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2024 India Healthcare and Lifesciences Investment Heatmap

2024 India Healthcare and Lifesciences Investment Heatmap

In 2024, the world will be as uncertain, if not more, as it was and anticipating what will happen next is an ever more challenging task for our Algorithms and our teams. Since 2013, our algorithms have been accurately predicting the investment heatmap in the healthcare and life sciences in India which were predicting with 95% accuracy on the sectoral investment cycle in India till the end of 2019. Since the Covid Pandemic in 2020 we lowered levels of prediction accuracy like we started back in 2013. The fake narratives and echo chambers that were peddled during the pandemic years of 2020-22, that vitiated our predictions during the pandemic years continues in for some other factors. 2023 was even more unpredictable in many ways. Our algos do not penetrate the terrorists, government intelligence and security networks and hence unable to consider events that playouts in the Middle East and impacting geopolitics, investments in Indian Healthcare and Life Sciences to some part of the investment flows from offshore. Hence, we have made attempts to analyse International ‘Geo Politics’ as a separate factor and bolt-on-top of our algo predictive models to adjust our heat map for 2024 to accurately predict whether the heat is on in our 2024 Heat Map.

2024: A Year of Geopolitics than Geo Economics

The biggest political event in India in 2024 will be the Lok Sabha General Elections. Hence H1 2024 will not see any major policy or budgetary directions to the sector till the new Government takes over in New Delhi by June 2024 and then presents its budget. For the first time, in the post pandemic era, almost all global funds, analysts and bankers have a unanimous consensus on India’s positive outlook for 2024, some even covering India as a separate chapter in their reports which was dedicated to China in their Asia Outlook till 2022. However, healthcare and life sciences sub sectors in India have its divergence to the overall India outlook for 2024. We have endeavored to bring out the deeper analysis and specifics out of the broad ‘India Positive’ Outlook for 2024 for the Healthcare and Life Sciences Sector in India.

The wave of optimism for 2024 in Indian healthcare and life sciences stems from the following:

  • The pace of digitization is now veering toward mainstream adoption of Generative Artificial Intelligence (AI) tools and solutions across that are being piloted.
  • New business models/incubation for investments are emerging (see out Future Bets in Healthcare) that will be cross-domain
  • The bills and laws introduced in the Parliament in the Session New Healthcare Bills 2023 Archives | Kapil Khandelwal KK are yet to shape bounce in investments.
  • Muted returns in the private markets will continue in 2024 as the winter of private investments continues in 2024. Let us understand that the best investments tend to occur during times when investment outlooks appear riskier, so the lower prices in many kinds of equity investments might well yield attractive returns over time.
  • Companies listed on the bourses have always underperformed the broader index in the last 2 general elections of 2014 and 2019 by -4.5 to -6.5%. We are expecting the elections results to be neutral this time on the Indian bourses. A few big names to IPO in 2024.
  • With one-third of India’s population now constituting Gen Alpha and Gen Z, the health and wellness aspirations of this cohort is the growing aspirational class that wants to live life post Covid-19 differently and different products and services will serve as the next growth opportunity.
  • The valuations have come back to realistic levels to the pre-covid levels for primary and secondary investments.
  • Debt and equity requirements have stabilised as the cash-crunch situation during the pandemic have ‘normalised’ and so are the return expectations. Both are negatively correlated with yields globally. In other words, investments in equity and its returns will tend to outperform the market, as yields decline.
  • As new Generative AI capabilities emerge, the investments in human capital for newer skills are emerging. Also, newer models of ‘sweat’ equity/debt are emerging.
  • Investments in newer health and wellness solutions to weather climate change are getting exciting. (see out Future Bets in Healthcare).
  • M&A and buyouts are expected to continue, but lower from the peak of 2022.
  • How India plays its geopolitics will also determine the quality and quantum of foreign investments in India in the various sub sectors.

The 2024 India Healthcare and Life Sciences Investment Heat Map is as under:

Healthcare Financing

Newer products for financing healthy lifestyle for the Gen Alpha and Gen Z are emerging. Financing ‘idleness’ and healthy entertainment lifestyle through innovative business models are the key. There is a consumer shift for spending on healthy lifestyle which is a personal investment in longevity of healthy life.

  • 2024 Outlook: Moderate
  • What’s going wrong: slower market/product innovation, right bite for the consumers, reach and penetration to New Gen consumers, financing costs
  • What’s going right: India stack digitisation, uberisation, AI solutions

Medical Education

Valuations are correcting and consolidation activity is accelerating. New regulatory regime will come into force and will require investments in managing the delivery and quality of content. New skills for the new AI tools and newer consumer’s requirements needs is accelerating but not in the curriculum.

  • Outlook: Moderate
  • What’s going wrong: Alignment to new consumers and care, increasing debt burden, new age skills certification, CME with AI-tools
  • What’s going right: Skill-mix churn, upgradation of skills, AI for frontline workers

Med Tech Innovation and Life Sciences Discovery and Clinical Development

Capacity creation and new product development continues as India is now into the China+1 club. Expect a few IPOs this year in this sector. Government grant funding will temper down. Geo polities is a key risk to create supply chain disruptions.

  • 2024 Outlook: Hot
  • What’s going wrong: IP regulation, regulatory bottlenecks on clinical development, newer skill sets for research and acceleration, PLI policy for sub sector, geo politics, supply chain disruptions
  • What’s going right: Human capital, emerging social innovation models, right products selection, market appropriate solution development, peptide based products, chronic diseases product innovation for co morbidities

Pharma and Therapeutic Solutions

Geo politics may affect supply chain and missed topline and profitability estimates. Cost competitiveness like Chinese players to compete globally is the key for growth. Expect a few IPOs, buyouts and exits via secondary sale.

  • 2024 Outlook: Moderate
  • What’s going wrong: price controls, wrong product portfolio, capacity scale up, global or China-level cost competitiveness, exit of PLI incentives, shortage of skilled workforce
  • What’s going right: distribution infrastructure, digital business models, government incentive programs

Healthcare Providers

High levels of leverage is still a concern. Private equity investments slowing down due to valuation expectations. Expect a few IPOs, buyouts and exits via secondary sale. Capacity creation is slowed down due to fund crunch.

