HEALTHCARE SCENARIO OF INDIA POST COVID19
Are you planning to build or restructure any healthcare venture in India? Looking for information about the major healthcare players in Government or Private diagnostic centers that are available in India? Are you looking to find out which part of the city is best to venture in or what all facilities are available and what all should be planned for the new setup? In this article, Hospaccx Healthcare Consultancy has mapped all on major players in terms of medical facilities and healthcare scenario in India.
COUNTRY OVERVIEW
India is the country that occupies the greater part of South Asia. Its capital is New Delhi, built in the 20th century to serve as India’s administrative centre. India has a constitutional republic that represents a highly diverse population consisting of numerous ethnic groups and likely hundreds of languages. With over one-sixth of the world’s total population, India is the second-most populous country, after China.
Demographics
The current population of India is 138 crore. According to the UN, India accounts for 17.7% of the total population of the world. It is now estimated that by 2027, India will presumably overtake China to become the most populous country in the world with 1.47 billion people. The population density in India is 464 per km2. The total land area is 2,973,190 km2 (1,147,955 sq. miles) which accounts for 2.4% of the total world surface area. 35.0 % of the population lives in urban areas (483,098,640 people in 2020). The median age in India is 28.4 years. As of 2020, the share of the population in the age group 0-14 is 26.16 per cent. Share of the working-age population (15-65 years) is 67.27 per cent. 6.57 per cent of Indians have age more than 60 years.
Sex Ratio
Sex Ratio of India is 108.176 males per 100 females in 2020. India has a 48.04% female population compare to 51.96% male population. India is at 189th position out of 201 countries in terms of female to male ratio. Among Asian countries, India is at 43rd position out of 51. As per Census 2011, the Gender ratio of India is 943 females per 1000 males. In the rural area, there are 949 females to 1000 men, while in an urban area there are 929 females to 1000 males.
Fig.1 Percentage distribution of the population by gender
Total Life Expectancy
The current life expectancy for India in 2020 is 69.73 years, a 0.33% increase from 2019. Life expectancy at birth for females is 71.8 years. Life expectancy at birth for males is 69.2 years. Life expectancy has been increasing gradually in India.
Fig.2 Life expectancy in India from 1950-2020
Literacy Rate
The overall literacy rate in Rural India is 64.7 per cent. In rural India, the literacy rate among females is 56.8 per cent and among males is 72.3 per cent. The overall literacy rate in Urban India is 79.5 per cent. In urban India, 74.8 per cent females are literate and 83.7 per cent males are literate.
Indian Economy
India’s economy slowed down to 3.1 per cent in the last quarter of 2019 as the coronavirus pandemic initiated a prolonged slowdown. Growth in the last quarter of FY 2020 has been the slowest since the global financial crisis more than a decade ago. Although the market analysts had expected a slower growth this quarter, the extent of the slowdown remains unpredictable.
Fig.3 Real gross domestic product (GDP) growth rate from 2009 to 2021
Industries
Amid the lockdown, as many as 122 million Indians were forced out of jobs. All the industries were closed, and the country had come to a standstill. With the relaxation of the lockdown, the country is begrudgingly moving towards normalcy. The major industries in India are Automobile, Agriculture, Textile, Aviation, Banking and Cement. To alleviate the effects of COVID-19 Indian government has been taking measures. Some measures taken by the government are as follows: loan repayment delayed, strict regulations delayed, monetary support for corporate borrowers, dividends of the banks halted, additional liquidity infused in the banks by RBI, tax payments deferred, deadlines extended and many more. The government needs to boost the growth of industries and bring in FDI to uplift the decelerated growth. Indian economy is expected to start making a slow recovery in the next financial year.
Connectivity with other countries
India is connected to the rest of the world thoroughly by airways, waterways, and roadways. There are projects operational to still improve the connectivity and cultivate trade routes with the neighbouring countries. India has also been investing in improving interstate connectivity.
HEALTHCARE SCENARIO OF INDIA
The whole world is trying to mitigate the damage the corona pandemic has caused. Countries, developing or developed are sailing in the same boat trying to normalize the situation. The healthcare industry has been most burdened and will remain so until there is a cure for this virus. The healthcare industry encompasses health insurance, medical tourism, pharmaceuticals, and medical device industries majorly. India was rapidly progressing in the above-mentioned industries before the pandemic struck. The scenario of the Indian healthcare sector is as follows:
Health Insurance
India is among the least insured countries and as of 2019, the density of non-life (which includes health) insurance in the country was a mere 19%, according to data from the Insurance Regulatory and Development Authority of India (IRDAI), and the biggest reason for this is the lack of trust. Medical inflation is increasing at almost double the rate of overall inflation and the cost of treatment, especially for modern technology treatments, is only going up.
As India targets for $5-trillion GDP, it will be important to design a structure that provides steadiness and inspires people to proactively cover their key economic and health risks. Moreover, this structure is ideally imperative for the middle class – which is going to represent this growth in the coming years – as the middle class is presently at 158 million households and will cross the 300 million mark by 2030. At the same time, the health insurance penetration in India is significantly low as 56% of Indians are not covered under any health insurance policy. Talking about the BPL segment that is predominantly covered under the government offered schemes, even less than 20% of the population is covered by any form of health insurance.
The government has relaxed the dates to pay premiums as the majority population faces money crunch. The pandemic has emphasized the need to have health insurance. There have been reports of private hospitals charging lakhs of rupees in bills, which is unaffordable to the middle-class population. The health insurance concentration is anticipated to rise in the coming year.
PMJAY Overview
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) is a part of the Indian government’s National Health Policy which aims to provide free health coverage at the secondary and tertiary level to its bottom 40% poor and vulnerable population. PM-JAY is the world’s largest and fully state-sponsored health assurance scheme which covers a population of the combined size of USA, Mexico, and Canada. It was launched in September 2018, under the aegis of Ministry of Health and Family Welfare in India.
Since the launch of PMJAY, the Government of India (GoI) allocations for health insurance have seen a significant increase. In Financial Year (FY) 2021-20, GoI allocated 6,400 crores to PMJAY, a two-fold increase compared to FY 2019-20 Revised Estimates (REs) but the same as the Budget Estimates (BEs). Across India, 73 per cent of eligible households are covered by health insurance, either through PMJAY or state schemes. Over 80 per cent of claims have been paid in 11 states and UTs. Of all claims submitted till 20 November 2019, 42 per cent were from private Empanelled Health Care Providers (EHCPs) and 58 per cent were from public EHCPs. The average claim amount in private EHCPs was higher at Rs.17,691 than the average claim amount in public EHCPs which was Rs.11,050.
