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Why is India’s National Digital Health Mission is likely to succeed?

Background

Last year the Government of India announced the National Digital Health Mission (NDHM). We were asked to review and comment on the draft as one of the stakeholders in healthcare. This inclusive approach to involve the various stake holders was never seen before. We believe that COVID-19 and NDHM has increased the pace of digital healthcare and can unlock USD 200 to 250 billion in next 10 years in terms of primary and secondary impact to the nation’s economic value. Such is the magnitude of the NDHM initiative for India. So will this succeed?

To understand the critical success factors for India, let’s understand some notable failures and learn from them. Also we need to learn from the currently ongoing Covid Vaccination Drive in the country that’s the largest in the world and the fastest that will cover over a billion people.

Notable Failures

We have several tech giants and countries that have invested and failed in rolling out digital health initiatives. Some of these that come to my mind are:

Google Health

I had written in my column on Why did Google Health Fail? (see text below)

IBM Watson Health

Some of the insider views on the closure of IBM Watson Health (shut down on 31 Dec 2020) are as under:

Business call by IBM leadership – viability of the case in oncology
Muted doctor’s acceptance
50:50 prediction accuracy of the algos
Wrong expectations set when initially selling the idea to the doctors and Manipal
Difference in clinical pathways of oncologists on the Watson output
Implementation was very complex due to the different oncology tumour and stage
Oncologists time to teach the system versus doing it by their own experience
- Doctors believed that they were recruited to treat the patient and not teach the Watson
Limited use case of the system
- More for research than for actual treatment and second opinion

UK NHS Spine Program

As part of the leadership team of one of the vendors involved in the UK NHS Technology initiative and also interacting with the Managing Director of British Telecom Healthcare that was leading the rollout in the UK of the NHS Spine, I gathered that the digital health (in those days-2007, this was not called digital health) in UK had a partial success. The reasons were multi-fold:

Exgaggerated benefits of the program
Botched up decentralized implementation at the different trust level
Multiple stakeholders with their wrested interest
Manpower and resources shortages
Multi-year delays and costs overruns
Poor change management and acceptance at the ground level with the clinical workers
And many more issues

African ICT and Digital Initiatives

As part of the Health and ICT Minister’s Panel for Africa, the major issues voiced by the Ministers from the African continent happens to be the disease of Pilotonomics. There have been multiple pilots of initiatives but none have actually fructified to be a mainstream as some of them have been abandoned by the sponsors and the donors as the budgets ran out

Have seen the failures across the Tech Giants, developed world countries and low income countries, the issues of failures are a myriad of technology, sponsorship, change management and end user acceptance.

Why will India succeed?

During the Covid-19 pandemic, India Government initiated a host of digital initiative (see blog Sustainability of Digital Health | Kapil Khandelwal (KK)). The most important being the roll out of the CoWin App for the vaccination of the citizens. For the first time on the world, a billion people would be mobilized through this initiative for their vaccination. With the pace and success of the initiative and the citizen acceptance, we will see that the National Digital Health Mission will succeed. Some of the positives that I am seeing include:

PMO and senior Ministers’ and Bureaucrats’ driving this Mission
Inclusive attitude to gather all the stakeholder’s voices right from the beginning
ICT framework and the National Telemedicine Act also being enacted bringing the decades of differences between the Medical Council of India (MCI) and various players to an end
- Many doctors have actually started using Telemedicine during the lockdowns

Let’s not belittle the National Digital Health initiatives for shorter political gains!

Also read: Digital Health | Kapil Khandelwal (KK)

Republished Column: A Dose of IT: Why did Google Health fail?

Google Health is not going to be there anymore.

After its launch in May 2008, Google Health has gone through its chequered existence till the Google Execs announced, last week, to withdraw the product by end of 2011. As I epilogue, I will use the PESTC model to conduct the postmortem analysis on the death on Google Health

Politically, 2007-08 was a time when concerns around reforming healthcare reform were at its peak and a one of the key agenda items in the US Presidential war. Such rhetoric on healthcare and need to reform healthcare was politically echoed world over by many leaders. This political analyst wanted to get more bang for the buck on healthcare spend. This meant more business for healthcare ICT to create solutions to address the issues of healthcare access, costs, quality, outcomes and so on. Politically, it made sense for tech heavy weights to put their might in launching healthcare solutions and in this political back drop that Google Health was launched. However since then and Obama’s healthcare reforms bill, not much impact for many tech major’s who waged on healthcare and hence to reassess their decisions to throw their towels in.

Economically, this was the time for world’s worst economic downturn since the Great Depression. Healthcare was seen as anti-recessionary. Tech major’s boardrooms and leadership strategy break outs discussed derisking and growth by enter social sectors such as healthcare, education and so on. Google’s board and leadership could not have been thinking differently when giving thumbs up to invest in healthcare business. However as many tech major now realize that healthcare requires long-term strategic vision and investments to stay in the game. Like many other tech major, Google has other investment priorities in other portfolios of their business such as android OS and mobile phones and devices, etc. It made sense for them to exit out of a sector that requires time and investments to change the way people and clinicians manage health.

Socially, the rise of social media is changing the way people manage information, communicate, exchange content and interact including their doctors and care givers. Google Health failed to capture this trend in their solutions.

Technologically, Google failed to learn from the failures of many others who failed in the past and replicated solutions where there are far more superior solutions and players in the field. Some major gaps, I guess alignment with doctors and clinicians is the first step towards creating a technologically superior solution that can align with healthcare consumers. Secondly, there were hardly any vertical partnerships in healthcare that Google went out to create an ecosystem. Lastly, Google did not integrate their other products such as Google Maps that could provide location aware services to the consumers on their health.

Consumers and competition, contributed to putting the nails in the coffin of Google Health. Google Health focused on one end of the healthcare value chain and did not believe in working in aligning the overall healthcare ecosystem. Moreover, consumers are moving towards mobile-based solutions on their smart handphones that Google Health failed to capture as a trend. Lastly, competition has far better ideas and staying power as health tech solutions is a long-term game.

With Google Health putting down their shutters on their shop, what are the implications? Firstly, the spotlight now falls on Microsoft HealthVault. Analysts will now try to second guess Microsoft’s response to this development. Health is a very large opportunity that Google may not like to miss. It may come back with an acquisition sometime later.

Google Health, RiP!

