flexible endoscopy & accessories:

India’s opportunities and challenges

5 March 2007
flexible endoscopy & accessories: India’s
opportunities and challenges Ivy Teh

The opportunities for growth of flexible endoscopy in India are tremendous, right from
continuing the procedure for the current indications to the newer indications such as extra-
luminal gastrointestinal surgeries, transgastric biliary surgery and endoscopic suturing.

However, like any other rapidly growing field in emerging market, the threats to the success
of flexible endoscopy in India arise from bogus institutes and untrained doctors who may
lure patients to make a quick buck, putting the patients’ health at risk. Unsanitary conditions
during the crucial stages like sterilization of instruments and accessories in the procedure
may lead to the transmission of infections. Also, the sale of faulty or imperfect instruments
due to the rapid demand may lead to complications during the procedure. Nonetheless, the
demand for flexible endoscopy remains high with a lot of room for organized players in this
field to expand on if they have the correct approach to the Indian market.

Gastrointestinal disease prevalence and trends

Although quite common amongst gastrointestinal diseases, the prevalence rate of

esophageal cancer is quite high and unevenly distributed in India. In recent surveys, the age
group of 40–60 years showed the highest prevalence (67%) of the disease. Assam
dominates with the highest prevalence of this disease in India. What is worse is that dietary
habits fuel the spread of this disease and so the risk is quite high. Local foods like Kalakhar
are seen as a threat due to the significant risk factors associated with them (odds ratio = 8.
0, 95% confidence interval = 5.1-11.5, p < 0.001). A recent study shows that the frequency
of ulcerative colitis in North India is as high as that in North America and Europe. Over
50,000 individuals showing symptoms were tested and 23 were found to be affected by the
disease. So, the disease prevalence rate is 44.3 per 100,000 people. This remains the
highest reported from the Asian subcontinent.

The prevalence of peptic ulcer disease is unevenly distributed again. The rate differs heavily
amongst the southern and northern part of India, with the disease being more prevalent in
the south than in the north. However, Kashmir is an exception.

When it comes to gastro esophageal reflux disease (GERD), the prevalence rate is high
amongst children in India and, unfortunately, is most often ignored. The Departments of
Gastroenterology (Pediatric GE Division), Surgical Gastroenterology* and Pathology**,
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, conducted a survey to
get to the root cause. They put all the children with “symptoms suggestive of gastro
esophageal reflux disease (GERD)” through an endoscopic and histological examination of
the esophagus and came up with these observations: “In our study 33 children who
presented with GERD, 26 (78.7%) cases had esophagitis on histology. Esophagitis has
been reported in 60%–80% infants and children with GERD (11). In 73% of our cases with
GERD, endoscopy was normal; however, on histology all these had evidence of esophagitis
(ENRD).” The best method for diagnosis therefore is endoscopy and histology.

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The prevalence of colorectal and gastric cancer in India is not as high as in the developed
countries. According to the Surveillance and Risk Assessment Division, CCDP, Health
Canada, 6.7 men and 5.5 women per 100,000 people have colorectal cancer in India. This
rate is 8 times lower than that in the US. And the credit for this goes to the lower intake of
red meat in India. Mohandas KM, Desai DC, in his work titled “Epidemiology of digestive
cancers in India: V. Large and small bowel” remarks, “The incidence of colorectal cancer in
India is one of the lowest in the world.”.

Gastrointestinal procedures: Trends

A slow yet gradual shift from diagnostic to therapeutic endoscopy procedures has been
seen of late in India. Endoscopy sessions are increasingly being conducted both for
diagnosis and treatment in the same sitting.

The diagnosis and management of bleeding esophageal varices can be taken as an apt
example in this regard. In India, Dr. Manish Motwani, a reputed surgeon from Mumbai
states, “Therapeutic process is performed very widely through endoscopy now using flexible
endoscopes because of cost effectiveness as compared to only diagnostic procedures.
Because of the high cost of equipment, most surgeons and hospitals purchase the entire
range of equipment and accessories and try to utilize them for maximum potential or
therapeutic processes.”

Treatments of these gastrointestinal disorders are also fast trending towards the swift, non-
invasive and safe care made available by the endoscopic procedures. non-invasive
procedures that can be performed on an out-patient basis and result in faster patient
recovery rates are common carried out in India. “With a lot of insurance companies
providing cashless Mediclaim facilities and thanks to the high rate of expertise, more and
more patients are now willing to go for minimally invasive surgeries. Less time in the hospital
and faster recovery ensures no one goes without work for a long time and the routine is
quickly established,” states Dr. Manish Motwani.

Concentration of sites for gastrointestinal procedures in metro cities

Presently, gastrointestinal disease management centers or hospitals are located mostly in

the metros such as Mumbai, Delhi, and Chennai. Some of the prominent centers in India
involved in gastrointestinal procedures are the Postgraduate Institute of India in Chandigarh,
All India Institute of Medical Sciences (AIIMS) in Delhi, Apollo Group of Hospitals in Delhi,
Sir Ganga Ram Hospital in Delhi, Lilavati Hospital in Mumbai, Bombay Hospital in Mumbai,
Jaslok Hospital in Mumbai, Apollo Group of Hospitals in Chennai, and Asian Institute of
Gastroenterology in Hyderabad.

