Covid Apartheid-Complete State-level Nationalisation of Hospitals?

Covid Apartheid

Background

There has been news floating on the WhatsApp on complete takeover of private and charitable hospitals by the Maharashtra Government. MAHARASHTRA TAKES CONTROL OF PRIVATE COVID HOSPITALS, FIXES DAILY RATES – The Daily Guardian. The article was published on May 7, 2021 and quotes Sudhakar Shinde, CEO, State Health Guarantee Society saying, “We have issued this order as per the suggestion of both the ministers.” This maybe a fake news as Sudhakar Shinde succumbed to Covid on Oct 10, 2020. IAS officer Sudhakar Shinde passes away in Pune due to Covid-19 | Hindustan Times

However the issue here is for debate is: Should the State Governments Nationalise Hospitals? Second issue here is the alleged hospitals charges being imposed by the private hospitals and how do we deal with it?

Private Hospitals Take Over in 2020 Wave one of Covid by State Government

As per the announcement last year in April 2020, 80% of the beds of the private and charitable hospitals in the state were taken over by the State Government for managing the first wave of Covid. As per the arrangement, the private and charitable hospital owners were free to charge their prices for the remaining as per their operating costs and charge masters. The citizens had the choice of going for treatment to the private sector on their own or request the State Government to allocate a bed in any of the hospitals in the state whether Government or Private as per the rates announced by the State Government.

Covid Apartheid-The Consumer Right of Treatment if They Choose

Last year a famous Indian Celebrity and Film star tested Covid Positive and was admitted himself and his family members to a private hospital in Mumbai. Amitabh Bachchan tests Covid-19 positive, admitted to Nanavati hospital (indiatimes.com). He had not approached the State Government for bearing his treatment costs. There was no negative media outbreak on how exorbitantly the celebrity was charged for his treatment and whether the private hospital in question chose to offer their services on their quota of beds under their management to the said celebrity free of cost, or at subsidized costs or at full price. Had the said celebrity in question chosen to request for his treatment to the State Government, he may have been admitted to Cooper Hospital or any other hospital facility that the State Health Officer (SHO) deems fit to allocate. But the said celebrity choose to deal the situation on his own and contract with the private hospital at a price which is agreed between the two parties and is mutually binding upon between the two parties. Similarly, if citizens opt for private hospitals on their own will, why should there be a hue and cry that there is a differential of prices between the State Government mandate prices for the beds being managed by the State Government in the private hospitals leveraging their infrastructure and staff and the prices being charged to the celebrities and those who can afford to pay the full price and exercise their right to treatment at a certain private hospital exercising their option to pay out of pocket or through their health insurance.

I call this Covid Apartheid. Therefore there should not be fake news escalations about the exorbitant charges. Covid emergency situation is like an SOS as like a heart attack. You have to either treat the person or if let untreated without medical intervention the person dies. So it is catastrophic. If a certain private hospital charges INR 10 lakhs for an open heart surgery and the State-level prices under various healthcare schemes is as low as INR 60,000 (in Karnataka), the real cost of which is much higher as the State Government is cross subsidizing through the tax payer’s money and budgetary support, the media should not make a mole out of nothing. It’s the choice exercised by the individual punting on his health and wealth. There cannot be an apartheid comparing the prices and the quality of services delivered. So is the Covid. The media should stop amplifying negative news about the pricing of services in the private hospitals. They are comparing apples and oranges and want an apartheid on the ability to pay and enjoy different standards and services between different classes and masses.

Dealing with Exorbitant Prices by Private Hospitals

There have been mechanisms in place for any adverse and or exorbitant prices being charged and how to escalate and settle these issues whether it is out of pocket or through a Third-Party Administrator (TPA) of the Healthcare Insurers. Let us understand that no private sector hospital in this country wants to profiteer. I agree with the media that there are rogue private hospitals who may have out of greed charged exorbitant prices playing on the situation. I too was a victim of such a private hospital when I was suffering life and death situation on a Covid like symptoms way back in 2012. However, I settled the issues through various redressal mechanisms in place including the malpractice by one of the treating doctor of the private hospital.

State Nationalisation of Private and Charitable Hospitals

Let us understand it cost over INR 1 crore to set up a hospital bed. If the State Government takes over 80% of that capacity and assuming that the state reimburses INR 10000 per day for those beds it has taken over, it would take around 6-years for the hospital to break even on their capital and operating costs. The hospital operator has bank loans and other liabilities to settle for the risk they have taken to set up the facility to treat their out of pocket and insurance customers. To offset these liabilities and daily losses on the State managed beds in their hospital, the private operator has to offset that from the remaining 20% of the beds it is free to charge whatever prices. The State Government has not taken over the proportionate liability of 80% of beds taken over. If you do the maths, it would require the private operator to charge anywhere from INR 45,000 to INR 90,000 per bed per day just to cover their costs.

We know the healthcare outcome of private sector hospitals and government hospitals. Therefore, there is a price differential. Let me give you an analogy here which is a bit far-fetched. From tomorrow the State Government says that 80% of your private wealth management will be under the Private Sector Bank will be managed like Public Sector Banks (PSU). PSU banks deliver Hindu rate of return of say 3%pa while the Private Banks deliver 15%pa on your money charging 3% fees for the wealth under management. So now you will get 3% pa return on 80% of your wealth banked while 20% of will deliver 15%pa. Will the media start writing that Private Sector Banks are earning exorbitant returns of 15%pa for the rich and the poor laborer who is banking and saving with PSU Banks is just getting 3%pa. Would you allow your personal wealth to be managed like a PSU Bank? Similarly will you allow your health to be put into PSU Hospital hands if you value it? Its your call and there is a price to pay.

We know the outcomes of Bank Nationalisation of the earlier era. Do we need to subject the healthcare sector to state nationalization?

Should We Impose Complete Lockdown Now?

Background

Our Supreme Court has directed the Central and state governments to consider imposing a ban on mass gatherings and super spreader events. “We would seriously urge the Central and State governments to consider imposing a ban on mass gatherings and super spreader events. They may also consider imposing a lockdown to curb the virus in the second wave in the interest of public welfare,” the SC said.