In Quest for Happiness

KK in Quest for Happiness

Background – I want to be Happy

Earlier this year I read an investment analyst’s report on Future of Happiness. The subject was very interesting given the current times in Covid. A lot has changed in the world in these times. Firstly, the pace of digitization and social isolation during extended periods of lockdown and secondly, losing some of our near and dear ones who succumbed to Covid in a tragic event. This crisis of mental and emotional well-being and suffering that me and fellow humans have undergone made me wonder about what happiness is and my quest for happiness alone. My journey was a difficult one but, I did see a sense of happiness and I am sharing this through my blog and my podcast.

The Happiness Movement

Even before Covid, in 2012, the United Nations (UN) declared March 20 to be observed as the International Day of Happiness. The day recognizes that happiness is a fundamental human goal and calls upon countries to approach public policies in ways that improve the well-being of all peoples. Venezuela was the first country to establish a Ministry of Happiness. Several other countries followed suit. Closer home, Madhya Pradesh Government under the BJP rule established a Department of Happiness and organized a week-long Festival of Happiness in 2017. The issue here is inspite creating bureaucratic and governance structures, the citizens and people were unhappy. This let me to believe that there is something fundamentally wrong. Therefore let me first define happiness and then decode how to achieve happiness.

What is Happiness?

A Google search on a formal definition of happiness lead me to the various online dictionaries and no formal definition of happiness. This fuzzy description of what we feel under the wide umbrella of happiness is a wide range of positive human emotions that we go through. However, a definition of happiness is well articulated in the book “The How of Happiness”, by positive psychology researcher Sonja Lyubomirsky as “the experience of joy, contentment, or positive well-being, combined with a sense that one’s life is good, meaningful, and worthwhile.” After having defined happiness, it’s now time to understand how we experience happiness?

How do We Experience Happiness?

The Western world scholars have two distinct explanations on Happiness and how to experience it? These are:

The “More” Approach: Here happiness is experienced by acquiring material objects that maximize pleasure and minimize displeasure. This approach hinges the fact that happiness depends on acquiring more things or experiences, depends on factors outside of one’s body.
The “Enough” Approach: Here happiness is happiness is experienced by our ability to ride the waves of human experience and cultivate internal wellness, even through turbulent times.

These two approaches however do not yield a perfect sense of emotional and mental well being as an outcome of happiness as it’s a bit alien to my values and personal belief system.

Indian Approach to Experiencing Happiness

Earlier this year, Dr. Devdutt Patnaik, India’s leading mythologist, speaker, illustrator and author, known for his writing on Hindu sacred lore, legends, folklore, fables and parables www.Devdutt.com released a book “Dharma, Artha, Kama, Moksha – 40 Insights into Happiness” This book resonated very well with me and my values when I read it. In fact, I invited Devdutt to my QuoteUnQuote with KK | Kapil Khandelwal (KK) Podcast. We discussed and dissected many issues around the whole architecture of the 40 insights and the 4 key pillars to experiencing Happiness.

Please read the book and listen to the Podcast “The Mantra for Happiness” to practice and experience Happiness in your life!

https://open.spotify.com/episode/2zKwiGBf6XObVCmSaisxfk?si=CCuMk8CsQ22-niFqA5EO7Q

Also Listen The Mantra For Happiness

Why India is not selling its Healthcare Assets Under National Monetisation Pipeline (NMP) 2021?

National Monetisation Plan 2021

Preamble

On 23 August 2021 the government announced a National Monetisation Pipeline of INR 6 tn, (~2.6% of GDP), aimed at monetising its brownfield infrastructure to fund greenfield ones. Most of these projects will be concentrated in the roads, railways, and power sectors and no monetisation of India’s healthcare assets. NMP provides the guide to funding the National Infrastructure Pipeline (NIP) announced by the Finance Minister on 31 December 2019. I had written an article on the NIP giving my observations and feedback on the NIP with respect to healthcare (see below).

National Monetisation Plan 2021 Sector Wise — National Monetisation Plan Sector-Wise

Why is Healthcare Assets Monetisation not Under NMP?

It has been clearly apparent from the Covid 19 pandemic the clear shortages in the bed supply whenever there was a spike in the Covid cases. The private sector just did not have the capacity to manage the situation, burdening the Government and its healthcare resources to step up. I had warned about the gross under supply of beds in my critique to the NIP, “As per one of our investment thesis on healthcare infra in India, to meet the global norms of 3 beds per 1000 population India needs an investment of $200 billion by 2025. This is approximately the total NIP projected across all the infra sectors. The current NIP shows a committed pipeline of $2.5 billion which is only through Center and State Governments. A gap of 99% of what needs to be invested for India to meet global norms for healthcare infra supply! Unlike roads which is hogging over 80% of NIP’s committed investments, healthcare infra is gestational. Therefore, there is a weak and lagging healthcare infra investment in India leading to demand gaps.” These concerns that I had voiced have come out to be true during the Covid pandemic. The issue here is not about how much to invest in healthcare infrastructure but the issue of would the Government want a political turmoil now to sell off its healthcare assets out. More importantly, for the monetization of healthcare assets, there are other regulatory and tax issues for the Government to iron out to be ready for this sector’s assets to be monetized.

I believe that it has been a prudent move by the Government to exclude healthcare out from the NMP.

National Infra Pipeline (NIP) – Where is the Healthcare Infra Connectivity like Roads for the Masses? (Published in Jan 2020 in VC Circle)

Background

Over the last few months of 2019, the Government through various Ministries and industry bodies and Political Forum have tried to reach out to investors in healthcare infra to compile the pipeline of investments that are at various stages of implementation. This report was announced by the Finance Minster on 31 Dec 2019. We congratulate the Ministry of Finance in coming forward with the efforts in reaching out various stakeholders and sets the focus and discussions back on the economy.

While the report recognizes the fact that various mechanisms need to be put into place to debottleneck and fast track the investment process into infrastructure to meet our goals of a $5 trillion Indian economy by 2025 and be the second biggest economy in the world by 2050. It also recognizes the issues relating to land reforms, which the Government dropped out in earlier regime due to political opposition, financing, regulations amongst others. As India’s dedicated healthcare infra fund, we point out some of our observations and feedback on the report with respect to developing and funding healthcare infra in India.