Some of the major initiatives taken by the Government of India to promote the Indian healthcare industry are as follows:
- In Union Budget 2020-21, Rs 35,600 crore (US$ 5.09 billion) has been allocated for nutrition-related programs.
- The government has announced Rs 69,000 crore (US$ 9.87 billion) outlay for the health sector that is inclusive of Rs 6,400 crore (US$ 915.72 million) for PMJAY in Union Budget 2020-21.
- The Government of India aims to increase healthcare spending to three per cent of the Gross Domestic Product (GDP) by 2022.
Medical Tourism
As per the latest FICCI report, Medical Value Travel (MVT) market or Medical Tourism has the potential to reach the $9 billion mark by this year-end. India is seen as one of the preferred medical destinations. Medical tourists have a liking to the country’s health industry, the reasons being many on the list. One of them is the treatment and travel costs when compared to western countries like the US and UK. The preferred destination among medical tourists arriving in the country remains Delhi, Mumbai, Chennai, Bangalore, Hyderabad, and Kolkata. It is reported that Chennai draws in around 15 per cent of the incoming foreign patients, while Kerala manages around 5 to 7 per cent. India has an impressive array of medical tourists, with several of them belonging to the South-East Asian countries, the Middle East, Africa, and SAARC countries. Besides, the quality of medical care is top-notch.
Going by the current calculations, 35 hospitals have got accredited by the Joint Commission International (JCI). 681 hospitals have been accredited by the National Accreditation Board for Hospitals and Healthcare Providers (NABH) and 832 Hospitals applied for NABH accreditation.
Fig.4 Total number of Hospitals accredited in India 2020
The whole world is battling against COVID-19 and healthcare systems of many countries are over-burdened. After the pandemic, Visa rules of various countries might change once the restriction on international travel is lifted. Many patients with chronic illnesses would want to get treatments done which were postponed due to the pandemic. Experts believe that the medical tourism industry in India would progress at a rapid rate post COVID-19.
Telemedicine
WHO defines Telemedicine as ‘The delivery of health-care services, where distance is a critical factor, by all health-care professionals using information and communications technologies for the exchange of valid information for the diagnosis, treatment and prevention of disease and injuries, research and evaluation, and the continuing education of health-care workers, to advance the health of individuals and communities.’
Telemedicine industry got a lot of attention amidst the pandemic. Telemedicine has been acknowledged in the healthcare system, but it is not widespread. The main reason being a lack of awareness. Due to various restrictions implemented on movement, many private and government hospitals adopted telemedicine to provide healthcare remotely. The telemedicine industry is going to permeate into healthcare progressively.
Pharmaceutical industry
According to the rating agency ICRA, the growth trajectory for the Indian pharmaceutical industry is likely to remain at 10-13 per cent in 2020-21 despite challenges. The expected growth in the next financial year will depend on healthy demand from the domestic market. There is an increase in spending on healthcare along with improved access which might help the growth of the industry.
India is the largest provider of generic drugs globally. Indian pharmaceutical sector industry supplies over 50 per cent of global demand for various vaccines, 40 per cent of generic demand in the US and 25 per cent of all medicine in the UK. Indian pharmaceutical sector is expected to grow to US$ 100 billion the medical device market expected to grow US$ 25 billion by 2025. Pharmaceuticals exports from India stood at US$ 19.14 billion in FY19 and US$ 13.69 billion in FY20 (up to January 2020). Pharmaceutical exports include bulk drugs, intermediates, drug formulations, biologicals, Ayush & herbal products, and surgical. The Union Cabinet has given its nod for the amendment of the existing Foreign Direct Investment (FDI) policy in the pharmaceutical sector to allow FDI up to 100 per cent under the automatic route for manufacturing of medical devices subject to certain conditions.
The drugs and pharmaceuticals sector attracted cumulative FDI inflows worth US$ 16.25 billion between April 2000 and June 2019, according to data released by the Department for Promotion of Industry and Internal Trade (DPIIT).
Some of the recent developments/investments in the Indian pharmaceutical sector are as follows:
- Environmental clearances to be granted expeditiously to projects related to active pharmaceutical ingredients and bulk drug intermediates.
- The Directorate General of Foreign Trade (DGFT) amended the export policy for APIs such as vitamins B1, B6, and B12, tinidazole, metronidazole, acyclovir, progesterone, and chloramphenicol, among others to ‘free’ from ‘restricted’ in a notification dated April 6.
- The government aims to develop 3 mega Bulk Drug parks in India in partnership with the States.
- The Government of India will give Grants-in-Aid to States with a maximum limit of INR 1000 Crore per Bulk Drug Park.
- Parks will have common facilities such as solvent recovery plant, distillation plant, power & steam units, common effluent treatment plant, etc.
- A sum of INR 3,000 crores has been approved for this scheme for next the 5 years.
Financial incentives will be given to eligible manufacturers of identified 53 critical bulk drugs on their incremental sales over the base year (2019-20) for a period of 6 years.
The pharmaceutical industry can seize this golden opportunity and expand its reach around the world amid this crisis.
Medical Device Industry
India has the 4th largest medical device market in Asia. The medical device industry in India has a significant foreign investment. The current market size of the industry is around $11 billion. The medical device industry allows 100% FDI for both Brownfield and Greenfield projects. $600 million were received as FDI in the last five years. Equipment & Instruments, Consumables, and Implants have attracted most investment form foreign investors. There are 750–800 domestic medical device manufacturers in India, with an average investment of $2.3–2.7 million and an average turnover of $6.2–6.9 million. Around 65% of the manufacturers are mostly domestic players operating in the consumables segment and catering to local consumption with limited exports. In the light to propel this segment for further growth, the Government of India has undertaken the following initiatives in the last month:
- More than 280 units in Special Economic Zones (SEZs), manufacturing essential items like pharmaceuticals and hospital devices, are operational.
- The exemption granted from Basic Customs Duty and Health Cess (till September 2020) on import of ventilators, masks, PPEs, test kits, and inputs used to manufacture these.