Let us understand that the national lockdown in the first Chinese Wuhan Virus Wave was to create the requisite infrastructure and capacity to ensure that the country does not go into a crisis and the 7-day moving average (7DMA) of infection does not increase the stipulated doubling rate of 1 day. Moreover, the cost of lockdown to the economy for a single day of lockdown is around USD 6.0 billion (INR 45,000 crores approx).

In the second wave, the issues are different. We have our 7DMA of infections is much lower and the doubling rate is much higher. Moreover, as the immunization drive picks up, we will see the two parameters of 7DMA and doubling rate become even more manageable.

So the issue in front of us is, should we impose a complete lockdown and for how long taking cognizance of the Supreme Court directives.

How Far Are We From the Peak in this Second Wave?

In order to arrive at a predictable view of how long should India and its states go into a lockdown and even out the daily economic losses to the country, there are several parameters which we need to consider:

Second Covid Wave in 12 countries before India
Second Covid Wave Peaks in Different States and Cities in India
Covid Immunisation strategy

Second Covid Wave in 12 Countries before India

we can learn from the other countries which have gone through the second wave before India. Based on the learnings from these countries, our Central and State Governments can work out a formula to impose lockdowns and unlockdowns without hurting the economic activity in the country. The table below gives out the duration of the second wave (in days) and % of population that was infected during the Second Wave:

While it is pretty apparent that each country reacted to the second wave differently. The chart below shows how effectively did each of the 12 countries manage the second wave.

Spread of the Second Wave of Chinese Wuhan Virus

Mexico, Turkey, Israel has the second wave duration of less than 100-days, while Germany and Canada had a duration of over 200 days. The peak of the Second Wave was around 120 days (ie 4 months) as an average). The average population that was infected in these 12 countries was around 2.5%.

This is valuable information and analysis for us to predict where India is in the second wave.

Second Covid Wave Peaks in Different States and Cities in India

Maharashtra including Mumbai was the first state to begin with the Second Wave in India. It has already seen the peak and is around the global average of around mid-point of the 120 days wave (ie. 60 days). We will see India as a country peaking by mid-June 2021, unless we solve all the infrastructure and logistical nightmares which some cities like Delhi is undergoing.

WhatsApp Image 2021 05 04 at 08.40.09 — Analysis by IIT Kanpur Prof Manindra Agrawal

The other silverlining is that many other Indian cities are already in their peaks. An interesting analysis by IIT Kanpur Prof Manindra Agrawal shows.

Covid Immunisation Strategy

As I have already written, our Covid immunisation strategy needs to be reworked. It’s not the political compulsions and broad headlines. We need to immunize over 15% of our population by Mid-May 2021 which we have not yet achieved and most likely going to miss the target for the total duration of the second wave and the imposition of nation wide lockdown durations to recede.

Therefore, the opportunity costs for the country in reducing the duration of the lockdown in the second wave is huge provided we implement our covid vaccine immunization strategy and coverage astutely. Invest, invest, invest in immunizations and make it free for all as an incentive. The rest the statistics at the end to the lockdown will reveal.

No Courts in the World Bear the Economic Outcomes of the Country based on their Judgement!

In Search for An End(Demic)

The Coming of End(Demic)?

I have been speaking with cross section of folks over the last few days. Covid Command Center Officials, Health Ministry Officials, Our Doctors, some experts across the world to understand what we are calling the ‘Second-Wave’ of Covid. Many social media posts, new reports are completely confusing the masses now that a few places have now imposed the so called ‘Second-Wave of lockdown to manage the situation. Let me dissect the situation and ally some of the misconceptions and fake news going around. So here are the issues I am hearing

With increased vaccination rate, there is increased covid infection rate
Are the spikes in coronavirus cases due to more coronavirus testing?
There is very high incidence in Maharashtra and Delhi and will spread across the country after the Kumbh Mela
There is shortage of beds, medicines, vaccines to meet the current wave
What should I do?

So is there an End(Demic) in sight to this Covid?

With increased vaccination rate, there is increased covid infection rate

This is totally incorrect. India had administered 111 million doses of vaccine and covered about 7% of the population with one dose. So there is no correlation between vaccination rate and the spike in the Covid Cases in this wave which is due to the following reasons:

A new double mutated strain of SARS CoV2 has been detected in second wave. This is in addition to Brazilian, South African and UK strain. This new mutated virus has the potential to skip the immunity and even vaccine. This is the reason for re-infection cases & cases among vaccinated people.

It is more infectious & affecting younger population of 18 to 45 years group and this group is “super preader”.
By passing RT-PCR – new COVID cases may not be detected by routine RT-PCR test.
R- value is increasing. This is reproductive value which tells one positive person will infect how many others.
Public carelessness & lack of adherence to COVID appropriate behavior (mask, hand sanitization, social distancing & vaccination).
Pandemic Fatigue

Are the spikes in coronavirus cases due to more coronavirus testing?

No. During a surge, the actual number of people getting sick with the coronavirus is increasing. We know this because in addition to people testing Covid positive, the number of symptomatic people, hospitalizations and later, deaths, follows the same pattern. Therefore there is a correlation.

There is very high incidence in Maharashtra and Delhi and will spread across the country after the Kumbh Mela

It is true that Maharashtra has the highest number of Covid positive cases in India at the moment. However other cities and states are quickly catching up with newer cases showing up with a lag effect. The latest map show the spread. (see the map below)

Covid Wave 2 Clusters and Lockdowns and Restrictions Imposed

There is shortage of beds, medicines, vaccines to meet the current wave

Yes there is a lag in the capacity creation and supply with this sudden surge in this wave. Many of the temporary facilities which were lying vacant as the Covid cases went down were utilized for Covid Vaccine Centers. They have now been been used for the treatment and isolation of Covid patients in this wave. On the supply of the injections, many of the manufacturers had now produced these medicines as the demand for them had reduced since October 2020. They are now ramping up production of Remdesivir and this should be available by next week. On the vaccination front, the politics still continues, while a third vaccine from Russia is being given emergency use approval and should also be available by the end of this month.