  • 2024 Outlook: Moderate
  • What’s going wrong: margin pressures, price controls, execution of programs on the ground, supply and demand mismatch in micromarkets, debt financing costs, gun powder churn, operating cash runway, liquidity and working capital crunch, not exploring newer formats
  • What’s going right: asset-lite models, medical tourism

Healthcare Insurance

Loss ratios and profitability is slowing improving as pricing and products are rationalized. Expect two IPOs of two major players. New products innovation for newer consumer’s requirements is lagging.

  • 2024 Outlook: Hot
  • What’s going wrong: product fit to consumer needs, product approvals, IPOs pricing and valuation
  • What’s going right: Consumer demand, reduced loss ratios

Health Retail

The Pharmacy Bill 2023 brings its own set of challenges. AI pilots once mainstream will reduce costs and margin pressure albeit very slowly. The valuation is still a challenge for raising fund and buy-outs, secondary exits. Expect an IPO.

  • 2024 Outlook: Hot
  • What’s going wrong: regulation, operating margins, spurious social media channels affecting consumer confidence, health UPI, time to scale
  • What’s going right: consolidation, newer cross-vertical innovative business models, profitability focus, AI adoption and models

Wellness

2021 was the highest growth year in the last 10 years on the back of discretionary consumer spending on wellness. Digital business model innovation is still lagging. Medical wellness tourism will be recover in Q3 of 2022. M&A activity and consolidation to continue in 2022 but at a slower pace. Corporate Wellness spends to continue to fuel growth in 2022

  • 2024 Outlook: Very Hot
  • What’s going wrong: regulation, maturity to scale, new mass market business models, repeat sales, spurious social media channels, fake outcome/claims
  • What’s going right: newer cross-vertical innovative business models, corporate wellness spending

Alternative Therapies

New Gen consumers are seeking unique experiences and combing with mental health and rejuvenation as their discretionary spends are increasing.      

  • 2024 Outlook: Very Hot
  • What’s going wrong: maturity to scale, consumer education and confidence, clinical research, new product development, inflated valuation, new mass market business models, repeat sales, spurious social media channels, fake outcome/claims
  • What’s going right: discretionary consumer spending, newer cross-vertical innovative business models, mainstream complementary treatment

Moving Forward

As one iconic smart investor said that one should be investing in healthcare and life sciences because you believe smart investing will yield results that are beneficial for society, not just to enrich oneself.

Happy investing and stay strong!

Also Published in Express Pharma February 2024

https://www.expresspharma.in/express-pharma-february-2024/

Will Ayodhya Be the Mecca of Medical Tourism?

Will Ayodhya Be the Mecca of Medical Tourism?

Preamble

Today (22 January 2024) marks the formal opening of the Ram Temple at Ayodhya in Uttar Pradesh. Opinion makers and politicians say that Ayodhya will be the largest religious tourist destination in the world in the non-Abrahamic religious category after Mecca and Vatican with an annual footfall of ~75 mil religious tourists annually. With this positive development, there are also thoughts and plans amongst the healthcare industry folks if Ayodhya can be one of the destinations for medical tourism. I can talk more about Mecca and Saudi Arabia as I was involved in the healthcare industry there in early 2000s and can draw comparisons on Ayodhya. 

What is the Tourism Potential for Key Religious/Spiritual Destinations of the World?

The following table will outline and compare Ayodhya with Mecca and Vatican City for starters.

  Vatican City Mecca Ayodhya
Annual Tourists ~ 10 mil  ~ 20 mil ~ 75 mil
Tourism Revenues ~ USD 0.5 bn (not including revenues from Rome) ~ USD 12.5 bn (not including revenues from Jeddah) Yet to start (expected to be ~USD 5.5 bn)
Travel Infra Well connected with Rome Well connected with Jeddah with a separate Haj Air Terminal to facilitate huge pilgrimage volumes Yet to develop an international airport. Rail and domestic connectivity being enhanced
Medical Infra Adequate for the local population Jeddah has over 8500 hospital beds with more being added including a Medical University. Mecca has over 1000 hospital beds Adequate for the local population. Lucknow is the current Tertiary and Quarternary care location including AIMMS
Medical Tourism Revenues NA ~ USD 0.9 bn NA

India ranks 17th in the world as a tourism destination with a share of ~1.5%. However, its share of GDP is ~6.5%. There is a huge potential for growth for medical tourism if international tourism grows. Ayodhya can provide this growth impetus if planned and implemented astutely. We can learn from the Mecca-Jeddah experience on Medical Tourism on what worked and what mistakes to avoid.

Mecca-Jeddah Medical Tourism – Case Study

At the turn of 2000s, Jeddah and Mecca had a very poor medical infrastructure with limited bed capacity. During the Haj season, millions of pilgrims would land at Jeddah’s Haj terminal. However, the quality of manpower and care was not upto international standards apart from not being cost competitive. Saudi Arabia embarked on the Gulf countries, US JCAHO quality accreditation. Two hospitals in the Eastern Province (Dharan and Al-Khobar) took the lead in JCAHO certification. The Western Provincial government and Riyadh Crown Prince took the initiative in boosting the bed capacity in Jeddah and Mecca which doubled in 5 years. In addition, a Medical University and four private medical colleges were established to increase the supply of doctors and nurses. Special travel privileges and visas were also provided by Saudi Arabia. Prior to the Haj Pilgrimage, specialist doctors were allowed to practice in Jeddah private hospitals as Locums/visiting doctors with accelerated credentialing. As a result, Jeddah’s hospitals earn around USD 1 bn through medical tourism.

Building a Case for Ayodhya Medical Tourism

India’s learnings from other medical tourism destination can be replicated here in Ayodhya. Here are some pointers

Learnings from Delhi-Agra-Jaipur Triangle

The golden triangle as a largest hub for medical tourism developed as these became as a go-to destinations for historical monuments. Delhi and Jaipur were the landing points and also significant healthcare infra which was eventually expanded. Ayodhya as a destination will need to add other co-locations either Lucknow or Delhi to grow the options and choices.