Indian Healthcare Infra Economics

As per one of our investment thesis on healthcare infra in India, to meet the global norms of 3 beds per 1000 population India needs an investment of $200 billion by 2025. This is approximately the total NIP projected across all the infra sectors. The current NIP shows a committed pipeline of $2.5 billion which is only through Center and State Governments. A gap of 99% of what needs to be invested for India to meet global norms for healthcare infra supply! Unlike roads which is hogging over 80% of NIP’s committed investments, healthcare infra is gestational. Therefore, there is a weak and lagging healthcare infra investment in India leading to demand gaps.

While there is a further ripple effect of this investment on the wider economy in terms of job creation, healthy and productive population amongst others which we believe will be the second order issues that can be addressed as investment flows in. The key issue here is what measures the Government and Private Sector needs to take to accelerate the pace of investments and delivery of healthcare infra to the masses like road connectivity.

Key Policies and Measures to Attract and Boost Healthcare Infra Investments from Private Sector

GST Bottlenecks on Input Side with No Pass Thrus on Output Side

Any healthcare infra investments structure whether PPP or private with asset-lite models is taxed under GST. While there is no scope for pass thrus of these costs on the output side. Several representations to the Government on correcting this anomaly have been presented at the highest levels. Unless this is corrected, private sector participation investment is only a minor aggregate to the investments.

Interest Rates YoYo Regime

RBI in its efforts to contain the inflation has not directionally provided a proper guidance of interest rates over the last few years. These changes in interest rates are difficult to model and predict for our investors both Indian and foreign. Healthcare infra investments require a stable interest rates regime.

Bank Leverage for Healthcare Infra

Over the last few years of liquidity crisis with the banking sector, healthcare infra financing like other infra financing has been deprioritized by the banking system as a whole as very high risk. Our discussions with senior leadership with various top banks does not give any confidence that the worst is over for the healthcare infra sector bank financing with many still negative with the burden of NPAs of the past. A policy to establish healthcare infra as a priority sector for bank would be in positive direction.

Pivoting Infra Models for Delivery of Ayushman Bharat

Ayushman Bharat is a positive step in Nation’s healthcare financing and delivery. However, the last report of Niti Aayug states that around 90% of all players in India owning healthcare infra employ less than 10 employees! Seriously, are these really hospitals delivering quality care? Given the current reimbursement rates, private sector participation in the whole scheme can only be marginal or absent in their current healthcare infra operating cost base. A more innovative low-cost infra investment model needs to be developed which some players are working towards to pivot towards the requirements of Ayushman Bharat.

Monetising Existing Gun Powder of Healthcare Infra

There is an approximately $45 billion of healthcare infra assets which are sitting on the books of Central and State Governments and Private and Social Sectors. Many of these require funding for upgrading and expanding their infra. Various archaic regulations and other operations bottlenecks are preventing investments flows into these existing healthcare infra from Indian and foreign investors.

Nine Men Cannot Produce a Baby in a Month (even in a test tube)

While healthcare infra is a highly gestational business, it is dependent on supply of adequate clinical and operational manpower from the investments in the education sector. The NIP duplicates the investments in AIIMs under health and education. A similar push is required in the education sector for private sector participation.

Social Stock Exchange – A Black Swan for Healthcare Social Infra

While working on the regulations for the Social Stock Exchange (SSE) with SEBI. There are several regulations that govern the social sector in terms of ownership of land and infra that need to be streamlined for a healthy investments in social health infra. We estimate that the addressable social ventures that would qualify to be listed on the SSE would potentially deliver an annual turnover to be around $5 bn on a conservative basis from various impact investors. If the regulations are streamlined, our expectations is that this would be increased by a multiple of 3X.

In Conclusion – Our Forward Looking and Safe Harbour Statements

While the NIP is a great exercise for setting the vision and strategy for the way forward. We believe that investor confidence is still muted and the dialogue between the Government and Healthcare Infra Investors and Operators need to be urgently set up for strategizing how the current estimates in NIP for healthcare infra can be boosted 100X to meet the current deficit to Healthcare Infra Connectivity like Roads for the Masses to meet the global norms.

Windows 11 for Healthcare: Cosmetic Surgery But the Chronic Aliments Still Persist

Windows 11

Happy Doctor’s Day!

Background

Last week, Microsoft showcased their latest Operating System (OS), The Windows 11. This is the new OS that will upgrade the Windows 10 that runs billions of computers globally. While talking to the analysts, Satya Nadela, the CEO and Chairman of Microsoft envisioned Windows 11 to be the ‘center’ of all the operating ecosystems. I downloaded the developers version on one of my tablet, Lenovo’s Yogabook, to test out the initial impressions of the new Windows 11 and does it meet the vision of Microsoft’s CEO and Chairman

Teething issues with the update to Windows 11

Microsoft has certain minimum hardware and security requirements which prevent existing systems to upgrade to Windows 11. Security enhancements in the new OS, requires TPM 2.0 (Trusted Platform Module) as well as Secure Boot, both security technologies, to run perfectly. This is why Microsoft has not listed Windows 11 support for a huge list of processors that do not come with these technologies. After many workarounds and system checks, I was able to get the Window 11 developer’s version update. This whole exercise took away over 11 hours of time from start to finish! Microsoft views to this is that its part of making more secure as a platform. However, unlike earlier upgrades to Windows 10, where many users complained that their files were deleted, this was not the case this time round.

Windows 11 minimum system requirements

Processor:	1 gigahertz (GHz) or faster with 2 or more cores on a compatible 64-bit processor or System on a Chip (SoC)
RAM:	4 gigabyte (GB)
Storage:	64 GB or larger storage device
System firmware:	UEFI, Secure Boot capable
TPM:	Trusted Platform Module (TPM) version 2.0
Graphics card:	Compatible with DirectX 12 or later with WDDM 2.0 driver
Display:	High definition (720p) display that is greater than 9” diagonally, 8 bits per color channel
Internet connection and Microsoft accounts:	Windows 11 Home edition requires internet connectivity and a Microsoft account to complete device setup on first use.

Cosmetic Surgery in the Windows 11 Operating System

There are a few positives in the first look at Windows 11 OS, the user interface is much cleaner, intuitive and clears all the patchwork of interfaces from earlier Windows OS in Windows 10. There is a feeling of an immersive experience. When I attached my system to external high-end curved monitor, the experience was very fabulous. For the doctors who want to view the radiological images, this would be a plus.