What Should I do?

Authorities, doctors, clinics and hospitals recognize that more waves are likely to occur. Here’s what you can do now:

Continue to practice COVID-19 precautions, such as physical distancing, hand-washing and mask-wearing.
Stay in touch with local health authorities, who can provide information if COVID-19 cases begin to increase in your city or town.
Make sure your household maintains two weeks’ worth of food, prescription medicines and supplies.
Work with your doctor to ensure that everyone in your household, especially children, is up to date on vaccines, including your Covid Jab

So is there an End(Demic) in sight to this Covid?

So how will these Covid Waves End? Do we see any endemic in sight? Throughout the pandemic, health experts have tended to set the magic number for herd immunity between 50% and 70%. Some of the data coming in shows that

Presumed ‘herd immunity’ is ‘the combined value of infections + vaccinations as % population > 60%

Let me explain the above formula:

Herd immunity is a public health term that refers to the fact that, when enough people in a community have immunity from a disease, the community is protected from outbreaks of that disease. More than 60% of the population needs to be immune to the coronavirus before herd immunity can work. People might be immune from the coronavirus, at least for a while, if they have already had it, but we don’t know this yet. Researchers are currently trying to determine if, and for how long, people are immune from the coronavirus after recovering from Covid. If it turns out that immunity only lasts for a while, people could get Covid again, resulting in even more death and disability. This is the lesson from this wave.

Our country needs to speed up the immunization rate which may take months before we see an end!

Yeh Hai Bombay Meri Jaan, Saab Hain Covid Se Paresaan!

Mumbai Covid Second Wave

Preamble

Earlier in the last decade I was part of the Healthcare Committee of Bombay First which was assisting the Maharashtra Government in the Mumbai Masterplan 2045. One of the key concerns and recommendations made by the Committee was building the healthcare infrastructure for the city, Mumbai lags behind in beds per 1000 population with several key peer Indian cities such as Gurgaon, Delhi, Chennai, Hyderabad and Bangalore. Alongside the shortfalls in hospital beds, there is also a shortage of healthcare professionals, equipment and infrastructure needed at various levels in the healthcare delivery supply chain. The second wave of Covid in the city has once again proved that the healthcare delivery to the Mumbai residents is again in short supply, be it beds, healthcare workers or vaccines. With the crisis looming large, the city is on the brink of a long second lockdown. Without delving into the politics and finger pointing, I want to point out the gaps.

The Gaps in Healthcare Delivery and Covid Response in the City

Hospital Beds Shortage in Skewed Distribution Geographically

In Early 2000s, Mumbai has around as per the Bombay First report, 24,984 beds. As per the recent Mumbai Municipality report, there are 24,039 beds in 2021 in Mumbai. In other words, hospital beds have actually reduced over the last 20 years in Mumbai. It is obvious that many nursing homes have shut down as the doctor/owner have found it lucrative to monetise their nursing homes to commercial real estate. As a result, Mumbai is amongst the worst cities in India with a bed to population ratio of 1.17 beds per 1000 (as against the WHO norm of 3 beds 1000). It was 1.63 beds per 1000 in 2000. Moreover, these beds have been unevenly distributed in Mumbai. South Mumbai has around three-fourths of the total beds in the city which was the case in 2000. This means as the city expands to the suburbs, no additional bed capacity has been augmented in the last 20 years in Mumbai.

**Map highlighting the Geographical Coverage of Prominent Hospitals in Mumbai**

Second Covid Wave in Mumbai and Skew in Spread

As per the recent Mumbai Municipality Report on Covid, the highest increase of positive Covid Cases in the Western and Central Suburbs of the City in the last 7 days. (See the chart below). While the alarming rate of growth of covid positive cases in these wards would take less than 28 days to double the cases. As compared to 35 days as an average for Mumbai city. While the response to Covid is in the Western and Central Suburbs, the concentration of healthcare facilities is predominantly in South Mumbai. While this is leading to a lot to movement of people seeking admissions to hospitals for Covid treatment.

Spread of Covid Positive Cases in Second Wave till 8 April 2021

Action Plan for the Future

The cost of real estate in Mumbai very prohibitive for private healthcare operators to set up greenfield hospitals unless there are regulations to incentivise them. Various recommendations provided by our Committee is not been implemented on the ground. The Covid Pandemic is a wake up call for the City administrators to buckle up and bit the bullet to accelerate healthcare infrastructure in the city by our planners for the future.

The Second Chinese Virus Wave – Trade Off Between Vaccine Strategy and Vaccine Diplomacy

Vaccine Strategy

There is a second impending Chinese Wuhan Virus Wave in India. Last few days have seen a huge spike in the number of Covid Cases. States like Maharashtra are contributing to over 50% of th cases in the second wave of this pandemic. There are hints of a lockdown while the immunisation drive is now open to second age cohorts of upto 45 years age. Let’s understand, a lockdown is like celebrating an Easter after the economic crusification of the masses when we have proven our vaccines and immunisation drive should be accelerated to cover maximum population which is at risk. Being a student of epidemiology, it begs to reason out the strategy that needs to be followed for immunisation to win over the Chinese Virus in India and sacrifice the wider world’s do good by supplying the vaccines to other countries when our own country is a peril. In this blog, I discuss on the various options for India.

Where do Indian Covid Vaccines stand in the World Vaccine Race?

India’s CoviShield (rebranded as Vaxzevria on rest of the world) has received the largest purchase orders by the Governments around the world with over one-fourth of the total are going to be supplied by AstraZeneca/Serum Institute. This is on the backdrop of certain adverse event in certain populations of blood clotting. The next in the race are Pfizer/Moderna which has around one-fifth of the commitments. India’s Covaxine from Bharat Biotech is still lagging behind on the 6^th spot.