Uttar Pradesh Health Infra Diversity

Our State Health Infra Health Map 2021 States Heat Map | Kapil Khandelwal KK had listed Uttar Pradesh as one of the hottest emerging states for investment in health infra. However, the Uttar Pradesh macro and Ayodhya micro health indicators have improved slightly since, but not radically. It seems that all focus was on planning for tourism and relevant infrastructure but not for healthcare infra. The Jeddah-Mecca case study is an example in the making for coordinated planning and development between the Western Provincial Government and the private Medical and Tourism industry. The nearest JCIA accredited international standard hospital is in 150 kms radius.

Niche Positioning of Ayodhya – Promoting Integrative Medicine

Indian traditional medicine and allopathic care needs to be integrated to provide unique wellness care experience along with the ambience and spirituality of Ayodhya to promote healthcare and tourism.

Geriatric Care is another Axis

Assisted living capacity can be built up for the senior citizens. However, this should not be on a push with real estate development without Golden Hour medical back up. Malaysia has promoted several locations for foreigner under the Malaysia My Second Home around Kuala Lampur along with golf tourism for the Asians expats. Ayodhya My Second Vaas would encourage HNI Indians and expats to explore this avenue.   

With the inauguration of the Ram Temple in Ayodhya, the transformation of the destination from a Spiritual Hub to a Medical Tourism Hub can be envisoned. However, we are still far away from being the Mecca of Medical Tourism. We are ranked 10th in the Medical Tourism Index (MTI), 12th in top 20 wellness tourism markets globally, and 5th in wellness tourism markets in APAC.

Jai Sri Ram!

The Pandemic of Eyes

The Pandemic of Eyes

Prologue

I wrote a blog on my issues with Hypermetropia, Myopia and Presbyopia Digital Ophthalmology | Kapil Khandelwal KK. It was around December 2021 and we were getting back to regular work after the Covid vaccinations. On my annual health checkup, my eye correction numbers were reduced for both my eyes for distance and reading glasses. But the eyes were seeing some other things. That’s the start of journey of my cataract.

Blurring of Vision

Over the next one year, I was able to see but there were situations when my eyes would hurt me especially under bright light. By December 2022, the eyes would accept my current spectacles would work on some days and on some days, there would be a hazy vision, dryness in the eyes. My lifestyle took a big dip as I was not able to play sports and do my regular walks. All activities were restricted to indoors. Work-life balance took a huge dip. Also my right eye’s vision was deteriorating faster and I could see better from the left eye. In other words, I would behave like the Mad-Eye Moody of the Harry Potter fame.

The Cataract – The Pandemic of Eyes

Cataract is a medical condition that causes clouding of the lens of the eye, which is typically clear. The cloudiness can cause a decrease in vision and may lead to eventual blindness if left untreated. Symptoms of cataracts include clouded, blurred or dim vision, trouble seeing at night, sensitivity to light and glare, seeing “halos” around lights, frequent changes in eyeglass or contact lens prescription, fading or yellowing of colors, and double vision in one eye. According to the Global Burden of Disease Study 2019, the global burden of cataracts has been increasing over the years, with a rise of 91.2% in disability-adjusted life years (DALYs) from 1990 to 2019. The study also found that globally, age-standardized prevalence and DALYs rates of cataracts peaked in 2017 and 2000, respectively. The prevalence rate of cataracts in 2017 was 1283.53 per 100,000 population, while the DALYs rate was 94.52 per 100,000 population in 2000. The burden of cataracts is expected to decrease by 2050. This may not hold true in the post Covid Era.

Earlier as per WHO, the prevalence of cataracts increases with age, from 3.9% at age 55 to 64 years to around 92.6% at age over 80 years. This epidemiology is fast changing to younger co-horts as per consensus building with the doctors and the intra ocular lenses (IOL) manufacturers. What is this new wave of cataract emerging from?

  • Sedentary lifestyle during lockdown leading to diabetes, high blood pressure or obesity
  • Excessive exposure to devices such as mobile, laptops over long working hours during work from home
  • Some of the experts believe (yet to be proven by longitudinal research) that it is the side effect of the covid vaccine.

But it is certain that cataract is spreading in a much wider age cohort.

Why did I go for Cataract IOL Implant Surgery?

After June 2023, the right eye’s sight started deteriorating faster than usual, despite the eye drops treatment. By early October, various tests recommended a surgical intervention. The surgeon also recommended for the IOL implant to the other eye within a month or two. Times up now. But the issue were:

  • What are my lifestyle requirements that the IOL implant needs to fulfill?
  • What type of IOL implant to select?
  • What make of IOL implant for the type selected?
  • Are there post-surgical life style modifications to be undertaken?

My Lifestyle Requirements

It is very important for those going in for surgery to decide on what sort of lifestyle modifications you would like to achieve post-surgery. In my case,

  • Reading: At the outset, I needed to get my eyes vision corrected that will enable me to read books, files on my laptop for 6 to 8 hours a day. I didn’t mind reading with corrective vision via spectacles. Therefore, post-surgery, there will still be a need for reading glasses.
  • Outdoor sports and activities: Wearing spectacles and playing aggressive sports has always been a handicap for me for years. Therefore, a full correction of my distance sight was very important to me

Types of Intra Ocular Lenses (IOL) to Select From

Depending on the requirements of the condition of the eyes and the vision correction for the lifestyle, there are different types of IOLs available. These include:

There are several types of lenses that can be used to replace the natural lens of the eye during cataract surgery. The most common types of lenses are:

  • Monofocal lenses: These lenses provide clear vision at a single distance, either near, intermediate, or far. You may need glasses to see clearly at other distances.
  • Multifocal lenses: These lenses have multiple focal points, allowing you to see clearly at different distances without glasses. However, they may cause some visual disturbances such as halos and glare.
  • Toric lenses: These lenses are designed to correct astigmatism, which is a common condition that causes blurred vision. They can also correct nearsightedness or farsightedness.
  • Extended depth-of-focus lenses: These lenses provide a continuous range of vision from near to far, with less visual disturbances than multifocal lenses.