Chronic Aliments Still Persists

Moving on to congratulating Microsoft on their efforts, let me critique Microsoft on the issues that still persist from the previous OS that it need to really work and iron out for the new OS to be a real clinical workplace productivity enhancer. Some of these options are very easy for Microsoft to incorporate with its final release of Windows 11 to the world at large. Here are some of my views, I will add more as I do use the new OS in the next few weeks to come.

Windows Dictation and Read Aloud Tools

I have been using Windows dictation tool to get many of my documents typed out. However when I say certain medical terms under ICD 10 or names of molecules or medications, there is a typo returned in the typed output. I have seen a demo of Microsoft Azure tools for healthcare that are available to enterprise cloud and app developers of Microsoft, why should it be so difficult to roll this out for students, medical workers on their retail license of Windows 11? After setting the regional setting to India, Indian accents and Hinglish is still not available. Microsoft keyboard on my android phone has been trained for the last 2 years, Windows 11 can take the same from the information stored on their Keyboard App on Android and use those to train the dictation tool. Read Aloud Tool still has a Caucasian woman and cannot Hinglish words well or recognize them.

IoT Device Integration

There are several devices that the doctor can control right from his desktop in his clinic without having to get up and switch or off during diagnosis. Amazon and Google has been working perfectly with on IoT devices through Alexa and Google Assistant. Cortana is still lagging on the same functionality and experience. Unless the Microsoft CEO and Chairman in his statement on being in the center meant that we may have to use the Windows 11 desktop and get over to Google Assistant (on the Android App or browser) or Alexa to command the IoT devices connected to the network.

Pen Writing and Annotation

There are enhancements in the pen settings. However the current handwriting recognition is same as the Windows 10. Fast scribbles of the prescription still show as typos. The auto completion of medical terms still give garbles. The pen annotation of radiological reports still need to give micro-level pinpointing at 10x zoom. Still the same experience continues from Windows 10.

Microsoft Teams Integration

Microsoft Teams which was more for enterprise customer as a video conferencing and virtual collaboration app is now fully integrated into Windows 11. This means the doctors and their patients can freely teleconsult through their desktops

Multiple Desktops

This was a feature in the MacOS for years is now introduced in Windows 11. Doctors can now have multiple desktops for their outpatients, inpatients, personal and other work and personal workplace segregation.

Android Apps in App Store

This is just a feature in the App store. We still have to see the power of running these app on the Windows OS run systems. One of the main reasons for updating the developer version was to check the apps compatibility on Windows 11 desktop.

The Rhythm of Blues

As the Windows 11 is a developer version of the OS. Please be prepared for the system to crash and show you blue screen a few times in a day.

Not Everyones OS for Healthcare in India

Microsoft has bumped up the minimum requirements for upgrading to Windows 11. As per Microsoft their justification is 3-fold

Security: Windows 11 requires hardware that can enable protections like Windows Hello, Device Encryption, virtualization-based security (VBS), hypervisor-protected code integrity (HVCI) and Secure Boot. The combination of these features has been shown to reduce malware by 60% on tested devices. To meet the principle, all Windows 11 supported CPUs have an embedded TPM, support secure boot, and support VBS and specific VBS capabilities.
Reliability: Windows 11 will now be in a supported and reliable state. By choosing CPUs that have adopted the new Windows Driver model and are supported by our OEM and silicon partners who are achieving a 99.8% crash free experience.
Compatibility: Windows 11 is compatible with the apps you use. It has the fundamentals of >1GHz, 2-core processors, 4GB memory, and 64GB of storage, aligning with our minimum system requirements for Office and Microsoft Teams.

IT hardware asset refresh cycles in India are not driven by change of operating systems requirements. As many of the old desktops and laptops will not be meeting the minimum criteria laid out by Microsoft, many of the older systems will be running on Windows 10 till they are refreshed in healthcare and their consumers. Let’s understand, Indians don’t buy new phones or desktops and laptops every year because there is a new model (as Apple assumes it to be).

I will continue to add over here as I come across the good, the bad, the ugly about Windows 11 as I test the OS futher.

Statutory Disclaimer: folks wishing to download it can do so from the Microsoft Insider website. However, people other than developers are highly recommended not to download the build as of now. This is because such early beta testing versions are full of bugs that are only ironed out as and when beta testers report them to Microsoft.

Healthy Financial Relief Package for People’s Health

Financial Relief Package by Finance Ministry

Background

Last week, India’s Finance Minister announced a slew of financial relief to the stimulate growth and improve the healthcare infrastructure of the country which has been affected badly by the second wave of Covid. The package worth INR 0.62 million crores can be sub divided in three broad themes:

Those that improve the financial liquidity through a guarantee. The impact will depend on how much money is borrowed through this route. The lower interest rate charged which can be 2-3% less than the normal rate will help to lower the cost of funds. It needs to be seen if such funds are taken for investment or for repaying old loans.
Provide direct relief for the weaker sections which will benefit the recipients.
Initiate medium terms reforms that will help farm productivity, exports, power sector and manufacturing.

This blog is about the healthcare sector relief measures announced and my comments and feedback on the announcement

My Analysis for Healthcare Sector Measures Announced

The presentation from the Finance Minister is in the link below. Here are the summary of the measures announced and the comments on the same:

Announcements engendering additional fiscal cost above the Budget FY22 numbers	Comments/Remarks/Feedback
Additional spending on health : Total amount: Rs 23,220 crs (of which Centre’s share is Rs 15,000 crs)The focus is on children and paediatric beds, increase ICU beds, oxygen supply, enhance testing facility among others	Welcome policy measure
Additional Food grains (already announced) In the wake of the second wave of COVID- 19 pandemic and to ensure food security to vulnerable, 5 kg food grains to be provided from May – November 2021	Food security and nutrition to the vulernable section of the society will assist in health and well being and reduce susceptibility to Covid and other infections due to malnutrition
Free Tourist Visa for first 5 lakh travelers with a total cost of Rs 100 crs	There could have been a Visa Fee waiver for the tourist visiting India for Medical Tourism
Additional outlay for broadband connectivity to each village under BharatNet PPP Model for expansion and upgradation in digit connectivity	This will give a boost to the National Digital Health Mission and private sector digital health enterprises in India
The PLI scheme for Large Scale electronics manufacturing has been extended by 1 year till FY26	There should be an exclusion clause for the innovation based enterprises for health sciences which are developing products and technologies for replacing Chinese/imported products
Announcements engendering increase in contingent liabilities/ Announcements engendering increase in contingent liabilities/ capital infusion	Comments/Remarks/Feedback
Loan Guarantee Scheme for COVID affected sectors aggregating Rs 1.1 lakh crs (Rs 50,000 crs for Health and Rs 60,000 crs for other sectors) Focus on guarantee cover for “expansion” and “new projects”Maximum loan amount of Rs 100 crs for a duration of 3 yearsInterest cap: 7.95% (For Health); 8.25% (For others)Guarantee cover: 50% (For expansion), 75% (For Others)	This is part of the overall investment required by the healthcare sector to match the global norm of 3 beds per 1000 people. This is in the right direction. The new trend in healthcare infra post Covid is not to build the large hospitals but smaller units. Also where is the manpower to run these new facilities set up under this scheme?
Enhancement of the Emergency Credit Line Guarantee Scheme from Rs 3 lakh crs to Rs 4.5 lakh crs	Positive for the healthcare operators who are cashflow strapped
Credit guarantee scheme for Micro Finance Institutions aggregating Rs 7,500 crs Guarantee to be provided to scheduled commercial banks for providing loan to MFIs for on-lendingMaximum tenure : 3 yearsInterest rate cap from loans from banks : MCLR + 2%Interest rate on loan from MFIs: 2% below maximum limit prescribed by RBI	Positive for the healthcare MSMEs who are cashflow strapped
Financial support for Registered Tourist Guides Guarantee cover : 100%Limits: Rs 10 lakhs for agency and Rs 1 lakh for tourist guide	There could be some investment for skill development for nursing assistants who accompany tourists during their convalesce period while tourism What about the airline sector which is suffering and not been able to provide connectivity as before Covid

New Streamlined Public Private Partnership (PPP) Policy

Recognizing the current process for approval of Public-Private Partnership (PPP) as long and cumbersome, the centre has announced the formulation of a new policy for appraisal and approval of PPP proposals and monetization of core infrastructure assets. This will help speedy clearance of projects. As I have been writing, PPP in healthcare has not taken off ever since I was on the Planning Commission’s PPP in Healthcare Regulatory Committee. These issues have to be ironed out as Government after Government have tired to draft policies for assisting PPP in healthcare sector, but there is not enough private sector enthusiasm and participation at a large scale to make PPP in healthcare a thumping success. Let’s wait for the fine print of the PPP policy that will come out.

Summary

The Finance Minister has forgotten that there is dire shortage of skilled front line medical workers. With the Covid pandemic, many youths are not forthcoming to join the healthcare sector. Measure could have been announced to make the healthcare sector more attractive for the youth of India to join. It looks like the stock markets have not give a warm response to these measure announced by the Finance Ministry and is running on its own steam.

Disclaimers: We have not used our proprietary algorithms for this blog

Privileged to be Part of World’s Largest Vaccination Drive on 21 June 2021

KK's Vaccination Experience

Introduction

I went for my first vaccine shot yesterday (21 June 2021). Little did I knew that I would be amongst the first 2000 of the innoculatees on the Covin App (I am informed that there were 2000 vaccination centers that logged in the Covin App at 9 am. I was numero uno at Wockhardt Bombay Central Center) of the over 8.6 million citizens who were vaccinated yesterday. This is a world record of sorts. This blog is about two issues. First, my experience at such a world record shattering vaccination drive and second, my experience of the vaccine shot dispelling all the negative experience, misinformnation and bull shit (one politician has voiced his concern around the vaccine containing the serum of cow or calf. It would have been slightly better if it was a chimp) around the Covid vaccination experience that Indians have voiced on the social media.

The Largest Vaccination Drive in the World

Acting on Supreme Court of India’s directive, Covid Vaccination was made available to all citizens of India, above the age of 18, free of cost from yesterday by the Central Government. While the policy decision is being welcomed by all the States and some of the political parties, managing the strategy, co-ordination and logistics is a herculean task. I must congratulate all the teams involved in the State and Central Government for their world record shattering performance. Let me explain the magnitude. There are 137 countries in the world which have a population of less than 8.7 million. See Chart. Or in another words, a certain politician governing New Delhi who promised to vaccinate the whole of Delhi in 2 months provided vaccines are made available by the Center and a prescriber of odd/even rule, would have completed vaccinating all the males of Delhi in one day!

India's Vaccination Drive on 21 June 2021 — India’s Vaccination Drive on 21 June 2021

My Experience with the Vaccination Drive

As I had opted for Covaxin (see below) and was on the priority list of the Maharashtra Education and Drug Department (MEDD) of medical workers in February 2021. Due to my trip to Bangalore, I had to miss my slot. For four months, there was no supply of Covaxine first dose at their designated vaccination centers in Bombay. The slots which opened up in private hospitals filled up quickly. Hence after a wait of 4-months, I was able to get the booking for 21 June 2021. The Cowin App has its own issues and crashes as millions are simultaneously trying to book a slot across the country. There is similar issue at the vaccination centers early in the morning at 9 am when all the centers simultaneously log in to the Cowin site. After a few minutes, the site starts accepting the innoculatees information and the process begins. The rest of the process and protocols are smooth.

Why I went for Covaxin?

As I already had a Covid/SARS like infection in 2012 and the experience of all the doctors working for us with the Covaxin, I preferred to go for Covaxin instead of Covishield. The key differences between the two are given below:

Covishield vs Covaxin – As per Mohfw.gov.in

Covishield details

Intramuscular vaccine
Developer – Developed by the Oxford-AstraZeneca and manufactured by the Serum Institute of India (SII).
Vaccine type –
- Prepared using the viral vector platform
- Contains harmless chimpanzee adenovirus – ChAdOx1 incapable of infecting the receiver
- Teaches the immune system to prepare a defence mechanism against the active virus.
- Similar technology has been used for developing a vaccine against Ebola
- Doses required – Two-dose regimen
Efficacy – A good result of 81.3% efficacy rate, as per Medical News Today.

Covaxin details

Intramuscular vaccine
Developer – Developed by Hyderabad-based Bharat Biotech International Ltd in association with the Indian Council of Medical Research (ICMR) and the National Institute of Virology (NIV).
Vaccine Type –
- Inactivated vaccine
- Developed with Whole-Virion Inactivated Vero Cell-derived technology
- Containing inactive viruses, Covaxin teaches the immune system to prepare a defence mechanism against the active virus.
- Similar technology has been used for developing vaccines for various diseases like Seasonal influenza, Rabies, Polio and more.
Doses required – Two dose regimen
Efficacy – A good result of 80.6% efficacy rate, as per Medical News Today.