India’s Vaccine Diplomacy

Although India is the world’s largest vaccine manufacturer, it has won the race against China’s vaccine silk route strategy to dominate the world Covid vaccine supply very early on. From unconfirmed news sources, around 70 million doses have been supplied by India to the world as part of various initiatives to aggressively outwit Chinese Vaccine Silk Route Strategy. India must aggressively meet its commitment for its country and the world to combat the Chinese Wuhan Virus and its various mutants emerging in the world. India’s success in being transparent in the trials of the vaccine and its efficacy is India’s strength in leading the vaccine diplomacy and emerge as a leader. However, India cannot let its own population face the second wave of the pandemic by short supplying the vaccines in India to its 1.35 billion population meet world’s requirements of over 7 billion population. It needs to secure its own borders from the Chinese Wuhan Virus before it can free the world from the invasion of the virus. This means, India need to repriortise its Vaccine Diplomacy strategy. New emerging is that India has slowed down or halted the supply of the vaccines to the world’s after around 65 million doses supplied already.

India’s Vaccination Strategy

India has already used around 65 million doses for covering around 65 million people (around 2% of India’s population) since the launch of the program in January 2021. The phased roll out of the immunization program is on the basis of age cohorts. After the front-line medical workers, the senior citizens were the first to be covered under the program. The second phase is underway covering population above the age of 45 years. The for India is to immunize over 250 million of its citizens by July 2021. Let’s analyse this scenario in the face of the second wave emerging.

Optimum Population Immunisation Coverage

It is believed that over 50% of the population immunized is the much comfortable situation for any country to manage and control the Covid pandemic. While no country has reached this so far, around 20 countries has performed better in their population immunization drive so far. UAE, UK, Chile, and the US have immunized over 20% of their population. The rest of the 16 countries faring better than India also are accelerating their vaccination strategy by ramping up the procurement and supply of vaccines. India has to also do the same.

Revised Vaccination Strategy in the Face of the Second Wave in India

While India may take some time to reach the 250 million population coverage by July 2021, it must rethink the vaccination coverage strategy. Here are a few suggested ones which obviously do not meet the cannons of vaccination in the face of a global pandemic never faced by the world before.

Total Vaccination of Population in States with the highest Covid outbreak:

In this scenario, India accelerates the immunization and opens it to all the age cohorts in the top-5 states which are contributing to over 80% of the current second wave of cases. These states include Mahrashtra, Kerala, Delhi, Karnataka, Andhra Pradesh, Tamil Nadu. This is going to be politically sensitive as other states which have better managed their Covid situation may let the current situation slip to demand total immunization coverage of their states

Total Vaccination of Population in States with the highest Covid outbreak:

Like the earlier strategy, the top 20-cities are contributing to over 50% of the second wave of the Covid cases. This may also be difficult and politically sensitive.

Open up the double bell curve of the Indian age cohorts at Risk:

At a median age of 27 years, its our 50% of the younger population which has to also be opened up for the inoculation strategy as newer mutations attack this population which is our country’s future productive resource.

While the above vaccine strategy would lead to some amount discrimination and political horse trading. Its time to our review and acceleration of the vaccine strategy. The vaccine strategy adopted by other countries as a benchmark would be another blog for another time. The priority of the immunisation strategy is to avoid another impending lockdown to control the spread of the Chinese Wuhan Virus infections!

Is Moving Healthcare to Concurrent List a Good Move?

List of Ministries

Background

My blog on healthcare investments in India heatmap 2021 States Heat Map | Kapil Khandelwal (KK) has shown the gaps in healthcare delivery system in the different states of India. Also over the last year, India’s health infrastructure came under considerable strain in 2020, with over 20 million Covid cases and perhaps over a million requiring hospitalisation. We have observed how each of the states of India have responded to the Covid Crisis and the variability of the best practices implemented by each of the states whether it is immunization for Covid Covid Politics | Kapil Khandelwal (KK) or the digital health initiatives Sustainability of Digital Health | Kapil Khandelwal (KK). Moreover, the passage of the Telemedicine Practice Guidelines and the National Digital Health Mission regulations, last year, would require the country needs unified implementation of healthcare policies and programs with minimal leakages and cost of administration at the state level.

Recently, a high level group has recommended the 15th finance commission to bring health under concurrent list and declaring health as a fundamental right. This recommendation would Bringing health into the Concurrent list would give the Centre greater flexibility to enact regulatory changes and reinforce the obligation of all stakeholders towards providing better healthcare. I completely endorse the recommendation. Here are some of my reasons.

Look what’s happening to the Police?

Recent police involvement in extortion and misuse of their powers have clearly shown that States can misuse their political powers in delivering pubic safety and security to their population. We have seen in the past similar political interventions by the States in curbing healthcare for vested political interests. Politicalisation of health would be curbed by this move.

Promote Private Investment in Healthcare

Our recent heatmap on investments in healthcare attractiveness for the States shows that top-10 states would attract over 70% of private healthcare investments. Many high-end tertiary and quarternary care investments have catchments beyond the State and National boundaries. Such investments get stuck in local and state-level politics for regulatory and other approvals. The bottom 12 States have to practically fend for themselves and are on YOYO (you are on your own) effects. High-level Center’s intervention would remove such imbalances.

National Healthcare Emergencies and Pandemics

The last year’s Covid Crisis has clearly paved the way for a concerted National level Program for Healthcare and justifies the move to a Concurrent List for Healthcare in India.

Other Justifications from Experts

Low healthcare spending

India’s government spends only 1% of GDP (Gross Domestic Product) on health (Ministry of Health and Family Welfare), of which 80% is raised and spent by the states themselves. Achieving a public health expenditure of 2.5 % can be done by bringing health under concurrent list.

Indigenous practices

States do minimum to preserve indigenous healthcare systems and practices. Bringing health under concurrent list would allow Centre to spend in a better way to preserve indigenous systems of medicine, like Ayurveda.

Cooperative federalism

Health Under concurrent list will further the spirit of cooperative federalism. State-level Policy implementation regarding the health sector has underperformed and is plagued by poor quality and corruption. With health as a part of the concurrent list, the government can ensure a better healthcare system by working with states in a better way.