Some of the factors that also need to be also considered are:

  • Visual needs: The type of IOL you choose will depend on your visual needs. Monofocal lenses are designed to provide the best possible vision at one distance, while multifocal IOLs have corrective zones built into the lens, allowing you to see both near and far objects. Extended depth-of-focus (EDOF) IOLs have only one corrective zone, but this zone is stretched to allow distance and intermediate vision. Accommodative lenses can also correct vision at all distances, using the natural movements of your eye’s muscles to change focus. Toric lenses have extra built-in correction for astigmatism.
  • Lifestyle: Your lifestyle can also play a role in choosing the right IOL. For example, if you enjoy outdoor activities or sports, you may want to consider an IOL that reduces glare and enhances contrast sensitivity.
  • Budget: Not all IOL types are covered by insurance, and some can cost more than INR 50,000 out of pocket. Medicare and most insurance companies cover the cost of the most common IOL, the monofocal lens. Multifocal, EDOF, toric, light-adjustable lenses, and accommodative IOLs are considered premium lenses and can reduce the need for glasses or contact lenses.
  • Health: Your overall health and medical history can also play a role in choosing the right IOL. For example, if you have a history of eye disease or other medical conditions, your ophthalmologist may recommend a specific type of IOL.

Based on the above-mentioned types and factors, I decided to go for monofocal IOLs.

Not all manufacturers make all types of lenses. Moreover, many of these players are leaders in one type of lenses in terms of innovation or have invented specific materials. So which are the key manufacturers that I shortlisted.

Key IOL Manufacturer’s in My Consideration List

For monofocal IOL, my recommendation list is as under:

  • Johnson & Johnson: Johnson & Johnson Vision is a subsidiary of Johnson & Johnson that specializes in eye health products. They offer a range of IOLs, including the TECNIS Eyhance™ Intraocular Lens.
  • Alcon: Alcon is a global leader in eye care and offers a range of IOLs, including the AcrySof IQ PanOptix Trifocal IOL.
  • Hoya Corporation: Hoya Corporation is a Japanese company that specializes in optics and photonics. They offer a range of IOLs, including the iSert Preloaded IOL.
  • Bausch Health Companies: Bausch Health Companies is a Canadian pharmaceutical company that offers a range of IOLs, including the Crystalens AO.
  • Carl Zeiss Meditec AG: Carl Zeiss Meditec AG is a German company that specializes in medical technology. They offer a range of IOLs, including the AT LARA Toric.

The key issue here is that not all eye surgeons implant all manufacturers IOLs. Therefore, eye surgeons will recommend the IOLs that they are trained to implant.

Post Operative Eye Sight Recovery

Voila! My distance eyesight was fully corrected. I have no myopia now. But there was residual eye sight correction for reading and near distance such as laptop. My eye surgeon recommended me for a progressive lenses spectacles. Although, progressive lenses are a popular choice for people like me, who need vision correction for both near and far distances. However, there are some drawbacks to consider when choosing progressive lenses:

  • Adjustment period: It can take some time to get used to progressive lenses. I experienced dizziness while my eyes adjust to the new lenses.
  • Peripheral distortion: Progressive lenses have a small area of clear vision in the center of the lens, with the prescription gradually changing towards the edges. This has some distortion in my peripheral vision.
  • Cost: Progressive lenses can be more expensive than traditional bifocal or trifocal lenses. The cheapest lenses are worth INR 15,000.
  • Limited frame options: Progressive lenses require a specific shape and size of the lens, which can limit your frame options.
  • Prescription changes: If your prescription changes, you may need to replace your progressive lenses.

It has been 5 weeks since my surgery. However, I am still struggling with my progressive lenses from Titan EyePlus after two rounds of measurement and lenses. I have still 4 weeks of protective eyewear when I step outside. I have started using Polaroid Ultraviolet rays protection sunglasses when outdoors in the sun during the day.

This is my first extended time in front of the screen to work. Coming back to the Pandemic of Eyes. I did see people who were younger than me for cataract surgery waiting in the pro-operative area getting prepped. Look out for more on this issue.

Growing the Investments in India Tech Stack and New Age Internet and Ecommerce

Growing the Investments in India Stack and Ecommerce

Podcast

QuoteUnquote with KK and Kevin T Carter, Founder and Chief Investment Officer, EMQQ Global, An Emerging Markets and Indian Exchange Traded Fund (ETF) on NYSE

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A Random Walk Down Wall Street | Burton Malkiel | Talks at Google

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Holy Crap – Caste Discrimination in Silicon Valley Land

Holy Crap - Caste Discrimination in Silicon Valley Land

Background

The word going around is a that what happens in Silicon Valley’s deep tech innovation in start ups hits India’s Silicon Valley within months. Such is the bridge between the two start up ecosystems. However some nasty developments in the Silicon Valley is something that India’s Silicon Valley would not like to discuss and emulate. Yes, I am taking of Hindu Caste Discrimination as a law in California. Today, the Governor of California vetoed and refused to sign, the unanimously approved Senate Bill (SB) 403 that aims to amend Section 51 of the Civil Code, Sections 200 and 210.2 of the Education Code, and Sections 11135, 12920, 12921, 12926, 12930, 12931, 12940, 12944, 12955, 12955.8, 12956.1, 12956.2, and 12993 of the Government Code to prohibit discrimination on the basis of ancestry and caste. I am sure many Indian Senators cutting across party lines and various Indian Activists would have lobbied with the Governor for the veto!   

Let’s trace the journey on SB 403.

As a global senior leadership of Cisco, as part of the leadership induction, I was walked through the performance management system, the inclusive culture and innovation through its start up spin outs to accelerate the product development and go to market. Cisco in this acts as a venture capitalist funding its own employees to form start ups. One such start up was of Sundar Iyer, a Distinguished Engineer in the CTO group in the Insieme Business Unit at Cisco and co-founder and head of Candid Systems, a Cisco Alpha Company. Iyer as his family name says is an Upper Indian Caste. One Dalit employee (code named “John Doe” filed a caste discrimination case against Iyer and one of his co-colleagues and Cisco for Caste discrimination for his promotion and increment. Imagine this in Silicon Valley!

Iyer and John Doe’s co-colleague have been absolved from the case by the Courts in the US, but the case against Cisco continues. In the meantime, Aisha Wahab is an American politician who has been a member of the California State Senate from the 10th district since 2022. Aisha Wahab is the sponsor of Senate Bill 403 (SB 403), which was introduced on February 9, 2023, in the California State Senate. The bill passed with a vote of 34 to 1 in the Senate floor on May 11, 2023. If enacted into law, SB 403 would make California the first state in the US to ban caste-based discrimination.

