TECHNOLOGY AND P&O SERVICES IN INDIA
Respected office bearers of ISPO, distinguished delegates, Ladies & Gentlemen,
It is indeed a great privilege for me to have been invited by the ISPO management to address this congress which is being held in India for the first time and I am grateful to the authorities for this unique honor.
The holding of this P&O conference of International importance in India, clearly underscores the importance of India not only as a fast developing economy, but also as a huge market in need of the technology based state-of-the art Prosthetic & Orthotic products and services with a big potential for their adaption and utilization, in the best long term interest of the large physically challenged populace in our country.
Firstof all, my greetings and a very warm welcome to all the delegates and to all the experts and specialists in this field who have gathered here from different parts of the world. I am sure this congress is going to provide an excellent platform to all the participants, to have an excellent debate, sharing of great thoughts & opinions and exchange of ideas, sharing your deep knowledge as well as the various interesting developments of the recent past or which are likely to be achieved in the times ahead in this important humanitarian field of prosthetics and orthotics. I am sure that the large number of physically challenged in India and across the Globe, who are actually the cause and the purpose and the real force behind your mission and your passion in life and for your various accomplishments in this sector, they all will immensely benefit by making their life a little more comfortable in the times to come, as a direct outcome of deliberations and the expositions in this high importance International conference.
Prosthetics & Orthotics as we all know, has existed since ancient times. The technology as a game changer entered this field only after the world wars when the numbers needing P&O products and services increased many fold. Increase in natural and manmade disasters as a consequence of rapid industrialization for instance, has further aggravated the problems by hugely adding up to the numbers. The requirement of catering to their needs and ensuring their rehabilitation, was therefore taken up on war footing, mostly by the western countries, and as a result, research in the field of Prosthetics and Orthotics, received a big boost.
Much more than ever before, and more particularly over the last few years, there has been a spurt of activity in these P&O disciplines due to the advancement in technology and also by way of a quantum leap in application of technology, like in the case of our day-today lives too, which we all know, totally transformed our lives and the way we live in today's time.
In the manner technology is touching our daily lives today and at the rate it is further evolving, it is hard to predict, what will happen in the near future. What is today everyone’s favorite handy gadget may not be so tomorrow. New products will appear in the market, a few will reign, and the rest will disappear with further technological innovations. However the change they bring into our lives will remain. Or in other words, the future changes in the level of technology, will continue to change our lives perhaps many times over and for sure, till eternity. Quite naturally, the impact of this continuously evolving technology has been equally significant, also on the P&O sector.
Robotics, bionics, electronics have all penetrated this field and their impact on P&O world has been massive. Even if these revolutionary developments are available only to a limited few at present in our country, I am sure, it's availability and usage in the not so distant future will be pretty wide spread, as has been witnessed for instance, in the field of healthcare sector in India in the recent years.
I may like to share with you all, that technology has been the prime mover in the Prime Group of Companies as well, and I am privileged to have founded this Group 27 years ago, totally on technological foundations. The Group’s constant focus on technology solutions in various spheres of Power, Engineering, IT, Aerospace, Space, Railways & Defense among others, helped the Group to grow and in the process, we could also contribute in our own humble way, towards the Country’s growth on technological lines in some of the critical areas of our economy in which our Group has been active. This contribution was duly recognized by the Govt. of India and I have been truly privileged to have been honored with the Padma Shri in the field of “Technology Solutions” in the year 2009.
And, I have now, the privilege of sharing my thoughts and my insights with this august gathering, about the importance of technology and it’s application in the field of Prosthetics & Orthotics, particularly with relevance to our country.
P & O discipline can broadly be categorized under the health care industry and we have all seen that the Indian healthcare industry of late, has been on a robust growth path, with enormous scope for investments in the new, specialty as well as multi-specialty hospitals, as also, the expansion of the existing facilities in this vital sector. A large number of modern private healthcare facilities are mushrooming across the Country today, not only in the Metros, but also in Tier 2 & Tier 3 Cities. Though all major specialties are being catered to by these modern hospitals, but most unfortunately, the P&O aspect is generally missing. This is primarily due to lack of sensitization of the public in general, and also due to the lack of awareness of the private sector about the huge importance and about the financial viability, of the provision of P&O services within their Healthcare centers and within their Hospitals, in today’s time.