Better policy implementation

With health under concurrent list, the central and state governments would find a way to collaboratively design better policies and better implementation of union government initiatives. For example, a health scheme launched by the centre is implemented by states and funded by them makes its implementation poor.

Promote Universal Health Coverage

The key objective to promote Universal Healthcare Coverage in India are pivoted on the key axis which will be accelerated by this move

Social justice: A fundamental right is justiciable. Once health is made a fundamental right the citizens can approach the courts for its violation. It can prevent poor from being denied basic health services on basis of various factors like race, religion, caste etc.
Unaffordable health system: The large number of people still living below the poverty line in India. Thus the affordability of quality healthcare is a problem and needs to be addressed.
Discrimination: Cultural differences such as social, cultural, and linguistic barriers may prevent patients from accessing care. E.g. minorities may face discrimination in accessing quality health services.
Increasing risks: Environmental challenges, which include unsafe streets, asthma exacerbated by air pollution, leading to unnecessary hospitalisation and minimal or no spaces for physical activity or exercise all add to risk to health of millions of poor.

Accelerating Digital Health Initiatives

The Telemedicine Practice Regulations and the National Digital Health Mission would increase the complexity of regulating Digital Health in India if the current status quo continues. Imagine a situation where the technology infrastructure for digital health is hosted in a certain state, the doctor delivering the virtual health services in another state and the consumer in a third state? Which State will command the hegemony in such a case? Moreover, there are Centrally controlled Ministries which also regulate sectors such as Telecom and IT which will regulate digital health. There would be a barrage of court cases when we would have to adjudicate who has the right to regulate in such circumstances.

The move to move healthcare to the concurrent list is therefore the right move!

India should introduce Repairability Index like France

Repairability index icons

India should introduce Repairability Index like France

Preamble

This year Indians are going to buy over 760 million mobile handsets. Assuming that the life of a mobile phone is 3 years, I am assuming that mobile phones are being upgraded every year! Imagine what happens to the 700 million handsets bought in 2020. Around 225 million handsets are being replaced in India every year. An industry news carried out states that more than 5 million mobile phones have piled up for repair and servicing in India during the first phase of the lockdown enforced to control the spread of the coronavirus in 2020. This itself shows the gap in the handsets which could be avoided replacement due to the fact some of these handsets cannot be repaired. This is particularly in high end handsets. Look at the opportunity cost of replacement of handsets just because these handsets are not repairable. Moreover, this would be applicable to other consumer electronic products. Consumer electronic products take a serious environmental toll, and one of the best ways to mitigate that is to use them for as long as possible before replacing them. But it’s hard to know how long a new gadget will last if you’re unsure how easy it will be to fix. Consumers need additional information regarding the repairability of the product as an additional information to aid in their purchasing decisions. France was the first country in the world to introduce a Repairability Index on 1 January 2021. It is hoped that the momentum of this law will gain EU-wide recognition and move on to other large, well developed markets like US, Japan and China and maybe India.

Why should India not introduce its own Repairability Index?

What is France’s Repairability Index?

Since January 1st 2021, France is the first country in Europe to have implemented a repairability index on 5 categories of electronic devices. The goal is to inform consumers about the repairability of a product. a grade out of 10 will be added to the labels of washing machines, laptops, smartphones, TVs and lawn mowers. the repairability index that is defined by the French government. According to their ruling, all new smartphone sold in French must display the repairability index in the stores and website. The repairability index has a score from 0 to 10 and is defined by 5 criteria which has equal weight. Each criteria has 20 points and all adds up to 100 points which will be divided into 10 for the final score. The five criteria is

Documentation – Available documentation from the manufacturer.
Ease of disassembly – The ease of disassembly of the smartphone.
Spare parts availability – The availability of spare parts from the manufacturer. How easy to get them.
Spare parts price – The relationship between price of most expensive spare part item and price of original product. The bigger the differences, the better the score.
Specific Criterion The quality of information given by the manufacturer such as the information of the update, the ability to reset software and free remote assistance.

While France won’t be enforcing use of the index with fines until next year, some companies have already begun releasing scores for their products.

According to experts, the repairability index represents part of France’s effort to combat planned obsolescence, the intentional creation of products with a finite lifespan that need to be replaced frequently, and transition to a more circular economy where waste is minimized. But it also has global implications. Repair advocates say that the index will serve as a litmus test for other nations weighing similar regulations, help consumers make better choices, and hopefully incentivize companies to manufacture more repairable devices. Eventually, France intends to expand the score to other classes of consumer products. By 2024, the repair index will transition to a “durability index” that not only tells customers how repairable a product is but also describes its overall robustness.

According to the experts, The French Repairability Index has its limitations as they were developed through an intensive stakeholder process that involved input from manufacturers as well as consumer advocacy organizations. For instance laptop and smartphone makers can get a “free point” by providing consumers with information about different types of software updates, such as security updates or system upgrades — information that may not have anything to do with how fixable the device is.

The Case for Repairability Index for India

I believe that the case for a Repairability Index for India is an open-shut case. High-end consumer electronics such as Apple iPhones have become more difficult to fix due to a combination of design choices and software locks that often require proprietary tools to get repair from their authorized service centers. These have given discretionary powers to Apple to charge for the repairs or disallow the repairs providing arbitrary reasons, requiring consumers to forcefully replace their older version of devices to newer ones. Moreover, there is no warranty provided for the repairs or replacement of the parts during repairs offered

RIP Apple!

A blog on how this Repairability Index would impact Apple states:

Apple is known for touting its green credentials. They are using renewables for their operations and has been carbon neutral for years and aims to be carbon neutral in its entire supply chain by 2030. It uses less packaging to reduce carbon footprint. It has remove chargers and headphones from their iPhone offering (much to the chargin’ of their competitors) as an environmental initiative. It has so much renewable energy that it contracts out their excess energy as Apple Energy. Apple recourage users to recycle their iPhones and demos their recycling robots. They wanted all their materials in their devices to be from recycle material instead of mined from the earth.

iPhone 12 and iPhone 12 Pro teardown by iFixit 2 — iPhone 12 teardown. Apple recently makes it harder to change the camera module not through hardware means, but software.