Future growth of gastrointestinal centers is seen in non-saturated areas such as the smaller
towns of India. These places are gradually drawing entrepreneurs into constructing centers
at the small town level. Also, the trend of pure gastrointestinal centers breaking away from a
mainstream hospital is on the rise, with the public and private sector believing that the
management and quality of work provided at a solely gastrointestinal center is much better
than that at a multi-specialty hospital. Factors like minimized risk and shorter hospital stay
are contributing to the significant shift in the therapeutic segment vis-à-vis its diagnostic

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counterpart as well. Although this movement is seen in relatively small proportions now, the
shift is expected to make ripples in the endoscopic market very quickly.

Professional users of the endoscope and its accessories

The main users of flexible endoscopes in India are primarily the gastroenterologists, but at
times it can be used by the ear, nose and throat (ENT) surgeons and general surgeons as
well. The choice of the type of instruments used depends to a great extent on the preference
of the performing specialists. This is dictated by various factors such as the availability of the
instruments, on which particular type of instruments the surgeon has been trained, and the
instruments the surgeon is most comfortable using. And this is why the gastroenterologists
play the most important role in the purchase and use of the endoscope and its accessories.

Supporting team members such as nurses and attendants play important roles during the
procedure and the patient care thereafter. Unfortunately none of them are provided with the
‘classroom type’ of knowledge about endoscopic procedures. Most of them learn ‘as they go
along’, acquiring knowledge from their peers and from experience. In order to make an
endoscopy session most successful, it is imperative that the staff assigned to this procedure
has undergone appropriate training.

Competitive landscape for the endoscope and its accessories

The competition in the market for flexible endoscopes and its accessories is fierce. More
and more companies stake their claim on providing the best instruments at the lowest
prices. Mr. Sharma, owner of Hospiline equipments says, “In India, competition is fierce
because of the general tendency of users who have a little knowledge to import these
equipments and accessories by themselves. Besides that, there are a lot of small importers
who import these products from various sources and sell them at a very low cost as they do
not have to provide any after sales service for the same”.

Major names in the market are Olympus, Pentax, Fujinon for flexible endoscopes while
major accessories suppliers are Welch Allyn, Boston Scientific, CR Bard, etc. A few Indian
companies who manufacture and sell flexible endoscopes do exist. PeeBee India, Medelec
Instruments, Expert Medical System, Hospiline Equipments, and Endocare are a few
brands. The local Indian companies are trying to gain share in the Indian market by
providing through very competitive pricing.

Challenges potentially hindering growth

India is considered to be an area that presents diverse challenges to flexible endoscopes

and accessories suppliers, ranging from affordability, accessibility, disease awareness to
technology adoption.

a. Private payment vs government subsidy: At the moment gastrointestinal procedures are

provided mainly at private institutes, at a price which the common man may not easily
afford. The only solution to this is the government’s initiative to provide subsidy for such
procedures. But this may not be possible due to the staggering population of our country
and the tremendous workload at such institutes. The health insurance sector in India is
growing rapidly. However, it is limited to a small population that could afford, which are
largely the middle income and above.

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b. Rural vs. urban wealth: Like in the other sectors, the great Indian urban and rural divide
is also seen in the health sector. A cursory glance reveals that the concentration of
gastrointestinal centers is high in the urban area. Since patients with financial grounding
have, over the years, migrated to the cities, the healthcare institutes too have come up in
such areas, forcing the rural people to travel great distances to acquire medical help.

c. High re-use rate: The move towards single use in flexible endoscopes accessories is
still at its infancy in India. According to a senior gastroenterologist consultant in Mumbai, Dr.
Bhandari, the multiple use of flexible endoscopes after sterilization is still very high here due
to cost concerns and most accessories even if they are for single use are re-used multiple
times after sterilization.

d. Limited technology adoption: One can find the most advanced and complex procedures
performed in the West are being routinely carried out in key facilities in India. But the
adoption of new technology are again limited to only profit making facilities in key metro
cities and is not wide spread across the nation.

The above raises the following questions:

ƒ Are the local Indian suppliers strong threats to foreign international brand names and
in which area/s will they capture the biggest share?

ƒ How long will it take before there is a real transition towards single-use accessories
and products in the Indian market?

ƒ Will there be a potential opportunity for international suppliers to manufacture in India

for costs savings?

ƒ How can international suppliers help in raising awareness and help in early
prevention of GI diseases?

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Ivy Teh is the Healthcare and Life Science global head at Clearstate. She has advised
global medical devices and healthcare equipment companies on market entry strategies,
acquisitions, R&D outsourcing, competitive benchmarking and marketing strategies.

You may contact the author via email at: thinking@clearstate.com

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