Creation of a proper environment for investment in the P&O sector, will surely enable all stake holders to serve the increasing P&O patient population as a great service to the society at large, since in the process, the needy will be able to access and receive qualitative treatment, products & services at their doorsteps and at affordable prices, and taking advantage of this opportunity, the huge growth coming in the healthcare sector that we are witnessing currently, can surely be channelized to drive the growth in the P&O sector as well, by some better planning and some motivational plans by the private players as well as by the Central and the State Governments of our country. If we were to further analyse this route and this possibility, we see numerous driving factors that propel this huge growth in the healthcare sector in our country which can drive the growth in the P&O sector as well, since the P&O sector is an integral part of the Healthcare sector. And some of these factors are:
1) Increase in patients’ population due to lifestyle related health issues.
2) Affordable treatment costs with increased prosperity.
3) Thrust on medical tourism.
4) Increasing health insurance penetration.
5) Increasing corporate support.
6) Government initiatives and focus on Public Private Partnership (PPP) models.
Now let’s look at the some of the Key Developments in Rehab Sector:
Physical Disability as we all know, is an important public health problem especially in developing countries like India, and this problem will only increase in future because of factors like increase in trend of non-communicable diseases, change in age structure and also, due to increase in life expectancy over the years. All these add up to the already very large number of disables. The issues are apparently different in developing and the developed countries and the rehabilitation measures therefore, need to be targeted according to their localised needs. In India, the majority resides in rural areas and therefore, provision of suitable rehabilitation products & services and their costs, pose a major challenge. Nonetheless, a series of steps have been taken by the Govt. as well as by the Private sector and these steps are gradually countering the local problems, at least somewhat, conceding the enormity of the problems that exist. To name a few of these important steps:
1) Govt. is getting aware of the availability of the new technologies and therefore, is gradually initiating new projects like up-gradation of their District Disability Rehabilitation Centres& Composite Regional Centres by procuring Hi-Tech Toolings& machineries to provide better quality Artificial Limbs & Limb Supports.
2) A few State Commissioners for Disabilities are beginning to procure Hi-Tech Artificial Limbs & Limb supports by tying up with the private players.
3) There has been an increased interest in P&O education and higher output from P&O colleges in the country, even though only marginally.
4) The government has permitted Exemption of custom duty on import of many of the products &components related to P&O application.
5) Encouraging Private organizations and NGOs and providing financial aid through Governmental Schemes such as “Assistance to Differently Abled for Purchase or Fitting of Aids and Appliances”, thereby displaying the intention to encourage public private partnership for the benefit of the disabled.
6) Increase in the number of national and multinational P&O Companies now actively operating in the country on the lines of the developed world markets.
7) Initiatives by public and private sectors in providing employment opportunities to affected individuals and to the physically challenged citizens to make them self-reliant.
The above facts, and the incentives already offered by the government to facilitate induction of technology in the field of Healthcare, which includes P&O segment as well, adequately demonstrates the intent of the Government to modernize the P&O industry in our country. We must not miss this opportunity and it must be our endeavor to constantly update ourselves with the latest developments in the P&O world, in as far as provision of services as well as manufacturing is concerned. And we must also broad base our outlook to ensure total rehabilitation, so as to take full advantage of the Government policies and it’s support, in the larger interest of the needy in our country.
However, despite the above initiatives at various levels, it needs to be understood and appreciated that the Government or private players alone cannot play a meaningful role, individually or all by themselves. Considering the huge size of the market and the extremely large number of it’s population, running into several millions needing such Rehab services, co-operation of both sides is an inescapable requirement for bringing up the P&O Sector in our country.
To meet this massive challenge of serving millions of P&O patients, Public Private Partnership (PPP) Models are undoubtedly inevitable. Let us have a closer look at what PPP models could really be:
Public Private Partnership broadly refers to a long term contractual partnership between the public and the private sector agencies, specifically targeted towards financing, designing, implementing and operating infrastructure facilities and services, that are traditionally provided by the Government and its entities, as it’s social responsibility. Such Public Private Partnership projects are expected to combine the financial strength provided by the Govt. and the Private players put together, and the innovative technology and operational efficiency of the private sector. This will ensure that technology based P&O facilities are provided with least cost and with improved services and efficiencies, in quality as well as in scale. It should therefore, be the endeavor of the Government to create a conducive environment for attracting investment in P&O sector through the PPP model, and more so, in the rural and semi-urban areas, for accelerated growth and more efficient handling of the beneficiaries in this sector, and that too, on technological lines.