That being said, Apple green credentials is not without flaws or critics. Its devices has been criticized as hard to repair. Apple is against the right to repair movement under the guise that the devices are more and more complicated. There has been reports that changing the camera modules in the iPhone 12 made the camera inoperable. The cost of repairing item is significantly higher than other manufacturers since you have to register to be a specialist from Apple. Even then, you might not be able to procure the parts necessary for the repair as shown for other Macs. And their iPhones require specialist tools as they use pentalobe screws which is a non-common tool.

This new repairability label will encourage Apple to rethink their position on repairability. Just like how energy efficiency labels encourage manufacturer to make more efficient devices, Apple will be compelled to make easier to repair phones.

Also see my post on Linkedin Rip Bad Apple! | LinkedIn on getting the repairs or replacement of their faulty products which echoes the same issues.

How can India take the lead here?

India needs to learn from the experience from France’s implementation of the Repairability Index and plug the loopholes in the process of creating its own index. As India embarks on the aggressive Make in India, it would serve well to also introduce the Repairability and Durability Index of the products manufactured in India to ensure that the Made in India products are accepted globally by the consumers and not fall in the trap the image of cheap Chinese manufactured products have attained globally of their poor quality perception.

It’s the right time to think about the Repairability and Durability of Made in India consumer electronics products given the direction EU is moving!

Fake, Fakier and Fakiest – The Fake News Pandemic – The New Normal to Denting Public Reputation?

The Fake, Fakier, and the Fakiest

The Pandemic of Fake News

During the lockdown there has been a marked increase in the incidence of fake news and its viral spread. According to a research falsehood diffused significantly farther, faster, deeper, and more broadly than the truth in all categories of information, and the effects were more pronounced for false political news than for false news about terrorism, natural disasters, science, urban legends, or financial information. False news was more novel than true news, which suggests that people were more likely to share novel information. Whereas false stories inspired fear, disgust, and surprise in replies, true stories inspired anticipation, sadness, joy, and trust. Contrary to conventional wisdom, robots accelerated the spread of true and false news at the same rate, implying that false news spreads more than the truth because humans, not robots, are more likely to spread it.

As case in point, even a celebrity like Amitabh Bachchan was not spared.

What is Fake News?

Fake or false news can be categorized in following ways:

Fake Article. The entire article is written with the intent of spreading false information.
Embellished Article. A real article or fact is enhanced and embellished to add fake information to it.
Fake Photo/Fake Video. A photo or video is enhanced and modified to add fake information to it.
Older Photo/Video or out of context photo/video. An older photo/video or a photo/video that’s from another country or another context is inserted with the intent of spreading false information.

The common intent of fake news can be:

Communal, news written with the intention of inciting religious and communal passion
Violence, Criminal and sexual.
Integrity and Authenticity
Questionable Practices and Rituals (Occult, Blackmagic)
Bullying and Terrorism
Misinformation (bank shutdown, currency devaluation, economy)
False Health Advisories, we see an uptick in these during the Covid-19 pandemic
Spreading false information about competition
Political misinformation
Satire
Propaganda
Personal Defamation

The Human, Economic and Psychological Damage from Fake News

Some estimates put the damage from Fake news in the range of 80 billion annually.

Fake News Stock Market damage – Fake news has caused losses of billions of dollars in company stocks. The damage last year alone was $39 billion or .05 percent of the markets value [1]. A letter purportedly sent by Larry Fink, CEO of Blackrock caused investors to panic and dump coal stocks. [2]
Health scares – fake news promotes the sale of questionable medical supplies and result in medical scares from visits to ER’s.
Destroying government machinery and loss of life – fake news has resulted in loss of confidence in government machinery and in cases of violence that have resulted in rioting and loss of life.
Politics – there have been innumerable news articles and posts on how fake news has resulted in election decision making in favor of the less desirable candidate.
Loss of sales due to fake propaganda, corporate espionage and loss of trust in brands – Fake news has resulted in loss of sales and goodwill. [3] McDonalds has been targeted by multiple instances of fake news and has lost customers each time. In addition they have had to spend money each time on advertising to promote facts.
Personality disorder in humans who read fake news analysis – Companies that manually curate news to figure out real from fake have high attrition. Employees get depressed from the psychological impact of reading fake news day in and day out.

Fake News Pandemic – How do We Tackle it and Mitigate Reputation Risk?

There are various ways social media platforms, law enforcement agencies, Governments, political parties, companies and individuals celebrities combat fake news pandemic. The tools available can be separated into three categories:

an increase in the use of human editors by the social media and publishing platforms. Given the volume of information being disseminated, it is practically inhuman to cover all the material being published
crowdsourcing initiatives being used by various initiative still not a viable solution of the joint forces to combat the evil forces of fake news; and
technological or algorithmic solutions

We would like to discuss on how we use our algos to assist in mitigating the reputation risks for different stakeholders affected by fake news

Common-sense techniques to find instances of fake news

Text Analytics

Subject detection, scan the article to figure out the theme and subject.
Use of provocative keywords, fake news usually contains provocative keywords.
Sense of urgency – Creating a sense of urgency to ask the reader to take action now by clicking on a link.
Spelling and grammar mistakes.
Creator credibility analysis, is this website credible, is this handle a new handle that hasn’t posted before
Links to websites that contain spyware/botware or other paid news
How fake news spreads (not spread by influencers, people with large number of followers), spread by accounts that habitually post controversial content. Truth spreads slower typically.
Does the social media account come across as a Bot. Bots have typical characteristics such as account age, account photo and posting only articles and forwarded content. Bots spread fake news faster than individuals.

Image Analytics

Fake news shows a tendency to contain graphic images that help drive home the point of the article. The following techniques help in analyzing the image and hence determining if the article is real or fake.

Reverse Image search, we search for images using a reverse search. This gives us context on when the image was first posted, what the original image looked like and what were the changes
Image authenticity, an image that diverges significantly from the original or shows signs of doctoring is probably a fake. Minor alterations such as brightening and color correction are acceptable changes to the image.
Image age, if the image is old then its irrelevant and is used to spread fake news
Image geotags, if the geotags on the image differ from the location mentioned in the article then the image is fake and the article is fake.