HEALTHCARE INFRASTRUCTURE
Healthcare in India is broadly classified into the public and private sector. The private sector comprises of majorly 70% of the total healthcare in India. The private sector is unorganized but forms an integral part of Indian healthcare.
Depending on the level of care required, healthcare in India is broadly classified into three categories. This classification includes primary care (provided at primary health centres or PHCs), secondary care (provided at district hospitals or DH), and tertiary care institutions (provided at specialised hospitals like AIIMS). Primary health care infrastructure provides the first level of contact between health professionals and the population.
Broadly, based on the population served and the type of services provided, primary health infrastructure in rural areas consists of a three-tier system. This includes Sub-Centres (SCs), Primary Health Centres (PHCs), and Community Health Centres (CHCs). A similar set up is maintained in urban areas. There has been an increase in the number of health facilities in India, but the growth has been slow.
The number of SCs, PHCs, and CHCs in 2005 and 2018 respectively across rural and urban areas are given in the figure below.
Fig.5 Number of Sub Centres, PHCs, and CHCs (from 2005 to 2018)
Overall, India’s public health expenditure (sum of central and state spending) has remained between 1.2% to 1.6% of GDP between 2008-09 and 2019-20. This expenditure is comparatively low as compared to other countries like China (3.2%), USA (8.5%), and Germany (9.4%).
In 2020-21, the Ministry received an allocation of Rs 67,112 crore. This is an increase of 3.9% over the revised estimates of 2019-20 (Rs 64,609 crore).
According to the National Health Profile 2019, there are 7,13,986 total government hospital beds available in India. This amounts to 0.55 beds per 1000 population. The elderly population aged 60 years and above is more vulnerable, given more complications which are reported for patients in this age group. The availability of beds for the elderly population in India is 5.18 beds per 1000 population. India is in dire need to build its healthcare infrastructure to meet the demands of the population. The Center for Disease Dynamics Economics and Policy estimates the existing hospital capacity of India’s public and private health sector in terms of the number of hospital beds, Intensive Care Unit (ICU) beds, and ventilators, across States and Union Territories (UTs).
Estimates suggest approximately 19 lakhs hospital beds, 95 thousand ICU beds and 48,000 ventilators are available in India.
Most of the beds and ventilators in India are concentrated in seven States – Uttar Pradesh (14.8%), Karnataka (13.8%), Maharashtra (12.2%), Tamil Nadu (8.1%), West Bengal (5.9%), Telangana (5.2%) and Kerala (5.2%). Existing bed capacity is mostly saturated at government hospitals.
MAJOR GOVERNMENT HOSPITALS IN INDIA
All India Institute of Medical Sciences
The initial rank in the top 10 government hospital goes to All India Institute of medical sciences that is located in Delhi. With a patient’s bed occupancy rate of approximately 1,766 beds, it is India’s most esteemed hospitals. It is popularly known for its medical professional team all over the world. It perfectly handles all medical specialities comprising medical casualties and emergencies. AIIMS has made appointment booking online very easy using AIIMS patient portal. Existing patients will be able to sign in using UHID and mobile no to take a new or follow-up appointment or will also be able to view laboratory reports using UHID.
PGIMER Chandigarh
PGIMER was established in 1962 and Pt Jawahar Lal Nehru inaugurated the hospital now named “Nehru Hospital” on 7th July 1963. It is among the top government hospital in India. According to The Week-NIELSEN BEST HOSPITALS SURVEY 2014, PGIMER has been adjudged as the second-best institute for medical education in India.
OPD block is a spacious facility with a covered area of 274000 sq ft. More than 3500 patients attend it every day. It has comprehensive diagnostic and therapeutic services under one roof for 90 Special Clinics and 6 Operation Theatres. The Nehru Hospital is for patient care- a 1400 bedded hospital with 98 rooms in the 5 private wards and two research blocks for basic sciences. The Advanced Eye Centre is the best in the country and runs several special clinics and services. For the first time in this country, laser treatment of retinal diseases and glaucoma was started in July 1989.
Safdarjung Hospital, New Delhi
Safdarjung Hospital is a leading and popular multispecialty hospital and teaching center located in Delhi just opposite to AIIMS. In India, it is one of the largest government hospitals. Currently, in all medical specialities, it trains postgraduate students from all over India. It is one of the largest, tertiary, level multi-disciplinary healthcare institutions in India. The hospital has the latest technology and world-class facilities from diagnostic and therapeutic aspects in all the specialities. The hospital which started with only 204 beds now has 1531 authorized beds. The hospital provides medical care to millions of citizens not only of Delhi and the neighbouring states but also to people of neighbouring countries.
Christian Medical College Vellore, Tamil Nadu
Christian Medical College Vellore is one of the best government hospitals in India. Every day over 8,000 patients choose to come here for their treatment. It also boasts the latest medical technology. It has comprehensive facilities and department from medicine to nearly every other super speciality. It has 39 major and 18 minor operation theatres, almost 3,000 beds, 95 wards, close to 3 million outpatients and 4 lakh inpatients. CMC hospital is one of the top hospitals in India. It is also known for its strong ethical standards. The doctors are employed full time, they have no other practices and receive a fixed salary with no incentive for unnecessary procedures or tests.
Deen Dayal Upadhyay Hospital, New Delhi
The Deen Dayal Upadhyay Hospital is situated in Delhi. It is one of the best hospitals for neurosurgery, psychiatry, and Plastic surgery. It also largely covers other specialities like orthopaedics, pathology, surgery, and radiology. It has a well assisted and supported emergency department. At present, it has been upgraded with bed strength of 670.
Ram Manohar Lohia Hospital, New Delhi
Dr Ram Manohar Lohia Hospital was previously known as Willington Hospital. It is affiliated with the University of Delhi. At present, it comes with 984 beds. In the 20th century, the hospital was founded by the British to serve its government employees and staff. It is a teaching hospital. In all specialities, it is committed and dedicated to training medical personnel.
King Edward Memorial Hospital, Mumbai, Maharashtra
In 1926, King Edward Memorial Hospital was founded in Mumbai, in the state of Maharashtra. In India, amongst the leading teaching and medical care providing institutions are the King Edward Memorial (KEM) Hospital and the Seth Gordhandas Sunderdas Medical College (GSMC). It staffs 550 resident doctors and 390 staff physicians. It provides advanced treatment facilities and basic care in all fields of surgery and medicine.