More about Aisha Wahab, she is a member of the Democratic Party and the first Muslim elected to the California State Senate. Born in Queens, New York City, to refugees who fled Afghanistan in the 1980s, Wahab was adopted by an Afghan couple in Fremont, California, and moved to Hayward after the 2008 Financial Crisis. She earned a Bachelor’s degree in political science at San Jose State University and a Masters in Business Administration from Cal State East Bay. Before entering politics, she worked in non-profit organizations and is currently an IT consultant. Wahab served on the Hayward City Council from 2018 to 2022 and was one of the first Afghan-Americans elected to public office, alongside New Hampshire state representative Safiya Wazir.

The Implications: Caste the New Hindu Divide in the US?

When I filled college admissions for my kids in the US, there was just a religion column. I am now informed that many colleges and universities in California have started asking for the caste to be filled in the admissions forms. We all know that there are not many merit quota seats in Indian premier educational institutions hence we as parents spend hefty fees to educate our kids in the US to offer them the best competitive environment. A caste-based system in the US colleges?

An upper caste or a lower caste, the person has made it to the Silicon Valley in the US is a validation that its all about merit and hard work. To taint the US system with another lens of Indian caste system is a bit of a stretch to me. If a Dalit who has made it to the Silicon Valley and now wants a quota for his raise and promotion is not fit for the US. The person should better apply for quota jobs in India and be happy for the reservation and its perks.

It’s just not about Indian Caste System. I am sure the Africans have their Tribes hierarchy and many other races and religions around the world have some sort of sub sects. Starting with the Hindus, will the State of California go on to protect these castes as well? I am not sure if the senator, Aisha Wahab, who pushed for SB 403 has ever understood Indian Caste System to enact such a bill. If SB 403 becomes an Act, will it mean that India’s Silicon Valley will also push for caste based quotas and shun its meritocracy?

As regards Cisco, it recruits the best of the best, irrespective of caste, creed, colour and conviction. I went through a global search for a leadership role there with 9 rounds of interviews, a business plan presentation and solid reference checks. After working with such breed of leadership, do I expect to play my caste card for increments and promotions. My work itself spoke for me. I was confirmed in 6-months (as originally signed 1-year) with half-yearly bonus, additional RSUs and other benefits. Leadership prides in working with such peers of leaders. Only weak leader such as John Doe will play the caste card and drag Cisco into a discrimination case.

Lastly, from the investor perspective, if SB 403 goes through, will the Silicon Valley VCs and LPs also have to provide for caste-based investment thesis?     

Holy Crap!

Why I Upgraded to Microsoft Surface Book 3?

My Surface Book 3

Background

I have been using a full operating system (OS) hybrid 2-in-1 laptop since 2011 with the launch of Microsoft Surface Pro 3. Some of the reasons for my preference is:

  • Powerful hardware configuration whether the display, keyboard, portability, handwriting recognition, memory expansion using micro SD cards
  • 3 inch high-res screen display that can tilt 170 degrees
  • Fan less cooling and therefore no-noise while operating
  • Really lap compatible
  • Light weight – around 800 gms
  • Great set of high-quality accessories
  • Full integration with the Windows OS and other apps such as OneNote, Office, etc
  • Handwriting and editing of the documents using the Surface Pen on Drawboard PDF on Acrobat PDF files
  • Illustration, annotation, handwriting to text recognition capabilities by using the Surface Pen
  • Light weight and carry it along as a note taking device
  • Long battery back-up of 10-12 hours initially!!!
  • Collaboration with my team using One Note
  • Accurate voice commands by voice training
  • Read aloud functions across apps that helped me not to look at the screen constantly and hence multi task if required.

Although Microsoft Surface product line is expensive as compared to other similar 2-in-1 hybrid products, I stuck with Surface Pro all these years by refreshing and trading in with upgraded Microsoft Surface Pro every few years. My last upgrade was the Surface Pro 6 in mid-2017. This one served me through the Covid Pandemic and beyond.

Need for Upgrade

While Microsoft kept on introducing several new products since 2017 when I upgraded to Surface Pro 6 (Surface Pro 7 was introduced 6 months later in India). These included:

  • Surface Pro: A versatile 2-in-1 device that can be used as a tablet or laptop.
  • Surface Laptop: A traditional laptop with a sleek design and powerful performance.
  • Surface Book: A high-performance laptop with a detachable screen that can be used as a tablet.
  • Surface Go: A compact and affordable tablet that is ideal for on-the-go productivity.
  • Surface Studio: An all-in-one desktop computer designed for creative professionals.
  • Surface Studio Laptop: The next generation which combines the benefits of Surface Book and Surface Studio as a portable device

During Covid and the lockdown, I kept working in the office from April 2020, being in healthcare and in came Microsoft Teams for virtual collaboration. Then came the Windows 11 Beta program which I upgraded to in Mid-2021 Windows 11 | Kapil Khandelwal KK. I added curved screen external high-res monitor, external keyboard and mouse for a immertive experience on my desk top in mid-2020 when I started my podcast show QuoteUnquote with KK QuoteUnQuote With KK | Kapil Khandelwal KK.

My working needs of the Surface Pro increased from regular emails, presentations, document writing and editing and excel sheets workings, virtual collaboration and conferencing to audio and video editing for my podcast. Around 4 months ago, the Windows 11 beta update started draining the Surface Pro 6 battery quickly. From 7 to 9 hours the battery of the Surface Pro 6 would last 3 to 4 hours. Also the device was becoming a bit slower. It was time to upgrade to a new 2 in 1 hybrid.

The Options

So amongst the options available in the Microsoft Surface products, I wanted to continue with Surface Pro 6 replacement as it would lead to continuity with the existing accessories such as the Surface Dock 2, Keyboards, Surface Pens, etc. But the upgrade to Surface Pro 7 was the redline for me as after this Microsoft has removed the MicroSD expansion slot. The latest Surface Studio Laptop is not a detachable although with latest chip and specs. Portability is an issue for me.