Video Analytics

Similar to images, articles contain videos that are provocative to drive home the point the article is trying to make. We use the following techniques to analyze videos

Video authenticity, a video that diverges significantly from the original or shows signs of doctoring is probably a fake. Minor alterations such as brightening and color correction are acceptable changes to the video. These videos undergo significant modifications in the post production phase.
TikTok analysis, TikTok is a growing source of modified videos.
Video age, if the video is old then its irrelevant and is used to spread fake news
Video geotags, if the geotags on the video differ from the location mentioned in the article then the video is fake and the article is fake

Article Analytics

A wholistic analysis of the article as a whole gives rich insights into the authenticity of the article. Some analysis that we perform here are

Author check, fake news generally does not provide the author name or comes from unknown authors that lack credibility.
Text to advertising ratio, fake news generally has a higher ratio of advertising or links as compared to text
Article layout, a badly laid out article on a website is a good indicator of the presence of fake news

Be Safe! Spread Genuine!

Footnotes

[1] Fake News Creates Real Losses https://www.institutionalinvestor.com/article/b1j2ttw22xf7n6/Fake-News-Creates-Real-Losses

[2] The Fake Larry Fink Letter That Duped Reporters https://www.institutionalinvestor.com/article/b1cqj0xmn5ds9t/The-Fake-Larry-Fink-Letter-That-Duped-Reporters

[3] French Fry Grease in McDonald’s Coffee https://www.snopes.com/fact-check/mcdonalds-french-fry-grease/

Excerpts of My Keynote Address to Healthcare and Education Start Ups

My Keynote Address to Start Ups

Salutations

Madam Secretary, members on the dais, dignitaries, my mentor friends and budding start up entrepreneurs. I invoke the blessing of his holiness to bestow the positive energies and blessing to one and all.

Delivering Key Note Address

Delivering keynote Address is always a matter of honour and pride on which one stands amongst ones own to share the experience. I remember delivering my first keynote at Arab Health 2003. I was part of the team that set up Cleveland Clinic in Abu Dhabi, Saudi Aramco-John Hopkins in Saudi Arabia, Cornell Medical College in Qatar and Joslin Clinic. It was definitely an honour to stand with the Royal and industry executives but no pride as I was not standing amongst my own. Today, when I am standing in front of you to deliver this keynote address, I feel honored and full of pride. And why not? Since I settled down in Bangalore, in 1998 till I migrated back to Bombay in 2017, this city has provided me with inspiration to do so many initiatives. So I am full of pride to be rightly one amongst you, although I no longer reside in Bangalore, my spirit and heart is still a Bangalorean. However, there is something in the air, water and weather of Bangalore that has motivated me to do so many initiatives. I feel that I am going to share some of my experience and motivations to you to do more than me while you are in Bangalore and deliver to the nation and the world.

In 1998, I worked on PM Atal Bihari Vajpayee’s Task Force on Food and Agri Reforms that set the direction and pace of reforms in Agri and Food Processing Industry right from my office on Airport Road
In 2008, I became world’s first CISO in the Drug Discovery Outsoucing, leveraging my learnings from Wipro as Head of Healthcare
From Bangalore, I was invited to Singapore Government to assist them in their Biotech and healthcare delivery model around Sing Health and Biopolis
In 2009, I hosted the Hon CM Yadurappa to showcase the smart ambulance and health presence while I was CEO of Cisco.
I was one of the member of the Planning Commission’s PPP Committee on Healthcare where we drafted the first PPP regulatory draft under Dr. Ramadoss. Later, I was invited by the Principle Secretary Health for working on the World Bank Karnataka PPP healthcare delivery model
In 2010, India’s first day care surgery chain was conceptualized and rollout by me as one of the early investors with the first 2-day care surgery centers at Koramangala and Sadashiv Nagar. This is now part of Apollo Hospitals now.
My investment in XY Clinic which was an innovation genomic, diagnostics and nutrigenomics. The first India flagship was launched here in Bangalore. The same year, we started Bangalore Angels with my school time buddies who had started Mumbai Angels. As of date over 75 start ups from Bangalore have been funded by Bangalore Angels. We also represented and fought with the Center on the removals of the demonic Angel Tax
This city’s Rotary Club in Bangalore which I was part of worked to make SMS mandatory working with the Planning Commission for eradication of Pulse Polio when there was a strong fake news like the Covid Vaccine amongst the villagers in Hosur District. With the SMS campaign, we saw 99.8% turnout in Bangalore while in Hosur it was less than 80%
As member of the FICCI National Committee nominated by Dr Jairam and my industry associate Rajen Padukone I delivered the country’s first Genomics Roadmap for mainstreaming India.
In 2013, at the behest of Kiran Majumdar Shaw, I took up the lead on Investment Committee of ABLE to deliver the Biotech Ignition Grant (BIG) policy, kicking of the public discussion with the current Principle Secretary right here at BIEC. This was further worked on to deliver the Start Up India Fund under the BJP in their first budget.
This city also kicked off Nasscom’s Product Conclave of which I was part of the committee for the first three editions.
In 2014, my firm completed taking Manipal Hospital to KL, Malaysia and consummate India’s first cross border M&A in hospital sector in India.
It was here from my World Trade Center Office, I conceptualized and launched 2 funds. India’s first healthcare REIT and India’s first offshore quant/algo hedge fund.

Position of Karnataka

Algo we developed from my hedge fund has been successfully predicting healthcare and life sciences investments in India with 95% accuracy since we launched in 2016, except last year. This year we reset out algo as our predictions for 2020 all went haywire. This year, for the first time we have created our heatmap on hottest states to invest in India for healthcare and life sciences. I must say, my pride is further validated for Bangalore and Karnataka as it has emerged on the top emerging states for investment for the sector. Bangalore, is the innovation hub not only for tech but for healthcare and life sciences in India. That attracts investments. I must say that this vibrant ecosystem creates a healthy pipeline for investments for our funds. This year, Karnataka will also delivery two more Unicorns to this nation’s list of unicorns.