Tata Memorial Hospital, Mumbai
The Tata Memorial Hospital was initially commissioned by the Sir Dorabji Tata Trust on 28 February 1941. Every year nearly 30,000 new patients visit the clinics from all over India and neighbouring countries. Nearly 60% of these cancer patients receive primary care at the hospital of which over 70% are treated almost free of any charges. Over 1000 patients attend the OPD daily for medical advice, comprehensive care or follow-up treatment. Supportive care in the form of total rehabilitation and counselling of patients is widely recognised to be very important aspects of therapy. Excellent work has been carried out in areas of rehabilitation, physiotherapy, occupational therapy, speech therapy, psychology and medical social work.
Lokmanya Tilak Municipal General Hospital, Mumbai, Maharashtra
Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Hospital is a premier medical institution in India. It recognized internationally and nationally. It is a 1462 bedded Hospital that largely treats approximately 81,000 in-patients and 1.9 million out-patients annually.
Institute for Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal
Institute for Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital provides the best medical services through its various departments. It comes with a good number of rooms readily available for Inpatients Special Clinics, Outdoor Clinics and Operation Theatres with latest medical facilities.
MAJOR PRIVATE HOSPITALS IN INDIA
Sir Ganga Ram Hospital
Sir Ganga Ram Hospital is one of the best private hospitals in the country and it was founded in the year 1921. It has a capacity of 657 beds with full-fledged patient care units. It is a premier medical institution that maintains 100% occupancy throughout the year. It provides the best quality treatment to the patients at affordable pricing. It still follows the vision of the founder’s Pandit Nehru and provides free of cost treatment to poor and needy patients.
Apollo Hospital
The Hospital was established in the year 1983 by Dr Prathap Reddy and later the chain opened hospital under the same umbrella in 25 more states. The headquarters of the hospital is in Chennai city and it has the best team of Doctors and world-class facilities to treat the patients suffering from various diseases. The Hospital is famous for the treatment of various diseases related to Heart, Kidney, Lungs, etc.
Fortis
Fortis was founded in the year 2001 and since that day it treats patients with care and dedication. It has hospitals in cities like Amritsar, Jaipur, Noida, Ludhiana, Kota, Odisha, and many more. The hospital is famous for its neuroscience, cardiac sciences, critical care and bone and joint treatment. The hospital management is planning to open and extend the chain by opening the hospital in other cities too.
Moolchand Hospital, New Delhi
As one of India’s foremost names in healthcare, Moolchand has been setting standards for the past 9 decades. At Moolchand Kharaiti Ram Hospital (Moolchand Medcity South Delhi) there is the expertise of more than 250 doctors from 50+ specialities available. Moolchand Care Pathways are protocol driven, reflect global best practices and ensure that our patients consistently receive quality care. They have created a hospital that is complete in all respects to give a holistic healthcare experience.
Medanta (The Medcity)
It was established in the year 2009 as a super speciality hospital in Gurgaon city. The hospital is spread in an area of approximately 43 acres of land and has around 20 special departments for research and treatment. It has cutting edge technology to treat patients under the observation of highly trained doctors and nursing staff. It has around 1250 beds and 45 OT to provide treatment to Indian and international patients both. It is famous for its Cardiac Surgeries and is the first hospital in Indian history to perform robotic surgery.
Kokilaben Hospital
It is a super speciality hospital in the country that made its name and reputation within a short period of time. It was initiated in the year 1999 and since then the hospital has been providing medical treatment of its strong principles only. It provides high-class facilities and medical equipment for the treatment of patients. They have a capacity of over 750 beds and the largest number of critical care beds in Mumbai, with 180 ICU beds.
Tata Memorial Hospital
It is a hospital founded by the Tata Group in the year 1941. It is located in Mumbai and considered the largest hospital for the treatment of Cancer. It has a huge infrastructure and research units to research and find treatment for deadly diseases. They have a bed capacity of 600.
Lilavati Hospital and Research Centre
It is one of the famous hospitals in Mumbai and the country. It was founded in the year 1978 and is equipped with world-class facilities. It has different diagnostic centers. The hospital has won various awards and certifications for the services offered by them to society. They have a bed strength of 320.
It is famous for its diagnostic services, paediatrics, gynaecology and obstetrics, rehabilitative services, paediatric ophthalmology, maternity services, neurosciences, orthopaedics, etc.
Narayana Hrudaalaya
It is one of the famous speciality tertiary care hospital chains which is situated in Bengaluru city. It offers affordable treatment to the patients which helped the hospital in getting “Good Company Award”. It was founded in the year 2000 and currently has 31 chains across the country. The hospital employs around 15000 staff members which include doctors and nursing staff both.
Artemis Hospital
Artemis hospital was founded in the year 2007 with world-class technology and facilities in it. It has a capacity of 380 beds with the latest medical equipment. It uses the latest medical technology to treat patients. It has a team of highly experienced and talented doctors. It helps in creating new standards in the industry. The medical treatment and procedures followed by the doctors are research oriented. The hospital has a great hygienic environment and great caring nursing staff.
MAJOR SINGLE SPECIALTY HOSPITALS IN INDIA
Some major single speciality hospitals in the country include:
Fortis Escorts Heart and Research Centre (New Delhi)
With a legacy of over 30 years, Fortis Escorts Heart Institute, New Delhi has established itself as a pioneer in the field of cardiac care and is recognised for its path-breaking work and services to numerous heart patients. Armed with clinical expertise and cutting-edge technology, Fortis Escorts Heart Institute has enriched numerous lives through its world-class treatment and compassionate patient care. With Padma Shri and Padma Bhushan awardees serving as doctors, the hospital is recognised in the world as a centre of excellence, today.
Tata Memorial Cancer Hospital (Mumbai)
TMC is a comprehensive centre for the prevention and treatment of cancer, and research. It is a landmark on the global health map and particularly important to this part of the world. Nearly 25,000 patients visit the clinics each year, not only from all over India but from neighbouring countries as well. They now have more than 600 beds spread over almost 70,000 square metres. About 60 per cent of patients seeking primary care are treated free of charge. Over the years, TMC has also realised the importance of preventive activities and is reaching out to create awareness even in rural areas.
Sankara Nethralaya (Chennai)
Sankara Nethralaya is a not-for-profit missionary institution for ophthalmic care (an eye hospital) headquartered in Chennai, India. Sankara Nethralaya has over 1000 employees and serves around 1500 patients per day, performing over 100 surgeries per day.