I therefore feel that the Government should offer necessary financial and infrastructural support to as many P&O projects as possible, in the States across the country under the PPP model, by first providing the most expensive and prohibitive component i.e. the land and building required for such projects and also, subsequently, financing of their rehabilitation schemes and the complete projects for providing quality and technology based P&O products and services, with the ultimate aim of providing resettlement of affected individuals and their families in large numbers across the country, so as to make them self-supporting and in the process, help them to lead a dignified life.
Challenges and Opportunities for P&O Services in India:
In India, historically, Rehabilitation has always been treated as a social welfare activity and hence always seen as service to be doled out only by the Govt,, either directly or through the NGO’s. Almost till Two decades ago, it was not even considered as an organized and a professional service. Coming in of Endolite in India could possibly be hailed as an advent of a well organized and a modern P&O industry in India. But then, there are many challenges that this organized P&O sector has to face even today, that have prevented deeper ingress of technology in this extremely important social field in our country, something which we would have very much liked to witness.
Some of these challenges for the P&O sector in India are:
1) To control cost of treatment and fitments, since large number of those needing these Services are from the lower strata of the Society and therefore, cannot afford technology based P&O products and services.
2) Lack of access to insurance and cashless treatment options. Although the health insurance sector is growing at an impressive rate, but the health insurance penetration is very low with only about 2 % of the total population being insured at present and still worse, in most cases the insurance policies do not even cover prosthetics & orthotics.
3) A severe shortage of qualified professionals and the workforce to provide these P&O Services, is another major challenge.
4) Highly inadequate training resources & other infrastructure being provided to P&O professionals, and that too, with no standardized training norms.
5) No budgetary support is being provided for technological investment in R&D in P&O developments and we can see almost total dependence on imports, particularly when it comes to high quality and high technology P&O products.
With the Govt., unfortunately not being able to fully take up these challenges so effectively in terms of time & scale, particularly when it comes to adaption and induction of technology based P&O services, it will be left to the private players to seize the opportunity and take up these challenges on their own.
It is heartening to note that in line with such thinking, even hospitals are now a days taking up this issue and some of them have lately been seeking to set up P&O Centres within their own premises. One also notices, more often than ever before, that doctors especially Orthopedic Surgeons, diabeticians, oncologists & vascular surgeons, are raising queries and getting involved in the post-operative rehabilitation processes. All these are welcome signs and all these are opportunities which are meant to be grabbed by the P&O industry.
Now let us look at the effects of Technology on the Physically challenged and how it can change their lives:
In recent years technical innovations have combined to make P&O componentry much more comfortable, efficient, and life-like than the earlier versions. Future innovations are likely to depend on the interaction between three powerful forces, namely, the demands of the end user, advances in Science and engineering, and very importantly, healthcare funding sufficient to sustain development and application of P&O technological solutions.
Prosthetic& Orthotic technology has advanced to a fair degree in the past two decades, driven largely by the end user's demand. Today, the otherwise healthy individuals with below knee or above knee amputations, are able to participate in a full range of nearly normal activities and responsibilities and in many cases, to walk without any perceptible limp, and to even engage in recreational and sports activities.
Some of the high-end examples that have helped in technological enhancements in P&O sector are:
1) Carbon Fibre& Dynamic Response Feet
Carbonfibre composites, developed by the aerospace industry, are increasingly being used in artificial limbs now a days, largely because of their superior strength to weight characteristics. The combination of enhanced socket comfort and prosthetic feet having dynamic response, enables amputee even to run. The South African bilateral amputee, Oscar Pistorius Known as the "Blade Runner" is one of the live examples of what wonders can really be done in today’s time, simply by using the available P&O technological advancements and of course, the will power of the user.
2) Shock Absorbing Mechanisms to reduce Impact Forces
Use of hydraulics to counter the torsional, torque & the shear forces, hugely improve the biomechanical characteristics of the prosthetic & orthotic components, thus making up for considerable gait comfort and almost like normal movements.
3) Microprocessor Controlled Movements
The first artificial knee with an “on board” computer to improve the symmetry of amputees' gait across a wide range of walking speeds, was developed by Blatchford in the early 1990s. Studies have confirmed that these “intelligent prostheses” offer amputees a more reliable gait pattern during the swing phase of the gait cycle, permitting them to walk with more confidence and in a more energy efficient manner. There are now a large number of highly advanced microprocessor controlled knee joints, and of late even foot and ankle movements are having microprocessor controls, and all these are helping the end user to perform their functions more efficiently than ever before. And I can say here, that more and more of microprocessor controls are going to be seen in the various joints movements in case of prosthetic limbs in future.