Post Vaccination Experience/Side Effects

As per the typical side effects mentioned for Covaxin, here is the summary of what I experienced

Injection site pain or swelling or redness or itching Stiffness in the upper arm Weakness in injection arm Body ache Headache Fever Malaise Weakness Rashes Nausea Vomiting	Yes No No No No No No No No No No
Others symptoms that I experienced	First urine after vaccine (2 hours later) was very brownish. Kidneys were cleaning up the mess

This morning I woke up as per my normal timing and even went for my daily walk (completed my 6000 steps target) https://www.linkedin.com/posts/kapilkhandelwal_beating-the-vaccine-jab-side-effects-to-the-activity-6812945231244333056-Qvxm I was in office today and worked through the day without any symptoms of any side effects (a slight head ache in the afternoon post lunch). It’s 12 midnight and I am still working on posting this blog.

Should Indian Government TikTok Twitter out?

Jack Dorsey in India 2018

Preamble

In November 2018, I attended a session with Jack Dorsey, the founder of Twitter organized by the ORF foundation at the Taj Lands End in Mumbai. During the session I vividly remember Jack Dorsey talking about his vision off Twitter has as a platform to provide the voice to the people of the world for better democracy and better governance of democracy. A strong, functional democracy relies upon the public’s access to high-quality information. However, the very next day, the social media was abuzz with a picture of Jack Dorsey demonstrating his hatred towards Hindu Brahmins. That’s not the beginning of Twitter’s bias to a certain religion in India. Raheel Khursheed who headed Twitter in India till 2018 also drew some backlash from several groups, who accused him of having associations with Kashmiri separatists, and were upset over Khursheed’s criticism of democratically elected PM of India Narendra Modi’s for his leadership and scraping unethical status of Kashmir. He is formally accused of not being neutral and fit for the job by blocking accounts of prominent Indians. During his tenure he had issued blue ticks to several prominent people of the anti-national Azad Kashmir Movement.

However we have seen the words and actions of Twitter not only during the election off 2019 but also after that. It seems that Jack Dorsey’s agenda in India is suspect and he does not walk his talk. The recent lock loggerheads with the Indian government and Twitter seems to indicate that Twitter itself is perpetrating religious hatred and other vicious political agenda in India. At the recent Parliamentary Committee meeting with Twitter it seems that Twitter doesn’t seem to respect the laws of land of India and countering it that it has its own policies that it follows in India. Twitter’s leadership and team in India actions are only heightening political polarisation, diminishing public trust in institutions, and further undermining the democracy in India which needs to be curbed. In the recent wake of events of Twitter with the Indian Government and its actions not just in India but also around world, it’s time that that we tic tok Twitter out for its agenda on impacting India’s internal peace. Last year when the Chinese invaded India at the Galvan valley, India retaliated with banning of Chinese apps including Tik Tok because of security threat.

How Important is India for Twitter

India is the third largest base for Twitter in the world after USA and Japan. Twitter may lose a approximately 55 million users from India if banned. Therefore, Twitter would have to tow the line of the Indian Government. Currently, Twitter has lost its safe harbour legal status in India and would face more legal cases in India if it continues to operate and be biased towards certain political and religious ideologies in India. Getting banned in India would be a huge set back for Twitter’s international user base. Many countries such as China, North Korea, Turkmenistan, Myanmar, Nigeria and Russia have restricted or totally blocked Twitter in their country.

Oxford Internet Institute has monitored the rapid global proliferation of social media manipulation campaigns, which we define as the use of digital tools to influence online public behaviour in its recent report has found that organised social media manipulation campaigns are now common across the world. It identified in 81 countries in 2020, up from 70 countries in 2019. The map below shows the global distribution of these 81 countries, marked in dark blue.

Global Social Media Manipulation by Country

Between January 2019 and December 2020, Facebook removed 10,893 accounts, 12,588 pages and 603 groups from its platform. In the same period, Twitter removed 294,096 accounts, and continues to remove accounts linked to the far right.

Atma Nirbhar of Twitter – The Koo

Government of India has started endorsing Koo as a microblogging platform as an alternative to Twitter. Aprameya, the co-founder of Koo was also the co-founder of Taxi For Sure (now Ola). He had worked in one of my healthcare venture where he was moonlighting to start up Taxi For Sure. I had been one of the early stage investor in his venture then. He is focused to making Koo a success in India and already entered Nigeria after the ban of Twitter. Recently, Koo has raised USD 10 mil to build and expand the reach of their platform. Last evening, I had a call with their team and provided them with points for enhancing their product from the user point of view. I am sure that Koo would emerge in moving the 55 million users of Twitter in India on their platform as it grows in popularity.

Disclaimers: My Koo handle is IamKK. My main go-to social media platform is Linkedin where I am amongst the first 0.25 mil users and I am still going strong on Linkedin. I have suspended my Twitter handle 3 time in the past and hate the constant ‘We Miss You’ emails from Twitter every week.

A Tale of Two Medical Systems: Revolution Ahead?

Background

The current spat between the Indian Medical Association (IMA) and Baba Ramdev of Patanjali is like a modern version of Charles Dickens’ famous novel A Tale of Two Cities, that led to the French Revolution. The Federation of Resident Doctors’ Association (FORDA) has decided to execute a Black Day on the 1st of June against the controversial statements made by Baba Ramdev against Allopathy and the video shared by him on Twitter. These activities by the allopaths are only goes on to strengthen the value proposition of Alternative Therapies and Indian Traditional Medicine in the minds of the consumer and view IMA and the Allopaths with suspect. The louder the decibel in media the faster would be the Medical Revolution against Allopathy.

Having led the world’s first Integrative Medicine Partnership at the Institute of Ayurveda and Integrative Medicine (IAIM) and served their Advisory Board, I would like to request both sides to set aside their differences and work towards delivering innovative integrative solutions between the two systems for the consumers before it is too late that the consumers bring about a Medical Systems Revolution. Here are some of the points and issues that I would like to lay down for the jury of the consumers to judge and adjudicate.