Vasan Eye Care (Chennai)
Vasan Healthcare Group is a health care group in India. Founded by A. M. Arun, the group is based in Trichy and has more than 170 eye care hospitals in India and 27 dental Hospitals across 4 states in South India. The company also operates two multi-speciality hospitals in Trichy. Vasan Eye Care Hospitals are day-care centres for treating eye ailments.
HOSMAT Hospital (Bengaluru)
HOSMAT Hospital for Orthopaedics, Sports Medicine, Arthritis & Trauma, is a 350-bed speciality hospital in central Bengaluru, India. It also includes HOSMAT Joint Replacement Center and HOSMAT Neurosciences. It is currently undergoing expansion to 500 beds, which would make it the largest speciality hospital of its kind in Asia. Initially known as the ‘accident hospital’, later it was in the news as a centre for knee transplantation procedures. Now it is India’s largest orthopaedic and neuro center.
Fortis La Femme
Fortis La Femme is a 72 bedded boutique facility dedicated to women and childcare. Fortis La Femme is India’s leading healthcare provider for all stages of a woman’s lifespan-birth, adolescence, motherhood, menopause and beyond. A unique health care concept that’s tailor-made for your every need, at every stage. They have centers all over India.
Apollo Cradle
Apollo Cradle & Children’s Hospital is the country’s leading and most trusted healthcare destination, both for the mother as well as for the child. Apollo Cradle & Children’s Hospital offers patients the highest quality care and most advanced treatment in the country in nearly every medical speciality including Gynaecology, Laparoscopy, Paediatrics & Neonatology, Fertility, Fetal Medicine & NICU etc., all supported with the highly qualified specialists. A comprehensive range of health care services under one roof to provide the growing medical needs of today’s women and children are available here. They have centers all over India.
MAJOR ORTHOPAEDIC HOSPITALS IN INDIA
- Indraprastha Apollo Hospital, New Delhi
- Medanta – The Medicity, Gurgaon
- Kokilaben Dhirubhai Ambani Hospital, Mumbai
- Apollo Hospitals, Greams Road, Chennai
- Fortis Memorial Research Institute, Gurgaon
- BLK Super Speciality Hospital, New Delhi
- Manipal Hospitals Dwarka, Delhi
- Artemis Hospital, Gurgaon
- Global Hospitals, Chennai
- Max Super Speciality Hospital, Saket, New Delhi
MAJOR NEPHROLOGY HOSPITALS IN INDIA
- Fortis Memorial Research Institute, Gurgaon
- Medanta – The Medicity, Gurgaon
- Indraprastha Apollo Hospital, New Delhi
- Kokilaben Dhirubhai Ambani Hospital, Mumbai
- Apollo Hospitals, Greams Road, Chennai
- BLK Super Speciality Hospital, New Delhi
- Artemis Hospital, Gurgaon
- Global Hospitals, Chennai
- Max Super Speciality Hospital, Saket, New Delhi
- Narayana Multispeciality Hospital, Bangalore
- MAJOR CARDIOLOGY HOSPITALS IN INDIA
- Fortis Escorts Heart Institute, New Delhi
- Medanta – The Medicity, Gurgaon
- Apollo Hospitals, Greams Road, Chennai
- BLK Super Speciality Hospital, New Delhi
- Indraprastha Apollo Hospital, New Delhi
- Max Super Speciality Hospital, Saket, New Delhi
- Narayana Multispeciality Hospital, Bangalore
- Artemis Hospital, Gurgaon
- Global Hospitals, Chennai
- New Age Wockhardt Hospital, Mumbai
MAJOR NEUROLOGY HOSPITALS IN INDIA
- Fortis Memorial Research Institute, Gurgaon
- Indraprastha Apollo Hospital, New Delhi
- BLK Super Speciality Hospital, New Delhi
- Artemis Hospital, Gurgaon
- Medanta – The Medicity, Gurgaon
- Apollo Hospitals, Greams Road, Chennai
- Kokilaben Dhirubhai Ambani Hospital, Mumbai
- Global Hospitals, Chennai
- Neurogen Brain and Spine Institute, Mumbai
- IBS Institute of Brain and Spine, New Delhi
MAJOR ONCOLOGY HOSPITALS IN INDIA
- Dharamshila Narayana Superspeciality Hospital, New Delhi
- Indraprastha Apollo Hospital, New Delhi
- Kokilaben Dhirubhai Ambani Hospital, Mumbai
- Medanta – The Medicity, Gurgaon
- BLK Super Speciality Hospital, New Delhi
- Cancer Institute (Wia) Adyar, Chennai
- Apollo Hospitals, Greams Road, Chennai
- Artemis Hospital, Gurgaon
- Fortis Memorial Research Institute, Gurgaon
- Global Hospitals, Chennai
MAJOR GASTROENTEROLOGY HOSPITALS IN INDIA
- Indraprastha Apollo Hospital, New Delhi
- Medanta – The Medicity, Gurgaon
- Kokilaben Dhirubhai Ambani Hospital, Mumbai
- Apollo Hospitals, Greams Road, Chennai
- Fortis Memorial Research Institute, Gurgaon
- BLK Super Speciality Hospital, New Delhi
- Artemis Hospital, Gurgaon
- Global Hospitals, Chennai
- Max Super Speciality Hospital, Saket, New Delhi
- Sir Ganga Ram Hospital, New Delhi
MAJOR GYNECOLOGY HOSPITALS IN INDIA
- Nova IVI Fertility, Ahmedabad
- CK Birla Hospital, Gurgaon
- Miracle Mediclinic Hospital, Gurgaon
- Lotus Hospitals for Women and Children, Hyderabad
- Advance Fertility and Gynaecology Centre, New Delhi
- Indraprastha Apollo Hospital, New Delhi
- Parampara Fertility and Gynaec Centre, Chennai
- Medanta – The Medicity, Gurgaon
- Kokilaben Dhirubhai Ambani Hospital, Mumbai
- Apollo Hospitals, Greams Road, Chennai
MAJOR BARIATRIC HOSPITALS IN INDIA
- Indraprastha Apollo Hospital, New Delhi
- Medanta – The Medicity, Gurgaon
- Kokilaben Dhirubhai Ambani Hospital, Mumbai
- Apollo Hospitals, Greams Road, Chennai
- Fortis Memorial Research Institute, Gurgaon
- BLK Super Speciality Hospital, New Delhi
- Artemis Hospital, Gurgaon
- Global Hospitals, Chennai
- Max Super Speciality Hospital, Saket, New Delhi
- Sir Ganga Ram Hospital, New Delhi
MAJOR UROLOGY HOSPITALS IN INDIA
- Blue Ribbon Prostate Clinic, New Delhi
- Indraprastha Apollo Hospital, New Delhi
- Medanta – The Medicity, Gurgaon
- Kokilaben Dhirubhai Ambani Hospital, Mumbai
- Apollo Hospitals, Greams Road, Chennai
- Fortis Memorial Research Institute, Gurgaon