4) Interface between Stump and Socket
The single most critical aspect of any prosthesis is the quality of the interface between the limb remnant (stump) and the artificial prosthesis. The portion of the prosthesis that fits snugly over the limb remnant, what we call a “socket,” determines the amputee's comfort and ability to control the artificial limb. Since the 1980s, prosthetic clinical experts and researchers worldwide, have made breakthroughs in design and materials that have greatly improved the connection between the stump and the socket.
a. Currently, the silicone elastomers are widely used to create a soft and slightly elastic inner liner, providing a thin, comfortable, and compliant barrier between the amputee's skin and the more rigid, weight bearing portions of the prosthetic socket.
b. In recent years, researchers have developed a variety of thicker gel materials that add a measure of cushioning and pressure dissipation while retaining the benefits of the original liners.
c. Rather than using cumbersome belts and hinges, today's prostheses may be suspended via a cushioning sleeve that the amputee rolls on to the limb stump.
The fifth example of the P&O technological advancement is the Use of CAD–CAM in Fabrication and Fitments.
As we all know, the computerization of contemporary manufacturing has been termed as the Third Industrial Revolution. The rapid advancement in microchip technology over the past decade, combined with drastic reductions in cost, particularly during the recent years, have helped make Computer Aided Socket Design (CASD) and Computer Aided Manufacturing (CAM) a clinical reality in prosthetic practice, as well.
At present there are several software/hardware packages available which permit successful fitting of P&O componentry after an average of just one or two check sockets.
This has completely computerized and actually revolutionized the socket making process which has already been introduced in India, though in a limited way, and has yet to take off on a larger scale. And hopefully it will, in the coming years as a huge benefit to the amputees.
6) Gait Analysis Technology
This is to analyse the system output as to how much of accurate improvements can really be achieved, by small biomechanical corrections, which a professional is not able to identify manually. This technology has somehow, yet to take off in the Indian P&O Services.
7) Osseo integration or Skeletal Attachment of Artificial Limbs
Directly anchoring of prosthetic system to the stump or Osseo-integration, eliminated the difficulties inherent in creating custom-designed prosthetic sockets, where fitting comfort depends on volumetric matching of the amputed stump. Normally, the stump being a dynamic organ, tends to shrink over time, or it may also swell with heat or weight gain, which can lead to chafing. However, with Osseo-integration, the prosthesis fit is unaffected by such volume changes. This technology, though over a decade old is yet to be accepted worldwide, possibly since it involves complex invasive surgery and also, perhaps due to it’s cumbersome subsequent management.
The Potential of Low Cost, Limited Function Prostheses
All these high-end technological advancements are laudable and have immensely benefited the users. But being very highly prohibitive to afford, these have been able to support only a very small percentage of the physically challenged. The bigger challenge now before us is that how to use such technological developments, to achieve high quality, high performance and durable P&O products and yet low in cost, even if these are with limited functions which are more relevant to daily use by the masses. The resultant lower manufacturing costs of such “limited function” devices when produced in bulk, permits their use in India & other developing economies, where presently, the cost of fully loaded and therefore, more complex technology, is quite prohibitive.
Apart from some private P&O companies, the International Committee of the Red Cross has also established an initiative to produce low cost polypropylene plastic prostheses, for areas where conflicts or environmental catastrophes have resulted in large numbers of traumatic amputations. These devices are well accepted clinically and are extensively used in India.
As for the future developments in the P&O field, microchips will undoubtedly become the norm of the day for any kind of products that may be designed and developed anytime in future. While technology makes rapid inroads into the P&O Sector, yet, one can foresee a lot of need based changes.
1. Advanced Technology to co-exist with Low Cost Limited Function Devices
While the market for low cost, limited function devices will continue to expand in an effort to meet the exponentially growing needs of India & the developing world, at the same time, innovative technologies will continue to be adapted and applied to high performance artificial limbs whose function will more and more closely approximate to the missing limb, although, we may still be a few years away from producing a `Blade Runner’ in India !