Investor Perspective: Larger Flow of Investments in Indian Alternative Therapies

Investors and companies invest in opportunities where they see money and value proposition for the consumer’s needs. Let’s understand from the consumers point of view the world over which is becoming more and more skeptic of the allopathic system and their preference towards Indian Traditional Medicine or Alternative Therapies and Medicine for treatment and wellness. Our annual Healthcare and Sciences Heatmap 2021 Investment Heat Map | Kapil Khandelwal (KK) every year is measuring the investment in different sectors including Alternative Therapies. Our conclusion is that Indian Alternative Therapies and Medicine have been gaining wider consumer acceptance and affirmation leading to increased investment activities. Apart from the shift from Allopathy towards Some of the key drivers for investment in this sector are:

Economic growth and rising incomes
Rising per capita expenditures on healthcare products
Low cost of production
Improvements in the distribution network
Increase in accessibility in both urban and rural regions
Awareness programs and subsidies
Rise in non-communicable and chronic diseases

It’s not Baba alone who is the key enemy of the allopaths As per our analysis over 60 corporate groups, pharma and consumer companies, including Multinational Companies (MNCs) have diversified into Indian Alternative Therapies and Medicines with an overall investment of over INR 80000 crores. Moreover, as a boost to this sector, the government recently introduced an economic stimulus package under the Atmanirbhar Bharat and has allotted INR 4,000 crore to the sector for promotion of herbal cultivation. The move aims to cover 10 lakh hectares (24.7 lakh acres) under herbal cultivation over a period of two years

Defamations Cannot Muffle Consumer’s Choice

Nearly 75 per cent of Indian households already use some form of Ayurveda to treat a variety of problems. The writing is on the wall for Allopathy during the current Covid Pandemic, when those who were the forbearers of medical treatment had no answers to treat Covid and the consumers themselves had to search for home made solutions to build immunity and treat mild forms of the infections themselves. Rather than take the prescribed Allopath Doctor’s prescription of artificial vitamins, zinc and tablets, etc. consumers preferred gilroy, kali mirchi, methi, nimbu pani, turmeric, kada, etc. Where was IMA hiding in 2020 with a mass campaign to debunk all these stuff that the consumers were ingesting based on Indian Alternative Therapies and Medicines. I am sure with the current spat between the Baba and IMA allopaths, pharmaceutical companies, doctors and others seem to fear that their dominance is at stake is very apparent.

Indian Alternative Therapies and Medicine are Learning from The Chinese Traditional Medicine

Indian Traditional Medicine and Chinese Traditional Medicine are equally older than Allopathy. However, Chinese export over 5 times more in value their traditional medicines to the world than the Indians. The Chinese were able to lead this sector globally by publishing and sponsoring enough research on quality, effectiveness and safety of their traditional medicine. Moreover they were able to invest aggressively in research in combining their traditional medicine with western medicines into integrative medicine. Why is there no spat between Chinese and the large pharma companies of the West?

India is learning from the Chinese catching up by investing heavily on:

Product innovation is the core to the healthcare solutions that consumers are seeking against allopathic medicine
Study Ayurveda and Alternative Therapies by using the methods and means of western medicine. (As a side note: I know for sure that the same Baba recruited one of my ex-colleagues who was from allopathic drug discovery having worked in US and India to set this up at his Patanjali Research. I am sure he has some aces up his sleeve when he is challenging IMA in the courts rather than just tendering an apology.)
Innovate the basic theory of Indian Alternative Therapies. Different from the western medicine which starts from the molecular biology, Ayurveda is researched and developed based on systematic biology of Kafa, Wada, Pitta. Clinical trials and research is strengthening this potential
Big Data solutions into health informatics to empirically proving where Allopathy stops and Ayurveda starts. At IAIM, there is a large initiative to collect data to prove what limits Allopathy and where Ayurveda benefits the consumer.
Integrating genetics with the systematic biology of Ayurveda leveraging the big data. Apart from the phenotype, genotype and other information is strengthening innovation in the products.

So, my concluding comment on this is spat between Ayurveda and Allopathy is that it’s a lose-lose for both not just in India but internationally giving the Chinese Traditional Medicine a chance to grow its pie internationally. The win-win solution for both the sides is not to prove who is right or wrong on their claims and counter claims and defame both the systems of Medicine in India but to work out an integrative medicine solution between the two. Else we are heading down to the wire on a medical revolution like the Tale of Two Cities dictated by the consumers choice and preferences.

Ask What You Can Do for Me, My MP and MLA

Vaccine Politics and Funding

Background

India is the world’s leading vaccine producer. However, a lot of discussions in the media by the politicians blaming the Center for the shortage of vaccines has been doing the rounds. One politician even went to the length of sharing the ‘formula’ of the vaccine to other so that they can manufacture the vaccines. A lot of the noise on the increased supply has been creating smoke screens and mirrors to deflect the current mismanagement and blame game between the center and the states for the second wave of Covid. India had set up its vaccine strategy which was

Phase 1: Healthcare and other front-line workers, while gradually opening it up to the 45 plus age group.
Phase 2: Vaccination for all persons above the age of 18 years from 1st May 2021 under phase 3 of its vaccination
From 1st May, under a liberalised & accelerated phase, vaccine manufacturers would supply 50% of their monthly released doses to the govt and would be free to supply the remaining 50% doses to the state govts. And in the open market at a pre-declared price. States are empowered to procure additional vaccine doses directly from the manufacturers. So far, many states have placed their orders directly with the manufacturers and most states have decided to provide free doses to adults. That said, vaccination will continue as before in govt vaccination centers, providing free of cost to health care workers, front line workers and all people above 45 years.

In between, Investeq, a leading financial analyst states in its report Vaccine Supply Modelling for India: Supplies set to improve, Foreign Vaccines to make a big difference Vaccinations: Total spend of $8 billion on Covid vaccines for India in 2021: Investec, Health News, ET HealthWorld (indiatimes.com).

Why is this noise and panic been created? First the politicians, then some equity investment analysts and then even some scientific journals like the Lancet have started voicing this issue of shortages of vaccine all-together. Is this a foreign vaccine lobby playing to put pressure on India to buy their vaccine as India is one of the biggest markets that they cannot ignore as demand saturates in the US? The second issue is why should states or their politicians not fund the vaccine costs for their constituencies?

Indian Vaccination Drive versus The World/China

The chart below shows that India has started out early and is better in its vaccination drive than 90 percentile of the countries of the world.