- BLK Super Speciality Hospital, New Delhi
- Manipal Hospitals Dwarka, Delhi
- Artemis Hospital, Gurgaon
- Global Hospitals, Chennai
MAJOR FERTILITY HOSPITALS IN INDIA
- Nova IVI Fertility, Ahmedabad
- World Infertility and IVF Centre, New Delhi
- Parampara Fertility and Gynaec Centre, Chennai
- Advance Fertility and Gynaecology Centre, New Delhi
- Rainbow Children’s Hospital, Hyderabad
- CK Birla Hospital, Gurgaon
- Medicover Fertility Center, Delhi
- Fortis Memorial Research Institute, Gurgaon
- W Pratiksha Hospital, Gurgaon
- Sir Ganga Ram Hospital, New Delhi
MAJOR DIAGNOSTIC CENTERS IN INDIA
- ONCQUEST LABORATO
- RIES LIMITED
- HITECH DIAGNOSTIC CENTRE
- SRL DIAGNOSTICS
- SUBURBAN DIAGNOSTICS
- LUCID MEDICAL DIAGNOSTICS
- VIJAYA DIAGNOSTIC CENTRE
- METROPOLIS
- DR LAL PATHLABS
- QUEST DIAGNOSTICS
- THERMO FISHER
- SIEMENS
- ROCHE DIAGNOSTICS
- J & J (JOHNSON & JOHNSON)
- BIO MERIEUX
- BECKMEN COULTER
- ABBOT
TOP 10 HEALTHCARE STARTUPS IN INDIA AFTER COVID 2020
- DINGG is an intelligent queue management platform helps customers utilise their time better instead of waiting in a queue.
- AgVa has developed a toaster-size ventilator, Bio design Innovation Lab which is working on low-cost indigenous respiratory support devices.
- DronaMaps is providing its solution to map affected patients.
- mFine has developed an AI-powered tool that enables virtual medical consultation to assess patients.
- MicroGo provides hand hygiene products.
- Staqu is offering its AI-based video analytics platform.
- Jarvis to identify people neglecting social distancing norms or not wearing masks.
- Kaaenaat is working on deep tech and IT-based solutions.
- Qure.ai has partnered with Italy’s San Raffaele hospital to deploy new solutions to automatically read and interpret chest x rays.
- Bione has innovated in discovering specific gene variants that are responsible for an individual’s susceptibility to Coronavirus by developing a COVID-19 focussed Microbiome test, which combined with its AI, predictive analysis tools can provide tailored recommendations to individuals to strengthen their particular microbiome and thus be more immune to Coronavirus and be able to fight off COVID-19.
TOP HEALTHCARE INVESTMENT IN INDIA
1.HealthPlix Technologies raises $6 million in Series B round led by JSW Ventures.
Healthtech startup HealthPlix Technologies Founded in 2016 by Raghuraj Sunder Raju, Prasad Basavaraj, and Sandeep Gudibanda and led by JSW Ventures has raised $6 million. Existing investors Chiratae Ventures and Kalaari Capital also participated in the total equity funding raised at $10 million.
HealthPlix Technologies helps doctors in digitising clinical operations and clinical treatment methodologies. As a B2B2C solution provider, HealthPlix provides Electronic Medical Record (EMR) software to medical practitioners, assisting them with – clinical decision support (CDS), generating e-prescriptions and digitally managing the operations of their clinics. It helps doctors in India to elevate their clinical practice to truly an evidence-based treatment methodology using HealthPlix EMR and also use Real World Evidence (RWE) Platform to assess the efficacy of various treatments being deployed and thus contribute our bit in the research of much needed COVID treatment. It also has a consumer mobile app which enables patients to avail video consultations with a highly qualified specialist and super-specialist doctors. The company currently claims to assist with more than 50,000 consultations daily across 12 medical specialities, in more than 180 cities across India.
Healthcare start-ups are witnessing a surge in demand with doctors and patients logging in on their platforms to undertake online consultations. With patients unable to visit doctors and clinics physically during the COVID-19 pandemic, HealthPlix has also onboarded an additional 15,000 doctors to offer video consultations to their patients.
- PE firm InvAsent invests Rs 70 crore in Sharp Sight Group of Eye Hospitals.
Healthcare-focused private equity (PE) firm InvAscent has invested Rs 70 crore in Sharp Sight Group of Eye Hospitals. The funds will be used for the company’s expansion over the next three years into tier-2 cities. Currently, the company runs seven hospitals in Delhi NCR and Jammu & Kashmir.
Founded by Dr Samir Sud and Dr Kamal B Kapur in 1997, the eye care services provider has so far performed over 5 lakh surgeries and procedures for nearly 10 lakh patients. Besides its centres in India, the company also has two facilities in Tajikistan and Nigeria.
- Healthcare startup IVF Access raises $5 million from Vortex Ventures Southeast Asia and India.
Bengaluru-based healthcare start-up IVF Access has raised $5 million from Vertex Ventures Southeast Asia and India. The capital will be deployed to set up IVF clinics across India that will provide assisted reproductive treatments.
Founded by Naresh Rao, Nikhil Rajmohan, Harinath Chakravarthy and Pravin Sethuraman IVF Access is a healthcare company which is setting up clinics in India providing in vitro fertilisation (IVF) treatments.
According to a report by advisory firm EY, an estimated 10-15% of married couples in India, or 27.5 million couples who are actively seeking children, suffer from infertility. The increasing marital age, postponement of childbearing, demographic skew and lifestyle risk factors are key factors driving this trend. Despite the market opportunity, the penetration of IVF treatment is currently very low in India, according to the start-up. The company plans to change that by increasing the reach of such fertility treatments and procedures for couples all across the country.
