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© 2006 ReaMetrix, Inc. All rights reserved.
13thSeptember2008
TowardsIndigenouslyDeveloped,LocallyRelevant,AffordableDiagnos<cs
TheSearchforaSustainableModel
Page 2 © 2006 ReaMetrix, Inc. All rights reserved.
Disclosure
ReaMetrixisacross‐disciplinarygroupmadeupofBiologists,Chemists,PhysicistsandEngineers,basedoutofBangaloreworkingtowardsthevisionofaffordablediagnosHcsofrelevancetothedevelopingworld.
Wewouldliketohonestlyadmitthatallpre‐conceivedideaswithwhichwestartedexecuHngonourvisioninIndia,turnedouttobetotallywrong.
Thishasforcedustolookatcompletelynewparadigmsthatcanhelpbuildasustainableeconomicmodeltosolvethetwinissuesofaccessibilityandaffordability
Page 3 © 2006 ReaMetrix, Inc. All rights reserved.
FramingtheBigPicture
DiagnosHcsisanimportantcomponentindiseasemanagement.
DiagnosHcsisallabout“informaHon”generaHon:InformaHonisgeneratedtohelpthephysician(andinsomecasesthepaHents)makebeSerclinicaldecisions.
DiagnosHcsisneveraboutreplacingthedoctororareplacementoftheexperiencegarneredinalocalcontextbyadoctor
Page 4 © 2006 ReaMetrix, Inc. All rights reserved.
Howisthecostofdiagnos<csinfluencedindifferentcontexts?
Inmostdevelopingcountries,thediagnosHcsoluHonsusedareparachutedfromresource‐richcountries.
Duringdevelopment,thecosteconomicsofthesesoluHonswerehighlyinfluencedbythelocalmacroeconomicenvironmentprevailinginthosecountries.
DesigncriteriaopHmizedforoneenvironmentmaynotbetherightsoluHonforanother.
CANNOTHAVEAONE‐SIZE
FITSALLAPPROACH
Page 5 © 2006 ReaMetrix, Inc. All rights reserved.
Differentpriori<esindifferentenvironments
Inthedevelopedcountries:• LaborcostsdominatetheCOGS.
• TheemphasisisonreducHonoflaborbothinmanufacturingandinprocess.
• LessemphasisonmaterialconservaHon. Intheresource‐poorcountries:
• MaterialcostsdominatetheCOGS.
• Theemphasishastobeonmaterialrecovery–moreoftherawmaterialhastoendupinfinishedgoods.
• LaborcomponenthasasmallcontribuHontoCOGS.
Page 6 © 2006 ReaMetrix, Inc. All rights reserved.
AnOpportunitytoChangetheParadigm?
Re‐Posetheprobleminthelocalcontext
QuanHfythecostofgeneraHngclinicalinformaHoninthelocalcontext
Define“theaffordabilityindex”inthecontextoflocalmacroeconomicenvironment–howmuchwillthestakeholderbewillingtopay?
Affordabilityindexdrivestheappropriatetechnologythatcandeliverthegoodandserviceswithintheaffordabilityindex.
Pu#ngthisParadigmtoTest…..ACaseStudy:AnAffordableCD3/CD4Diagnos@cTestinManagingHIVPa@ents
PRICEDETERMINESTECHNOLOGY,TECHNOLOGYDOESN’TSETTHEPRICE
Page 7 © 2006 ReaMetrix, Inc. All rights reserved.
CaseStudy:AffordableCD3/CD4Diagnos<cs
TestisusedforthemeasurementofimmunesystemT‐Cells–toenableadoctortomanageHIV/AIDSpaHents
Diseasemanagementisabouttrends–notdecisionsbasedonasinglepoint
CD
4 C
ount
Time
CD
4 C
ount
Time
Rs.500 – Rs.1200 per test ? Cost per test
Page 8 © 2006 ReaMetrix, Inc. All rights reserved.
AnatomyofClinicalInforma<onGenera<onintheIndianContext–esp.inoutreachcenters
SamplejourneyandcostaccumulaHon
Acquire Process Run Provide Results Transport
Collection centre
Path Lab Doctor
Hospital
Centralized Path Lab
Layers of margin at every step
Page 9 © 2006 ReaMetrix, Inc. All rights reserved.
IssueswiththeCurrentTes<ngMethodology
Technical Agedbloodsamples Accuracyandreliabilityofresults
Timelagfortreatmentdecisions
Traceabilityofsample
Commercial EncouragestoomanylayersofmarginaffecHngaffordability
CapitalcostsforimportedequipmentsactasbigbarriertoentryaswellasinadopHonofclosertocustomermodels
IssueswithCD3/CD4Diagnos@cs
Non‐LocalManufactureof
Reagents:RelianceonImportedReagents
Lackofamechanismtogenerateclinicalinforma?on
closertowhereitsneeded
Non‐localManufactureofInstrumenta?on
o@enwithfeatureswith
minimalrelevanceintheIndiancontext
Page 10 © 2006 ReaMetrix, Inc. All rights reserved.