2. In future, we also foresee continued and considerably increased Private Sector interest in the P&O sector.
Prosthetic innovations are often used sparingly, by a limited few, primarily by High Net Worth amputees, amputees with private funding, and particularly those who have very high activity level or those who are competitive athletes and they can afford to pay as well or get some sponsor to fund. As experience is gained, manufacturers discover how to apply the same principles to moderate cost of devices intended for less active individuals, and as a result, performance of prostheses in general will gradually improve to take full advantage of the availability of technology.
Increased Govt. Funding
I also foresee that some of the newer materials and applications will be used even by the Govt. run P&O facilities for the benefit of amputees in our Country and on similar lines also by other developing economies. It is really the financial constraints that limit the rate of advancement in prosthetic rehabilitation, and one of the greatest challenges during the next few years will be for our Govt. to find the will and the way to fund widespread adaption and application of technology based prosthetic innovations. And I hope and pray that they will succeed in their efforts.
Simultaneously with the advancement in P&O technologies, assistive technology to help the disableds, has also grown considerably. Assistive technology, as we all know, is an extremely useful technology facilitator in easing daily life of the P&O patients. It helps them:
a) To have greater control over their lives and their mobility and therefore, less dependence on others for help.
b) To participate in, and contribute more fully, in activities in their homes, schools, and work environments, and in their communities.
c) To be able to interact to a greater extent with people who do not have disabilities.
We can foresee a great future for assistive devices and these will greatly assist the physically challenged in easing their daily living activities such as, through remote operation of electronic devices, facilities, doors & locks and many other “hands free’ and movement free operations using technology to the fullest.
A word about Education & Training
While we talk of further advancements of P&O technologies and services for the welfare and betterment of the physically challenged, it is important that we do not overlook certain other important aspects to achieve success in our mission. First and foremost is the issue relating to education of people with disabilities i.e. the patients themselves.
The importance of educating the physically challenged, using various technological advancements for various types of disabilities, so as to make them aware of the environment and to assist them in merging with the Society without any inhibitions, cannot be overlooked. Equally important is the need for educating the Society to treat the people with disabilities with compassion and respect and not with pity and sympathy. The physically challenged must therefore move ahead, and in step with the technology, and not reconcile to accepting their disability as an impairment, which can considerably be overcome, at least in today’s time, with the level of technology that exists today.
Stereotyping the Physically Challenged in our society is another important issue to be addressed through education:
Inadequate support for assistance in both, the developed and the underdeveloped countries can often be traced to discrimination against the physically challenged. Throughout history and in most cultures, attitudes toward people with disabilities have been exceedingly negative. The disabled are often viewed as objects of charity or pity; they are seen as sick and in some cases, even as dangerous or as a menace to others. They are also sometimes characterized or stereotyped as burdens to the families or the very society, that is supposed to provide care for them.
Historically, the physically challenged have always occupied the bottom rung of the social and economic ladder. Even in developed industrial nations, unemployment rates for people with disabilities are more than 10 times that of people without disabilities and unfortunately, even among those having proven capabilities. The human rights of the disabled are routinely ignored, and their social participation is markedly diminished because of societal attitudes. Rehabilitation experts and clinical psychologists who are conscious of this stereotyping and its impact on victims, can provide and must provide as their professional duty and as their social responsibility, comprehensive quality rehabilitation services by promoting a positive image of people with disabilities. It is now time that the public mindset, needs to undergo a change and we all can play a very positive and a vital role in that direction. The recent accelerated level of initiatives shown by the corporate sector to provide employment opportunities to the specially ableds, is indeed laudable and we hope such policies will be further replicated by many others in the corporate world.
There is much debate in general over what training and certification, that Prosthetists and various level of technicians should have? What credentials are necessary among the Prothetists to ensure that only consistent and high-quality prostheses are produced? However, as far as India is concerned, while we go into the challenge of meeting the growing requirement of improving the standard of existing training to match the current technological standards, we first need to look into the bigger challenge, and that is to fill in the huge gap in availability of adequate number of qualified Prosthetists and Technicians in our country, even to meet a small part of the huge demand.
In India, though some estimate the specially abled population at 100 Mill, but even going by the official data given out by Ministry of Statistics vide NSS Survey of 2002, extrapolated to present population, indicates that approximately 1.8% of our present National Population i.e 22 Million persons were disabled and out of this approximately 12.5 Million are estimated to be with Locomotor disabilities. In spite of such a large number of persons with Locomotor disabilities requiring the services of Prosthetists and Orthotists, barely 5% of the required qualified Prosthetists and Orthotists numbering just about 3000, are currently available in the country.