- DocsApp announces merger deal with HealthTech platform MediBuddy.
Online doctor consultation app DocsApp announced a merger with Bengaluru-based healthcare platform MediBuddy. Launched in 2015, patients connect and talk to specialist doctors online using the app. The startup offers over video calls, voice call and an in-built chat application for consultations with a doctor. The merger will help the expansion of the business into new healthcare categories including online specialist doctor consultations, lab tests, preventive health checks, and delivery of medicines.
MediBuddy was initially launched as a tool to schedule hospital visits, raise and track health insurance claims, search for insurance-covered network hospitals. It later branched into doctor consultation and home-based blood tests.
The merged entity will serve the healthcare needs of over 3 crore Indians, with a partner network of over 90,000 doctors, 7,000 hospitals, 3,000 diagnostic centres and 2,500 pharmacies covering over 95% of pin codes in India.
DocsApp has raised close to $19 million in venture capital and debt funding since its launch in 2015. Its merger with MediBuddy is significant considering that many consumer-facing startups are facing bankruptcy due to COVID-19.
- Max Healthcare completes the merge of Radiant Life Care’s healthcare assets with itself
Max India Ltd has completed spinning off its hospital operations under Max Healthcare and the subsequent merger of Radiant Life Care Pvt Ltd with it. Radiant had acquired a 49.7% stake in Max Healthcare in June 2019 for a consideration of around Rs 2,136 crore.
As a result of this merger, shareholders of Max India will receive 99 equity shares of the merged Max India-Radiant Life Care for every 100 equity shares of that they hold in Max India, while they will also get one share of Advaita for five shares of Max India. All Max India shareholders will be allotted shares of Max Healthcare and Advaita Allied Health Services, which will be renamed as Max India Ltd later. Both Max Healthcare and the new ‘Max India’ are expected to be listed on the Indian stock exchanges in August 2020. Advaita Allied Health Services is a wholly owned subsidiary of Max India Ltd.
After the merger, MHIL will operate over 3,500 beds across India, including tertiary and quaternary care facilities such as Nanavati Hospital in Mumbai and BLK Hospital, Max Hospital Saket, Max Smart Speciality Hospital Saket, Max Hospital Patparganj, Max Hospital Shalimar Bagh in Delhi.
Following the demerger and spin-off, today, Radiant Life Care’s healthcare assets, which included the Nanavati Hospital in Mumbai and BLK Hospital in Delhi, were merged into Max Healthcare.
- Online fitness startup Fittr raises $2 million in a pre-series A funding from Surge.
Fittr, a Pune-based online fitness startup, has raised $2 million from Surge, Sequoia Capital India’s rapid scale-up programme for early-stage startups in India and Southeast Asia. Founded in January 2016 by Jitendra Chouksey, Fittr is an online fitness community that claims to have over 850,000 members. The company has achieved a cumulative revenue of $13 million.
Fittr provides free access to diet and training tools, over 5,000 healthy recipes, live fitness sessions with experts, Q&A with coaches, and connects users to a community of fitness experts and enthusiasts. Users can get a personalized nutrition and exercise plans to reach their health and fitness goals by paying a small premium. The customised plans are provided by one of Fittr’s 200 certified coaches. Subscribers get consultation call with the coach, as well as weekly check-ups on their progress via the app. The central philosophy underpinning Fittr is to empower the end-user to transform and inspire others to get fit.
- Healthcare analytics firm Tricog raises $10.5 million in Series B funding round from Japanese and US investors
Healthcare analytics firm Tricog has raised $10.5 million from Japan’s University of Tokyo Edge Capital (UTEC), Aflac Ventures, LLC and Dream Incubator and US-based fund TeamFund. The funds will be used to expand its product line for remote patient monitoring and to establish a strong presence in Asia and Africa.
Tricog has grown its presence in over 12 countries in Southeast Asia and Africa, it said. The company’s AI-powered platform has been used by over three million patients for wellness, screening and diagnosis of acute and chronic heart diseases.
Founded in 2015 by Bhograj, Zainul Charbiwala, Udayan Dasgupta and Abhinav Gujjar, Tricog provides virtual cardiology services to remote clinics. Tricog’s InstaECG platform has been deployed in over 2,500 cath labs, hospitals, clinics and diagnostic centres.
- Healthcare startup Qure.ai raises $16 million led by Sequoia India.
Healthcare startup Qure.ai has raised $16 million in an equity funding round led by Sequoia India. Founded in 2016 by Prashant Warier and Pooja Rao, Qure.ai provides interpretations of radiology scans within seconds, reducing time to treatment in the critical moments of care. It also claims to be the only solution in the industry to detect every critical brain abnormality on a head CT (Computed Tomography) including five types of intracranial haemorrhages, cranial fractures, infarcts, midline shift, and mass effect (for tumour detection).
Qure.ai was incubated in data analytics Fractal Analytics, which is currently valued at over $500 million. Sequoia was an investor in Fractal as well. The startup is present in over 20 countries with a database of over seven million scans.
Medical imaging is one of the fields in healthcare where there is enough digitized data to turn the promise of Artificial Intelligence (AI) into a reality. The sophistication of Qure.ai’s algorithms and predictive analytics tools, coupled with their expert team of data scientists and physicians positions them very well versus their global competitors.
- Healthtech startup Innovaccer raises $70 million in Series C funding round from Steadview Capital, Tiger Global, Dragoneer, Westbridge, Mubadala and M12.
Healthcare technology company Innovaccer Inc. has raised $70 million from Steadview Capital, Tiger Global, Dragoneer, Westbridge, Mubadala and M12 (Microsoft’s venture fund). Innovaccer has raised $120 million till date.
Founded in 2014, Innovaccer leverages artificial intelligence (AI) and analytics to automate routine workflows and reduce manual overhead. Its Data Activation Platform has been implemented in healthcare institutions, government organisations, and corporate enterprises. By further advancing its core technology, Innovaccer aims to generate 100 million unified patient records accessible to 500,000 care team members through its platform, over the next few years.
- Syneos Health of USA invests in Indegene Omnipresence Inc, a subsidiary of health-tech
American biopharmaceutical solutions company Syneos Health has invested an undisclosed amount in Indegene Omnipresence Inc., a subsidiary of Bengaluru-based health tech firm Indegene.