So here are the options shortlisted by me.

Device Surface Pro 6 Surface Book 3 Dell XPS 2-in-1
Processor 8th generation Intel Core processor 10th generation Intel Core processor 12th generation Intel Core processors
RAM Up to 16GB Up to 32GB Up to 32GB LPDDR4x
Storage 217 GB SSD SSD 256 GB PCIe SSD 512 GB M.2, PCIe NVMe, SSD
Graphics Intel® UHD Graphics 620 Intel Iris Intel Iris
Display 12.3” PixelSenseTM Display Resolution: )  Screen: 13.5” PixelSense™ Display 13″, GorillaGlass Victus,  500-Nit Display
2736 x 1824 (267 PPI)  3000 x 2000 (267 PPI) 2880×1920 (3K)
Aspect ratio: 3:2 Aspect ratio: 3:2 Aspect ratio: 3:2
Touch: 10 point multi-touch Touch: 10 point multi-touch G5 Touch; AR+AS
Battery Up to 13.5 hours Up to 15.5 hours of typical device usage Worked for 9 hours in my test
Ports 1 x full-size USB 2 x USB-A (version 3.1 Gen 2) 2 Thunderbolt™ 4 (USB Type-C™) with DisplayPort and Power Delivery
1x 3.0  Mini DisplayPort 1 x USB-C® (version 3.1 Gen 2 with USB Power Delivery revision 3.0) 1 USB-C to USB-A v3.0 adapter (included in the box)
3.5 mm headphone jack 3.5mm headphone jack 1 USB-C to 3.5mm headset adapter (included in the box)
 1 x Surface Connect port Surface Type Cover port 2 x Surface Connect ports (one on base, one on tablet) nil
MicroSDXC card reader Full-size SDXC card reader Nil
Weight 770 gams 1,534 grams 736 grams 

Dell was kind enough to let me explore and try out their Dell XPS 2-in1 for over a month. Inspite of the latest Intel chip, I did not feel the speed rush of the chip speed. Also, the keyboard had only 2 viewing angles which was very restrictive. Moreover, Dell needs to work on its pen technology that was still to mature. Moreover, many of the drivers were Dell proprietary. Some of the native Microsoft apps do not function seamlessly and do not provide the experience like the Microsoft Surface products which are well integrated with the Microsoft Software. These were additional investments. Although Dell’s specs were high-end, the screen and video conferencing immersive experience was not that great despite of downloading some of the Microsoft drivers. The speakers on both Dell and Microsoft products needs much more improvement. If I had to move to Dell, then I would have to invest into a ton of accessories apart from the upgrade to Windows 11 Pro (the boxed product comes with Windows 11 Home). Though Dell has a solid product in hand, it will perhaps catch up with the Surface product line in a few iterations.

Kapil Khandelwal KK with Dell XPS Product Specialist
Kapil Khandelwal KK with Dell XPS Product Specialist

The Surface Book 3 Experience

After the exercise, I have now the proud owner of a Surface Book 3. There have been hick ups though. Firstly, the product arrived dead and had to be replaced. In addition, some other accessories that I added. These included the Surface Slim Pen 2 with an external charger, a case with a hinge for the screen panel so that it will give me a Surface Pro like experience when detached from the Surface keyboard. Overall, a great experience and continuity of a Microsoft Surface product.

Also See: Microsoft Event 2023

Growing India’s Artificial Intelligence Ai X-tiple Times

Growing India’s AI X-tiple Times

Podcast

After, ChatGPT has taken the world by storm after it was launched on 30 November last year. Sam Altman the founder of OpenAi who was the developer himself warned to the US Senate Committee that if gone unregulated how it would fall in wrong hands and create havoc for the world and that all the countries of the world should regulate AI for its development and use. In June when he visited India, at an event in Delhi, Sam Altman was asked whether three Indian engineers with $10 million could build something similar to OpenAI. In response, Altman said it was “hopeless” for a young team from India with limited resources to build a foundational artificial intelligence model similar to OpenAI.

QuoteUnquote with KK and Authors of AI Rising – India’s Artificial Intelligence Growth Story : Leslie D’Monte and Jayanth N Kolla Leslie debunk this and discuss how India can move forward from mobile first to AI first nation.

 

Also Read

AI Rising : India's Artificial Intelligence Growth Story
AI Rising : India’s Artificial Intelligence Growth Story

Amazon Link: AI Rising: India’s Artificial Intelligence Growth Story

Mckinsey Report: The Economic Potential of Generative AI


Stanford AI Report 2023


Governing AI : A Blueprint for India


Also Listen

Governing AI – India’s Opportunity to Lead by Brad Smith Co-chair, Task Force on Tech, Innovation and R&D; Vice Chair and President, Microsoft Corp, USA 

Elon Musk Most Shocking Interview With AI!

New Healthcare Bills in Parliament in Monsoon Session 2023

New Healthcare Bills in Parliament in Monsoon Session 2023

Background

The Covid Pandemic exposed some of the short comings and lacunae some of the Acts and Bills that have been enacted in India to regulate the healthcare and lifesciences industry. You may be surprised that some of these regulations pre-date the pre-independence British Era Regulations in this country. While healthcare and lifesciences products, services and professionals have progressed significantly over the last 75 years since Independence their regulations from the British Era hampered the progress. Six bills are being introduced are expected to be passed in this ongoing session of Parliament which commenced on July 20, 2023 and will be in session till August 11, 2023. These include:

  • Drugs, Medical Devices and Cosmetics Bill, 2023;
  • National Dental Commission Bill, 2023;
  • National Nursing and Midwifery Commission Bill, 2023;
  • Biological Diversity (Amendment) Bill, 2022;
  • Forest (Conservation) Amendment Bill, 2023; and
  • DNA Technology Bill (Use and Application) Bill, 2023

Let’s understand some of the Bills are being introduced directly by the Ministry of Health and Family Welfare while others are being introduced by other Ministries but have an impact on healthcare and lifesciences industry indirectly. Let’s quickly understand what these Bills are going to be enacted for.