Just about ten recognized institutes jointly train about a 100 Prosthetists and Orthotists each year which means a maximum of 100 trained Prosthetists become available annually. Considering that even if 50% of persons with locomotor disabilities (say about 6 million) were to utilize the services of qualified Prosthetists and Orthotists, and assuming that one trained ProsthetistorOrthotist takes care of at least 200 patients, there would be a need for a minimum of 30000 Prosthetists and Orthotists in our country at any one time as against the current availability of less than 3000 which account for the total number trained since 1985. It means that barely 10% of those 50% needing P&O services, can be managed by qualified professionals currently. Clearly, a huge demand supply gap. And please remember, the remaining unattended 90%, cannot even be factored in our plans due to present acute limitations of the training institutes in our country in terms of capacity constraints. And how helpless we are on this vital front of having trained P&O personnel in our country?
We therefore, need to address this issue urgently along with a comprehensive exercise in adopting a syllabus for training which is in conformity with international standards, for better and faster adaption of using the currently available technologies to the fullest usage. We hope that the concerned authorities will realize the enormity and magnitude of this massive inadequacy and take corrective steps, at least in the medium to long term since nothing seems to be practically and realistically possible in the immediate short-term, and most unfortunately so.
P & O Marketand the Road Ahead
Major technological advancements are driving the prosthetics & orthotics market today. Outstanding innovative advancements in technology have catalyzed the modernization of prosthetics & orthotics, spurring a significant growth in the P&O market. Thanks to these developments, today’s prosthetic & orthotics devices cater to the specific needs of patients. Products ranging from conventional knees to energy-storing feet to robotic devices, help the needy to lead more normal and productive lives than ever before.
The impact of technology on this market is tremendous and will surely continue for the next several decades in response to innovations such as bionic technology, sensor technology, artificial intelligence, and micro mechatronics. The growing level of education and the consequently enhanced affluence level, at least among the urban population, automatically and considerably enhances the already growing consumer base for P&O products & services which actually drives the market with demands for improvement in quality of life, and as a result, technology based innovation will surely address the growing needs for a “Life with quality”.
To conclude, I would like to say that, notwithstanding the hurdles, the P&O Industry is poised for a very healthy growth. Technology has been & shall always be there to play the role of option provider to the end user. The end users will have the option of low-end economical P&O products, mid-range products or high-end products depending upon what is the need and activity level and who can afford how much or where the reimbursement is coming from.
The ability to provide the most, cost-effective and clinically appropriate P&O care, will be dependent on having a large enough numbers of trained and certified Orthotists and Prosthetists. Involving certified P&O experts in reimbursement policy decisions regarding new technological advancements, will also be another cost-effective way to enable individuals to have appropriate life-changing and life-enhancing P&O devices. Modernisation of existing infrastructure for the disabled, developing innovative ideas like PPP projects, Govt. sponsored R &D in the field and sensitization of the masses towards the needs of the physically disabled, will go a long way in total rehabilitation of the physically disabled who will then be able to usefully contribute to the Society.
I sincerely hope that the future will see the Govt. playing a much more active and a positive role in this field and that it will be accepted as a rehabilitation service, and not as a social welfare dole.
In the end, I would like to take this opportunity, only to emphasise upon the fact that each one of us present here today, has in some way or the other, a very deep and long term connectivity and commitment to the ‘Rehab world’. It could be an occupation or a profession or some business to manufacture and supply P&O products or services, the success and the future of each one of you totally depends upon how much you really care to make the lives of the physically challenged, a little more comfortable and a livable. Technology can do a lot and will do a lot. But in addition, and actually much more, we must also have a Humane touch and a Humanitarian mindset when dealing with those who are truly your mission and your motivation for your life and your carrier. How big is your success can only be measured in terms of how big is the smile on the face of your patients and believe me, no amount of success will make you so much happy as much as the happiness of your patient and therefore, always have the motto in your P&O life as “PATIENT FIRST” .
My sincere thanks once again to the ISPO organisers to have given me this opportunity to address this wonderful and professional congregation and my thanks to each one of you present here today for your kind and patient hearing.
You all are doing a wonderful job in serving the specially ableds and MayGod bless you for that.
My sincere thanks to each one of you and I wish this 2013 ISPO World Congress, a grand success.