My Message to the Start Ups in the New Normal

2020 was a disastrous year for world in terms of employment and investments. I must warn that emerging out of the situation of 2020, please do not profit out of the misery of others and make money out of this situation for your venture and investors. This would be the biggest disservice you would do to yourself and mankind. I will be discussing on the emerging business models and tech in healthcare and life sciences and what would be the lessons learnt and the key opportunities for start ups in the new normal in my other session. All I want to say now is that don’t be guided by the events of 2020 that your venture’s value proposition is narrowly defined. The time of the first-generation cohorts of start ups which were imitating the models of the west is now over. We have witnessed in 2020 that their advancements and innovation in tech could not prevent the catastrophe of 2020. Its now time to innovate for Bharat for the Bharat Stack. Karnataka is one of the best sandbox for rolling out your ideas to the world. Let me assure you that there is no shortage of capital for the right ventures.

My Message to the Government of the Day in Karnataka

Madam, I would like to also leave a message for you today from this podium. While drafting the BIG policy, we analysed all start up in healthcare and life sciences across the world including India. One of the key issues that healthcare and life sciences start ups require is a longer gestational cycle to mature their tech and innovation as there is risk of lives. We discussed at length at the DBT BIG policy back in 2013, how do we mitigate this. I believe that Bharat Biotech is a shining example of how DBT and the state administration collaborated to its success. In the past, Karnataka was diametrically opposite to the political party ruling Delhi. This time round we have alignment both at the Center and State. I would like to emphasise in no uncertain terms that the success of Bharat Biotech in our neighbouring state was not incubation but acceleration and grants for the scientific innovation. Please do consider this when you are drafting policies to support start ups and ventures in healthcare and life sciences. I must also request you to consider developing the infrastructure in Karnataka like the erstwhile Andhra Pradesh has developed in Hyderabad for the Biotech industry.

Healthcare and education are social services and goods. During Covid, I was part of the committee that drafted the Social Stock Exchange. Karnataka has been misfortunate to have divergent governments in State and the Center and hence many of the initiatives could not be encouraged in the state. However, we now have the opportunity to align with the Center. Karnataka has the opportunity to be the first incubator and sandbox for social ventures. I would urge you to reach out to the Principle Secretary Finance and discuss the issues and requirements with the Minister of State for Finance at the Center.

My Message to Mentors to Be Ready for New Technological Disruptions

My message to the mentors is very straight and simple. We are at the cusp of new slew of disruptions in technology. Our neighboring state has already tested 5G and would be rolling out in the state and the country very soon. Please do get ahead of these developments to be able to guide your start ups on what to expect in the future. Also instead of going with the feeling of Never Done Before, it would be better to leverage the technology and platforms already developed and operational to partner. Do not fall into the heady lure of make versus buy just because you have a personal point to prove yourselves. Look at this LG Velvet phone which I am using for testing some of the healthcare solutions and delivering my keynote. This handset is as powerful as my tablet giving a full desktop experience while being so portable and enabling mobility with being 5G ready.

My Message to the Accelerator Operators is to Share and Grow the Ecosystem

I heard some of the positive developments in our journey here in the start up ecosystem. I would urge you to share your templates, learnings, best practices to others who are setting up new accelerators. Good Karma always comes back. Like open source, please be a contributors to the ecosystem and the ecosystem will grow further and stronger.

Finally, the Alchemy of Success

I would like to conclude now that the platform is very strong that is available to you. On one hand you have the encouragement and full endorsement of the ITBP Ministry of Karnataka. One the other hand, you have a solid mentor base. I have had the privilege to work and collaborate with some of the mentors who are associated with you here in your journey. Please leverage their experience to the maximum. Also challenge them with the problems you are solving in your venture so that they are also bringing out their best to you. Finally, you also need to share your experiences with your peers so that you all come out of this experience stronger and positive. From my end, there are a whole lot of resources available on my website www.kapilkhandelwal.com which is available free of cost with no GST to leverage.

I thank you all for a patient hearing and wish you all the very best in your entrepreneurial journey.

KK with ITBP Prinicpal Secretary and MD KBIT

Healthcare and Life Sciences in 2021: Part 2 – State Investments Heat Map

In Part 1 of the Healthcare and Life Sector in 2021, we focused on the heat map on different sub-sectors. 2021 Investment Heat Map | Kapil Khandelwal (KK), we predicted the investment activity for 2021. In Part 2, we focus for the first time State-wise investment Heat Map under Part 2, Hottest States to Invest for Healthcare and Life Sciences. These have been aggregated into our overall Heat Map in Part 1. In India’s federal structure of governance, healthcare is a State subject while some of the other parts of the healthcare and lifesciences value chain are Centre subject. Hence it is very difficult to isolate the impact of governance model on the overall investment activity. Also some States and Union Territories were demerged and hence historical data may be merged with erstwhile states from where the new States demerged.

The meta data from different states and social media feeds have been incorporated to produce India’s first state-wise heat map.

We have taken the following parameters on which we assessed all the States and Union Territories of India

Provisioning For Covid
Promoting Start Up Ecosystem
Participation of Value Chain
Policies and Regulations
Population Dependency
Penetration of Insurance
Preventative Health and Wellness
Penetration of Digital Health
Population Epidemiological Burden
Population Access to Beds Per Km
Point of Care Access to Doctors
Point of Care Access to Other Clinicians
Healthcare Pricing Competitiveness
Healthcare Disparity

States Heatmap 2 — 2021 State-wise Healthcare and Life Sciences Investment Heatmap

Hottest Investment Destinations for 2021

Andhra Pradesh/Telangana
Karnataka
Gujarat
Tamil Nadu

Emerging Investment Destinations for 2021

Kerala
Madhya Pradesh
Rajasthan
Uttar Pradesh
Maharashtra

Hottest Union Territories Destination for 2021

Delhi NCR
Chandigarh
Daman/Diu

Stay Safe and Happy Investing in the rest of 2021!