The Drugs, Medical Devices and Cosmetics Bill 2023

This Bill seeks to regulate the import, manufacture, distribution and sale of drugs, medical devices and cosmetics. The focus of this bill is to ensure the medicine and medical devices quality, safety, efficacy, performance and clinical trials of new drugs and medical device. Beside, the Bill seeks clinical performance evaluation of new in-vitro diagnostic medical devices including Ayush medicine, medical devices and cosmetics with the objective of the highest possible regulatory standards, ensure a transparent regulatory regime and to repeal the archaic Drugs and Cosmetics Act, 1940. We do remember what was going on during the pandemic to fast track the approval of Pfizer and other companies vaccines in India without any clinical trials and data on Indians. Hopefully, this Bill will plug some of those loopholes that were being exploited by some of the multinational pharma companies to push their products into India during the Covid pandemic.

The National Dental Bill 2023

This Bill repeals the Dentists Act 1948. The proposes to set up a National Dental Commission (NMC) to regulate dental education and the profession in the country. It also seeks to make dental education affordable and raise its standards, and make quality oral healthcare accessible.  

The National Nursing and Midwifery Commission Bill 2023

This Bill seeks to set up a National Nursing and Midwifery Commission (NNMC) and to repeal the Indian Nursing Council Act 1947. The Indian Nursing Council Act, 1947 is an act of the Indian parliament that regulates the nursing profession in India and was introduced by the Ministry of Health and Family Welfare in India.

The Drugs, Medical Devices and Cosmetics Bill 2023, The National Nursing and Midwifery Commission Bill 2023 and The National Dental Bill 2023 was introduced by the current minister of Health and Family Welfare, Mansukh Mandaviya.

The National Research Foundation Bill 2023

This Bill seeks to establish a National Research Foundation and repeal the SERB which is the Science and Engineering Research Board Act, 2008. The Science and Engineering Research Board Act, 2008 is an act of the Indian parliament that provides for the constitution of a Science and Engineering Research Board to support basic research in science and engineering.

The Science and Engineering Research Board Act, 2008 falls under the Ministry of Science and Technology in India.

The Biological Diversity (Amendment) Bill 2022

This was reported by the Joint Committee was introduced on December 16, 2021. The amendment report of the joint committee was presented to both the houses of Parliament which has proposed for consideration and passing. This Bill proposes to protect some of the plant species that would enable protection and development for Ayurveda.

The Forest (Conservation) Amendment Bill 2023

The controversial bill amends the Biological Diversity Act, 2002 to simplify compliance requirements for domestic companies. It also removes research and bio-survey activities from the purview of benefit sharing requirements. The bill also decriminalises all offences under the Act. Among several criticisms of the Bill was that it promotes ‘ease of doing business’ and would exempt users of codified traditional knowledge and Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy (AYUSH) practitioners from sharing benefits with local communities.

Environment Minister Bhupendra Yadav will be introducing the Bill.

The DNA Technology Bill (Use and Application) Regulation

In the case this Bill which was introduced in the Parliament on July 8, 2019 is seen to have an issue. This is despite the report of the standing committee on Science and Technology, Environment, Forests and Climate Change was laid on the table of Lok Sabha on February 2021 the motion proposed was for withdrawal.

The DNA Technology Bill (Use and Application) regulation is a bill that seeks to regulate the use and application of DNA technology for establishing the identity of missing persons, victims, offenders and unknown deceased persons.

The above three bills is being tabled in the Parliament by the current Minister of Science and Technology, Dr. Jitendra Singh

 

Agri Revolution 2.0: Debunking the Poor Farmer Politics and Growing High Nutritional Food

Agri Revolution 2.0: Debunking the Poor Farmer Politics and Growing High Nutritional Food

Podcast

QuoteUnquote with KK and Harish Damodaran, Agri Expert, Editor, Author

In this podcast we discuss the dire and immediate need for an Agri Revolution 2.0 in India. As our population is ageing and health acuity increasing towards food intolerance and diet restrictions, we now need to also start producing more nutritious and healthy food not just for the elite classes but the masses as India enters mid-income countries club and the food basket of the people of India improves towards better dietary habits and food consumption.  This may mean we may have to start growing new varieties of foods.

Also Read:

https://kapilkhandelwal.com/policies-and-regulations/pm-task-force/

Also Listen: 

Health Issues from Food 

Celiac Disease

Food Allergies

Lactose Intolerance

Where Are We Going Wrong with Unified Health Interface (UHI) – the UPI for Healthcare?

Where Are We Going Wrong with Universal Health Initiative (UHI)?

Introduction

In 2020, I wrote a blog titled From Telegraph Road to US$50 Billion Digital Health Silk Road Digital Health Silk Road Archives | Kapil Khandelwal KK celebrating the announcement of the National Digital Health Mission (NDHM) under the National Health Authority (NHA). We had worked out the direct and indirect impaction to the Indian economy that such an initiative will result. Over the next few years, the turn of events have led the country to not move forward on such a huge initiative for the healthcare of people of India. Let’s look at the turn of events leading up to the recent development and the way forward from here.

Key Developments in the Journey of Developing our Universal Health Initiative (UHI)

‘National Health Stack – Strategy and Approach’

In 2018, NITI Aayog released a document setting out the building blocks of the National Health Stack as ‘common public goods’ which are essential for an implementation of digital health initiatives in India. The key components described in the National Health Stack were national health electronic registries, claims platform, federated personal health records framework, national health analytics platform, and other horizontal components.

National Digital Health Blueprint (NDHB).

In 2019, Ministry of Health and Family Welfare (MoHFW) released the National Digital Health Blueprint (NDHB). The need for creating a framework for the evolution of a ‘National Digital Health Ecosystem’ (NDHE) – an ecosystem and not a system, was recognized in the NDHB. The NDHB lists out principles, building blocks, applications and digital services, standards, institutional frameworks etc, to create such an ecosystem.

National Telemedicine Guidelines

During Covid, the Medical Council of India (MCI) quickly released the National Telemedicine Guildlines to enable tele consultations so that limited capacity of the physicians is utilised for remote consultations during the pandemic and lockdowns.