Syneos Health provides drug development and commercialisation solutions to biopharmaceutical customers in over 110 countries. Omnipresence is a customer experience platform for healthcare and life sciences organisations with customer relationship management (CRM), omnichannel engagement, advanced analytics and artificial intelligence (AI) capabilities.
GOVERNMENT INITIATIVES FOR HEALTHCARE IN 2020
The Union Cabinet chaired by the Prime Minister; Shri Narendra Modi approved significant investments of Rs. 15,000 crore for ‘India COVID-19 Emergency Response and Health System Preparedness Package’.
The funds sanctioned will be utilized in 3 Phases and for immediate COVID-19 Emergency Response (an amount of Rs. 7,774 Crore) has been provisioned and rest for medium-term support (1-4 years) to be provided under mission mode approach.
Key Objectives of the package
- Mounting emergency response to slow and limit COVID-19 in India through the development of diagnostics and COV1D-dedicated treatment facilities.
- Centralized procurement of essential medical equipment and drugs required for treatment of infected patients.
- Strengthen and build resilient National and State health systems to support prevention and preparedness for future disease outbreaks.
- Setting up of laboratories.
- Bolster surveillance activities, bio-security preparedness, pandemic research.
- Proactively engage communities and conduct risk communication activities.
In Phase 1, the Ministry of Health & Family Welfare with the support of all the other line ministries has already undertaken several activities like:
- Additional funds to the tune of Rs 3,000 Cr have been released under the Package to State/UTs, for the strengthening of existing health facilities as COVID Dedicated Hospitals, Dedicated COVID Health Center and Dedicated COVID Care Centers. Detailed guidelines, protocols and advisory for quarantine, isolation, testing, treatment, disease containment, decontamination, social distancing and surveillance. Hotspots have been identified and appropriate containment strategies are being implemented.
- Diagnostics laboratories network has been expanded and our testing capacity increasing every day. Leveraging on the existing multi-disease testing platforms under the National TB Elimination Programme, orders for procurement of 13 lakhs diagnostic kits have been placed to augment COVID 19 testing.
- All health workers including Community Health Volunteers (ASHAs) have been covered with insurance under the “Pradhan Mantri Garib Kalyan Package: Insurance Scheme for Health Workers lighting COVID-19″. Personal Protection Equipment (PPE), N95 masks and ventilators, testing kits and drugs for treatment are being procured centrally.
The major share of the expenditure will be used for mounting robust emergency response, strengthening National and State health systems followed by strengthening pandemic research and multi-sector national institutions and platforms for One-Health, community engagement and risk communications and implementation, management, capacity building, monitoring and evaluation component.
HEALTHCARE EXPENDITURE AS PER GDP
According to data from CARE Ratings, India only invested 1.29 per cent of its total GDP in the financial year 2020 into its public health system. Capital expenditure stood at a paltry 0.19 per cent.
The latest Union Budget 2020-21 has also seen only a modest increase in healthcare allocations of 5.7 per cent to Rs 67,484 crore from the previous year’s Rs. 67,484 crore. Analysts have noted that if the healthcare budget continues to grow year-on-year at current rates, it will significantly fall short of the central government’s target of 2.5 per cent of GDP by 2025. The last five years have seen public expenditure on health grow at a 15 per cent CAGR, but most of this has been credited to rises in wages, rather than investment into infrastructure.
India has deprioritised its public healthcare system. At 3.6 per cent of GDP (out-of-pocket and public), India’s spending is far below the average OECD spend of 8.8 per cent. India also spends the least among all BRICS countries.
A shortage of hospital beds also sees dire conditions in hospitals, where patients are often forced to lie on the ground.
Approximately 65 per cent of healthcare costs come out of the pocket of the average Indian, plunging around 58 million into poverty every year. Despite public hospitals providing treatment at no cost, Indians still have to spend exorbitantly on medicine.
PREDICTIONS ON INDIAN HEALTHCARE SYSTEM
India braced itself for the COVID -19 by supporting its healthcare and pharmaceutical industry to ensure that the public healthcare system is not burdened by the onslaught of cases.
From educating the people about the virus itself to capacity and capability building in the healthcare workers and ensuring the availability of test kits and therapeutics to meet domestic and export demands, there has been immense cohesion in India’s approach to the pandemic.
Co-operation from the private sector, the public healthcare ecosystem has risen to the challenge posed by the pandemic and ensured access to affordable medicines and medical equipment.
There are still multiple variables which pose a hindrance to the growth of the health ecosystem which was brought to the forefront as a result of the pandemic were:
- The secondary healthcare system is still weak in the aspirational districts and rural healthcare (in the peri-urban areas) is under-equipped to sufficiently care for patients. These gaps were revealed consequently to the outbreak of the novel coronavirus.
- The pandemic paralyzed the private health system in the country as well as the public system. The migrant exodus only added to this paralysis.
- There should be a multi-sectoral outlook towards the healthcare ecosystem, with pharma as the nucleus.
- Involvement of pharma industry in sectors other than medicine such as venturing into manufacturing indigenous testing kits, whilst ensuring the highest level of quality standards & access to medicine, working closely with the ICMR.
The pandemic has provided with a unique opportunity to enable the enormous capacity building of the entire health sector which can be achieved through a multi-stakeholder approach. This is evident in approach towards the classification of the districts into red, arrange and green, depending on the caseload.
The healthcare ecosystem was scaled up to respond to the pandemic. The cohesion between the healthcare and IT sector was distinct, specifically with the launch of the tracking app Aarogya Setu. Besides, the Indian healthcare system, and the pharma ecosystem by extension, has immense potential too.
The Government has also provided a boost for domestic drug-makers and manufacturers by approaching them to manufacture active pharmaceutical ingredients (APIs) as well as personal protection kits (PPEs). This multi-stakeholder approach will enable the Indian healthcare ecosystem to scale extraordinary heights.
CONCLUSION
The Indian government is trying its best to curtail the pandemic, but with weak infrastructure, the task has become burdensome. Many steps to reducing costs and bring down healthcare expenses like capping the cost of private hospitals have been implemented. Speedy introduction of generic drugs into the market has remained in focus and is expected to benefit the Indian pharmaceutical companies. Besides, the thrust on rural health programmes, lifesaving drugs, and preventive vaccines also augurs well for the pharmaceutical companies. The problems faced due to the pandemic has expedited development in many sectors in India and the growth would continue if the resources are used effectively and efficiently.
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