Let’s understand that India is one of the most inhabited countries of the world. Their nearest neighbour China does not even provide information on their immunization status and yet report near zero Covid cases these days. China has procured for only 13% of its population while India 18% of the population so far.

Country	Vaccine	Amount (USD Mn)	Dosage	Population Covered (Mn)
India	AstraZeneca (Covishield)	417	2	209
	Covaxin	80	2	40
	Sputnik V (Russia)	3.15	2	2
Total			500 Mn	250

China	Sinopharm	177	2	89
	Sinovac Biotech	118	2	59
	CanSinoBIO	30	1	30
	Anhui Zhifei Longcom Biopharmaceut	18	3	6
Total			343 Mn	183

Asking our MPs and MLAs to Pay for the Vaccination

India has already administered 185 million doses. The current split is 166 million of Covishield and 19 million of Covaxin. There are around 315 million doses that has already been paid for. This would cover around 25% of our population. We will need another INR 75,000 crores to fund the immunization program to reach the Covid herd immunity. Now comes the political issue that some of the States want to deliver the vaccine free of costs to all in their states and do not want to pay or have the adequate budgets. Therefore the issue of political blame game between the Center and the States. If you see the current vaccination drive across the districts, some have a higher rate than others. When we dissect the same information as per Parliamentary there is a surprising revelation. Some of the Parliamentary Constituencies has performed better and are not correlated to the district coverage of the immunized population.

So why not decentralize this process of vaccination to the grassroots to the elected MPs and MLAs for their electorate so that all the politics of vaccine supply is nipped in the bid. We have 543 MPs and 4215 MLAs in India. An MP gets INR 5 crores while the MLA get INR 2 crores per annum to be spent on their in their constituency for the local development. This comes to INR 2715 crores per year from Lok Sabha MPs and INR 8430 crores per annum by the State MLAs. Over 5 years this amounts to INR 55725 crores. History shows that hardly 25% of this money is spent. As Covid is a black swarm event for the country, the next 5 years of the MP and MLAs Local Area Development Spend is advanced right now so that they can procure the vaccines for their constituency electorate and get them vaccinated as per the vaccination strategy announced. This will also ensure that the blame game between the parties and the Center and State is put to rest and the elected representative are put to work to deliver the results of the vaccination to their electorates.

Health Economics of Tomato!

Tomato Versus Zomato

Background

Finally one of the unicorns in the foodtech space has turned profitable. Zomato is going public with its IPO. With public money it will raise, will also come the public scrutiny of what it does to the public and society at large. Here are some of the data from the Zomato prospectus that summarizes the scale of its business model and its impact on Indian society.

Total reach of Zomato is in 526 cities
It has around 350,000 restaurants listed
Around 41.5 million people visit its app or website in a month of which around 11 million people place orders
It make around 400 million food deliveries in a year (averaging around 3 deliveries a month per user who places orders on Zomato)
Zomato earns around INR 90 per order of food. Their gross order value in 2020 was around INR 230 (increased substantially during lockdown)
Around 160,000 delivery partners are employed in the 526 cities averaging around 300 delivery partners for 3 shifts on 24/7 operations
Industry experts say that the delivery partners drive around 6 kms (during lockdown it was 7.5 kms) from their point to restaurant and the user delivery location to meet the time commitments of 30 minutes. The radius for the restaurant to the user comes to around 5 kms (during lockdown it was 6 kms)

I am assuming the metrics for Swiggy would be around the same metrics as Zomato. Both the Food Delivery Apps must be providing tremendous time and place value to its loyal consumers but at what economics. Let me debunk this now.

Economics of Food Delivery Apps in India

Assuming 800 million food deliveries with an average radius of 5 kms, the total distance traversed would be around 4 billion kms in a year. This is equivalent to travelling between earth and Neptune. That’s a long distance in terms of the food delivery only! The cost incurred for each food delivery was INR 50 per trip. The total cost incurred and cross subsidized by the Food Delivery Apps amounts to INR 4000 crores in 2020. This costs 10 Mars Missions from India in a year!

Now let’s turn to the carbon emission of the 2-wheelers used by the delivery partners. Assuming 4 billion kms travel would require around 80 million litres of petrol for the bikes in a year. They would release around 186.16 million Kgs of carbon in the environment assuming all the bikes are 4-stroke engines. That’s not a great environmental impact! I am not assuming the impact of plastics and other packaging material used by the restaurant partners and dumped into our cities dumps every year as this is not the responsibility of the food delivery apps but the consumer and the restaurant partners as a choice.

On an average INR 230 per order would provide around 1000 calories worth of food assuming all is healthy food ordered. The impact that the consumer feels by getting time and place value is hugely negative. So far these companies doing food delivery were not in public scrutiny but the reality is very negative. Are we creating Tomatos out of the Zomato’s consumers?

Not healthy for the Food Delivery Apps Companies, their investors or their consumers.

Health Economics of Tomato!

Now lets focus on the health of the tomatos who order food. I am assuming that they are busy enough not to be able to cook or step out to the restaurants and are intelligent enough to be aware of their health risks and well being and are only ordering bunk food (anti thesis of junk food) as nobody likes to eat healthy food which is not so delicious to the taste buds. At INR 230 per average order they are consuming around 1000 calories of food. As per ICMR the recommended daily calorie intake is 2100 Kcal for urbanintes. So the average order on food delivery apps is equivalent to a single meal which is around 800 kcal .

Let’s turn to the fitness. WHO recommends that a fit person should walk 10000 steps a day. This is around 8 kms a day. The 80 million consumers of the food delivery apps (Zomato and Swiggy divided equally) would be walking around 230 billion kms in a year. This is 60 times more than what the food delivery partner of these apps travel in a year. So, the question is, what is the health risk of those who order food on these apps really walking their quota of daily distance and prefer instead the meal right on their doorsteps?

Based on the penetration of cities of food delivery and the health risks penetration, the Tomatos are equally penetrated in states where the health risks are fairly high and shows a very strong correlation to food to be served at their doorsteps.

The remedial health issues and what the public subscribing to the IPO of Zomato should be inquiring into is a subject matter of another blog which may come some other time post IPO.

Disclaimers: I do not have Zomato and Swiggy Apps installed on my mobile phone and do not order any food from the food delivery apps. I am not an interested party in pooping the party of Zomato’s IPO.