraphic apparatus 9018.14 Other electro-diagnostic apparatus 9018.19 Radiation Apparatus Computed tomography apparatus 9022.12 Other medical X-ray apparatus 9022.14 Medical alpha beta, gamma ray apparatus 9022.21 Imaging Parts & Accessories Contrast media 3006.3 X-ray tubes 9022.3 Parts & accessories for radiation apparatus 9022.9 Medical X-ray film (flat) 3701.1 Medical X-ray film (rolled) 3702.1

DENTAL PRODUCTS

Dental Capital Equipment Dental drill engines 9018.41 Dental X-ray apparatus 9022.13 Dental & similar chairs (inc. parts & accessories) 9402.1 Dental Instruments & Supplies Dental cements & other fillings 3006.4 Other instruments & appliances used in dentistry 9018.49 Artificial teeth 9021.21 Other dental fittings 9021.29

ORTHOPAEDIC & PROSTHETIC DEVICES


9021.1 Artificial joints 9021.31 Other artificial body parts 9021.39

PATIENT AIDS

Portable aids Hearing aids, except parts & accessories 9021.4 Pacemakers, except parts & accessories 9021.5 Other aids for the disabled 9021.9

Therapeutic appliances Mechano-therapy apparatus 9019.1 Therapeutic respiration apparatus 9019.2 Ultra-violet or infra-red ray apparatus 9018.2

OTHERS

Wheelchairs, not mechanically propelled 8713.1 Wheelchairs, mechanically propelled 8713.9 Other medical, surgical, dental furniture 9402.9

Medical, surgical sterilisers 8419.2

Ophthalmic instruments & appliances 9018.5 Other instruments & appliances 9018.9





84 Quarter II 2011

Methodology

Figures for the national medical equipment markets are Espicom estimates, in current US dollars. This report uses a wide definition of medical equipment, similar to that used by the US FDA or EU regulatory authorities. In short it is defined as any piece of equipment or apparatus used to treat or diagnose an illness, which comes into direct contact with the patient. Pharmaceuticals, IV diagnostics and laboratory equipment are not within the scope of this report.

The markets have been estimated using a trade-based approach. Most countries are heavily reliant on imports; markets have been derived by looking at imports, and then adding in domestic production, minus any exports. Import/Export data is from national customs authorities, as compiled by the United Nations. For practical purposes, we define this range of codes as the entire market.

Domestic production data is estimated by Espicom. We take in a range of factors when considering this, such as the value of exported products, known presence of local and multinational manufacturers, sales data where available and officially published estimates of production, again where available. It has then been adjusted to take account of re-exporting, stockpiling and differences in the definition of medical production.

For projections, we first derive an estimate in US dollars for a base year. This is 2009 for the purposes of this report. Growth rates are calculated for each major category as a CAGR for the 2011-16 period. They do not attempt to track year by year fluctuations in growth, but rather provides a projection of the likely size of the market in five years‟ time. These rates are applied to the market in local currency terms, and then converted back to US dollars, using EIU exchange rate projections.

Growth rates are calculated by looking at a number of factors. These include economic performance, health expenditure levels, provision of medical staff and hospital beds, trends in equipment import levels, size and performance of domestic manufacturing sector, national healthcare development plans, and international aid projects, where applicable.

Sources

Medistat Outlook is compiled using, where possible, primary data from local sources. This comprises national Ministries/Departments of Health, statistical bodies and professional associations. Market profiles draw on detailed statistical work by our Healthcare Markets Team. This is undertaken specifically for this report, and also in the course of research for other Espicom services.

Forecast data for GDP and demographics is sourced from the Economist Intelligence Unit (http://www.eiu.com), where indicated.

Reference may also be made to a number of secondary sources, such as those are listed below.

OECD Health Data, http://www.sourceoecd.org

PC-TAS trade data, published by International Trade Centre, UNCTAD/WTO, United Nations.

World Bank, http://www.worldbank.org

World Health Statistics, World Health Organisation, Geneva, Switzerland. http://www.who.org

Need more information?

We welcome feedback on all our reports. If you have any further questions, comments or suggestions about the contents of this report, send them to the editor, at:

[email protected]



Medistat Outlook, India Q2 2011[1]

Documents

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