ASystemsApproach:Reagents+Instrumenta<on+DeliveryReagents
Strategy:TakeadvantageoflowlaborcostinIndiatodevelopreagentslocally
Focusonprocessimprovementshasincreasedmaterialyieldbyanaverageof400%‐higheryieldresultsinlowercostofatest:Rs100pertest(nearly5foldlower)
LowercostreagentsBUTwiththesamequalityasthemoreexpensivereagentsimportedfromoutsideIndia
Page 11 © 2006 ReaMetrix, Inc. All rights reserved.
ASystemsApproach:Reagents+Instrumenta<on+Delivery
Reagents:DesigningFeaturesthatareLocallyRelevant
ConceptofUni<zedDriedDownReagents
‐ Reagentsrequirenocold‐chain–fortransportaswellasforstorage‐ Upto8daystabilityofstained‐fixedsampleseliminaHngbloodstabilityissuesassociatedwithlongperiodsoftransportaHonfromcollecHoncentertocentraltesHngfacility‐ Reagentscanwithstandextremeheatupto45C
DriedReagentsarenotasignificantneedinthewesterncontext…butareasignificantbooninthedevelopingna?oncontext!Adv.ofdefiningtheproblemlocally!
Page 12 © 2006 ReaMetrix, Inc. All rights reserved.
ASystemsApproach:Reagents+Instrumenta<on+Delivery
Uni@zedTestCartridges
• AbilitytoberunusingacarbaSery
• UniHzeswastedisposal–minimizeschanceofimproperwastehandling
• Opensystem–abilitytoportmulHpletestsontothesystem–ItisNOTaninstrumentformeasuringonlyCD3/CD4counts
• Designedtowithstandharshenvironments
• Portable
• ReducedCapitalCost
• Minimalskilllevelneededtooperate
• RequiresnofieldcalibraHon
Page 13 © 2006 ReaMetrix, Inc. All rights reserved.
ASystemsApproach:Reagents+Instrumenta<on+Delivery
Howdoesthisenableanewparadigm?
• TheinstrumentaswellasthedrieddownreagentsenablegeneraHonofclinicalinformaHonclosertothedoctor‐paHentinteracHoncontext,thatiscurrentlynotpossible:
‐GP’sOffice‐OutreachCentres‐ICU’sinHospitals‐Mobilescreeningvans‐Ambulances
*Thoughthereagentsareaffordable–thereissHllenoughmargintopayforthecostoftheinstrumentaswell,overa1‐yearperiod
Page 14 © 2006 ReaMetrix, Inc. All rights reserved.
ASystemsApproach:Reagents+Instrumenta<on+Delivery
EnablingLocalEconomicAc<vityandEmpowermentofHealth‐workersbyNovelMethodsofDeliveringClinicalInforma<on
CaseStudy:SAANTWANAM
(WorkbeingcarriedoutbyHAP(hNp://www.hapindia.org/))
Page 15 © 2006 ReaMetrix, Inc. All rights reserved.
SaantwanamAhealthscreeningprojectinKerala
FighHnglifestylediseases–AnovelprojectbyHAP,Kutumbashree&StateBankofIndia.
ObjecHves‐ScreeningforDiabetesmellitus,obesity,hypertensionandgrowthretardaHon.
Referraltophysician&healtheducaHon.
Strategy–relyonlocallyrecruitedandtrainedyoungwomenwithhighschooleducaHonbutfrompoorfamiliesanddeploythemtoaccomplishtheobjecHveofwellnessmanagement
Page 16 © 2006 ReaMetrix, Inc. All rights reserved.
The first batch
Page 17 © 2006 ReaMetrix, Inc. All rights reserved.
Page 18 © 2006 ReaMetrix, Inc. All rights reserved.
Ques<onsthatarisefromthesecasestudies….
Whatmorecanbedoneusingthismodelofhealthcaredelivery?
HowdowecombineinnovaHonsinreagentdesign,instrumentaHondesignanddeliverytoimpactpublichealthespeciallyinthecontextoftheunderserved?
HowcanweextendtheseinnovaHonstobringabout“wellnessmanagement”ratherthanjuststoppingat“illness“diagnosis?
Page 19 © 2006 ReaMetrix, Inc. All rights reserved.
Insummary…
Onehastolookat“diagnosHcinformaHongeneraHon”holisHcally,notjustasasetofassayreagentsandhardwareplanorms.
Addressing“theeconomics”probleminnovaHvely,willleadtosustainablesoluHons.
“Importthescience”butnottheimplementaHonofthescience–greattothinkgloballybutsustainableinnovaHonisalllocal.
Usingthismodel,onecannotonlyaddresstheunmetneedsinresource‐poorseongsbutchangethewaydiagnosHcinformaHonisdeliveredglobally.
Page 20 © 2006 ReaMetrix, Inc. All rights reserved.
Thank You