Consultation Paper on Unified Health Interface (UHI)

In March 2021, MoHFW released a consultation paper on Unified Health Interface (UHI) to replicate its digital-payment success in healthcare. Taking cues from the Unified Payments Interface (UPI), it set out to establish a similar system for healthcare inclusion and universal health for the people on a ‘Bharat Stack’ for Healthcare. I am sure many of the tech industry bodies such as Nasscom, iSpirit and CII and FICCI would also have been consulted in framing the Consultation Paper.

Current Status

iSpirit, Indian tech industry body was appointed by National Health Authority (NHA) to lead the development of UHI. There have been delays in operationalizing the UHI and recent media reports state that key disagreement between the NHA and iSpirt on the nature of the UHI network-and iSpirit walking away from the project.

Why Did UHI not take Off?

iSpirit and Media View Points

There is a long format article from Ken that has been doing rounds and my talks with some of the Healthtech and other VC investors interested in this initiative have been summarized here:

  • Limited use of iSpirit partners for building components
  • Rationale of iSpirit partners that were short-listed for pilot and those left out for the wider roll out in the next stage
  • Conflict of interest between the iSpirit partners shortlisted that would push their product/components into the UHI pilot making it not a fully open system
  • Lack of openness between the iSpirit and NHA on the development and roadmap for wider participation of healthcare industry players
  • Slippage of deadlines for the teleconsultation solution multiple times drawing the ire of NHA
  • Self-doubts within iSpirit on the future success of the pilot and the eventual scale of UHI
  • iSpirits experience with other non-healthcare solutions roll-outs on the way forward in the roll out of UHI to the nation which is not true for healthcare as compared to fintech, social commerce and other digital solutions

My Views on Current UHI’s State

Let me tackle the lack of understanding of the reality of the Indian healthcare system and how it is evolving in the future for the UHI to succeed. These are some of the points that I have made in the past in various industry forum presentations, my articles and blogs. Then I will address the way forward from here for UHI to succeed

India’s Scale in UHI will be an Aggregation of its Diversity of People – The Markers for Healthcare Delivery

Based on my experience of rolling out the 104 and 108 helplines in late 2000s, for any solution to be successful, especially the teleconsultation that iSpirit and NHA were developing, it has to build for the different languages and dialects prevalent not only in a region of a state, but across states due to floating population. As recently as covid pandemic, when we were rolling out CovidBots for triage on the 104 for a few states, we have realized that nothing has changed in the last 20 years in India. The figure below provides the language diversity for which we will need to implement not a one product fits all under UHI.

India Diversity in Numbers – Genetio-Lingustic Segmentation
India Diversity in Numbers – Genetio-Lingustic Segmentation

With the best of the cloud services, India has a limitation of 23 languages being provided with voice translation capabilities.

What Scale are we talking of?

Based on our population genetic, epidemiological, chronic disease burden, I had released this state-wise risk map of India in 2010. This show that we have around 50 million households which have high-risk burden. This is twice as big as the population of USA. This is expected to touch over USD 150 bn of spend not just on curative but preventive care.

What is the scale?
What is the scale?

So what is the scale we are talking of? Is this not sizeable according to iSpirit? How does this compare with the subscribers are using UPI? As of July 2021, there were around 130 million monthly active subscribers on UPI after 5 years of its launch. As per industry estimates if I recall, the digital health services teleconsultations peaked during Covid lockdown and were around 100 million monthly active subscribers/teleconsultations consultations. This is even before the launch of teleconsultations module of UHI. Can you imagine the multiplier effect once it goes mainstream?

Why Not Partner with Nasscom’s Tech Services Companies?

On the issue of openness between iSpirit and NHA on the development and roadmap for wider participation of healthcare industry players, my take is that iSpirit’s objective is to promote product players from India. But, I must remind that large IT services players like Wipro, Infosys, Cognizant, TCS, IBM, Tech Mahindra, etc who have been building point-solutions for some of the leading healthcare players and governments globally for over twenty years. Not inviting and leveraging these partners from Nasscom is also one of the reasons for failure of UHI

Learning from Past Mega Global Healthtech Product Failures

I have written in the past on why global players with deep pockets like Google, Microsoft, IBM, etc have failed on their healthcare initiatives. National Digital Health Archives | Kapil Khandelwal KK Haven’t we any learnings from such mega failures?

Why Did Google Health Fail
Why Did Google Health Fail

Digital Health Penetration Across States is Not Uniform Nor is State-wise Regulations

In our 2021, State Healthcare Heat Map 2021 States Heat Map | Kapil Khandelwal KK, the first of its kind report for which are the hottest states to invest in healthcare, we have covered factors like Penetration of Digital Health. It is very clear that UHI to be successful, it is not going piecemeal staggered solutions go-live, but a big-bang all UHI solutions go-live in the states with highest digital health penetration. Moreover, have we not learnt lessons on how each of the states managed the delivery of Covid Care Sustainability Of Digital Health | Kapil Khandelwal KK as healthcare is a state subject. Have we not forgotten that West Bengal is not there for running the Ayushman Bharat. Nor does it run the National Health Emergency Ambulance number 108. Assuming, even if UHI would have gone live, there would be another layer of customisation that UHI would have to roll out for each of the states where the healthcare is delivered. Different states are at different maturity of implementation of various medical criminal code and consumer protection. Such state regulations and code cannot be circumvented by one EULA of the UHI and the modules. We are not transferring money like UPI, we are managing health of the people where there are risks of lives.

2021 States Investment Heat Map
2021 States Investment Heat Map

Start with the Building Blocks

Post Covid, a lot has changed. Since UHI wanted to start with teleconsultations, can we even get the ICD-11 codes live in India so that we are up to international standards? Since outpatient consultations/teleconsultations are predominantly out of pocket spend, there is least incentive for the care giver on the street to fill up the forms and ICD codes. With ICD coding in the UHI, AI tools at the back end would be able to assist not only the care givers but also the consumers, the other ancillary benefits of coding would follow.

In Conclusion

Setting aside the differences, it is clear that UHI’s scale and opportunity is even bigger than UPI’s and its impact on the people of India once it is fully implemented and evangalised by each of the states of India. Comparing success of UPI to UHI will be a totally wrong starting point. UHI is like the GST (GST has its own set of issues) with each state having its say in the GST Counsil. Let us reenergize the UHI with bringing in the States and Nasscom players into the solution to make it more viable and successful.