Science of Politics of Covid Vaccine in India

Covid Vaccine Politics

Background

India has finally developed a vaccine for Covid which was approved by the regulatory authority the DCGI and it now the front runner for production of vaccines in the world. This is a great moment for India’s scientific might and I want to congratulate all the scientists who have worked tirelessly to deliver this solution to fight Covid to the world. Let me tell you that having worked in the drug development industry and also on the boards of several pharma companies, and biotech industry policy making, all efforts of the scientists are guided towards drug safety and efficacy before the final vaccine candidate is commercially produced for the masses. In the last 24 hours, leaders of several political parties have placed their roles in shamming and shaming the Indian scientists on the Covid vaccines being approved by the regulators in India. Let me inform you that Indian scientists do not work for political parties, they work for the advancement of science and technology. In this blog, I want to debunk some of the politics going on around our Covid vaccine and the timing of their political statements

The Political History of Bharat Biotech

Bharat Biotech whose vaccine Covaxin started in 1996 in the Genome Valley in Hyderabad. At that time the Deve Gowda Government with the support of Congress was at the center and the Telgu Dessam Party (TDP) was ruling in Andhra Pradesh. Let me remind the leaders of Congress who have come out with some statements, why did your Minister heading the Department of Science and Technology under which Department of Biotechnology (DBT) comes in provide grants to such a company if you believed that today that company is a fraudulently and premature in producing a vaccine for Covid. Over the years under the Congress rule, Bharat Biotech received some many grants and awards from the DBT to further their development of various vaccines. Infact BIRAC an arm of DBT also owned equity in Bharat Biotech at some point in time for the funding that was provided to Bharat Biotech by the Congress Government. I had been associated with the DBT and the Principal Secretary, DBT during the Congress Government who I worked closely to deliver the Biotech Ignition Grant Policy to the nation. He was very appreciative of the work Bharat Biotech had done and achieved several milestones in its journey with several vaccines and patents.       

The Science into Politics – Way Forward

Rather than making baseless statements around the vaccines being approved, its time political parties appoint a Chief Scientific Advisor like they had Chief Economic Advisors in their party. The job of this Chief Scientific Advisor and his team would be to sieve through the clinical data presented to the regulators DBT, DCGI and other departments and raise scientific issues and challenge the science on the floor of both the houses of the Indian Parliament through their elected party representatives rather than make frivolous public and press statements outside the house. This would imbibe science into politics and allow for the ruling political party of the day to address any issues relating to the science of drug development through the right governance mechanisms of our Parliamentary Democracy.  All I must say here is: Dear Politicians, please do not debunk our Scientific progress for your political gains and headline statements for your parties and your social media impressions and eyeball. In the eyes of science, you all have been marginalized completely.

Jai Hind!

For more information on Covid Vaccine also visit:

Covid Vaccine | Kapil Khandelwal (KK)

Sustainability of Digital Health | Kapil Khandelwal (KK)

QuoteUnQuote with KK (kapilkhandelwal.com)

How can Social Media be Socially and Inclusive in Healthcare in the New Normal?

Social Media in the New Normal

How can Social Media be Socially and Inclusive in Healthcare in the New Normal?

With the recent US Government action on Facebook and the pace at which fakenews have been spread during Covid and now on the Covid Vaccine, I am tempted to share my earlier article on this subject.

Background

India is world’s second largest growing online population in the world after Brazil. Over the last one year, India witnessed a YoY growth of 31% in people going on the internet, making it the world’s third largest population on the internet. More importantly, this growth has been fuelled people using tablets and smart mobile to go online. However when we look at in absolute terms, only 73.9 million people were on the internet (less than 10% of India’s mobile connected population) of this only 86% of the population (63.55 million) is using social media. While the use of healthcare online grew by 17% last year, it is still lower than retail sector’s growth of around 80% last year. It is fairly evident that several vertical online and social media options have sprung up in India, which has led to the heady growth in retail social media in India. Social media is not about page views, eyeballs or clicks (see box – What is Social Media?). Healthcare is no exception to this, as social media platforms radically changes the nature of business relationships. While over $ 750 million was invested in social and online retail business models last year, why has online and social healthcare business models and solutions remained a laggard in India?

What is Social Media?
Social Media is different from other communication platforms and channels in four ways:
Content is generated and governed to a varying degree by the users
Communities connect people with common life experiences, preferences and interests
Information can be developed quickly and distributed broadly
Open, interactive dialogue and information sharing among media users is encouraged    

Top – 10 Need-to-Knows about Social Networking and Where It’s Headed
Social networking is the most popular online activity worldwide
Social networking behavior both transcends and reflects regional differences around the world The importance of Facebook cannot be overstated
Short Content and Microblogging has emerged as a disruptive new force in social networking
Local social networks are making inroads globally
It’s not just young people using social networking anymore – it’s everyone
“Digital natives” suggest communications are going social
Social networking leads in online display advertising, but lags in share of dollars
The next disrupters have yet to be decided
Mobile devices are fueling the social addiction

The Social Media Landscape

Today there are over 450 social networking sites globally and they collectively serve over 6.5 billion registered users. Nearly 1 in 5 minutes online is spend online on social media, with Facebook getting a lion’s share of the time spent on social media. Healthcare consumers are now starting to leverage social media globally and in India. However, healthcare decisions or dis-engagement at any point in time with the decision making process is a very complicated process and there are many factors associated with this in the social media usage. Nor this is about hospitals putting up their Facebook pages, doctors in India putting up their profiles on Linkedin or some surgeon’s putting up their videos of their procedures on You Tube. This fragmentation has led to assessing not only beyond Facebook, Linkedin, Google+, Twitter, Instagram and You Tube.

Understanding the 4Es in Social Media Usage in Healthcare

Enhance

These are players who enhance and push content into the social community. By seeding conversations and then enhancing it, healthcare companies create and perpetuate an ongoing focus group that can help identify opportunities to create, enhance and modify products and services for consumers. These also include tools that enable the social media networking

Engage

The are platform that are used by healthcare providers, payers and employers to communicate and create a dynamic interaction with their community of patients, members and professional affiliates

 Educate

There are several platforms where user generated content and shared learning supports improved healthcare.

Enable

Enabling consumers to take a lead role in finding, sorting and acting on health information.

There are over 40 different micro-segments from the 4Es for social media features and services that can be offered by different social media platforms in healthcare. This is where there is opportunity for Indian social media platforms in healthcare to emerge and grow out globally. Analyzing the marketplace for vendors marketing social tools related to healthcare and I found a wide variety of business models and

strategic approaches. Of the numerous healthcare-centric solutions, many are geared toward consumer use, most are small and a scant few have “platform features” where broad social initiatives could be supported.

Slide3

4Es of Social Media in Healthcare Representative Companies in India and Globally
Enhance LiquidGrids, Listenlogic, Pharmawall, Semantelli, Welltok, NodeXL, Gephi
Engage Shapeup, ExtendMD, FairCareMD, HealthCrowd, QuantiaMD, RN Rounds, Sermo, Wellness Layers, Healthcaremagic,
Educate There are about 150 players here in India and abroad
Enable Snapdeal, Groupon, CarePages, eCareDiary, FitBit, Digifit, Endomondo, Gamercize, HealthCentral, LivingSocial, ZocDoc, 15 sites in India

Roadmap to Business Models for a Social and Inclusive Social Media in Healthcare in India

As you will notice from the table above, there are handful of social media business models or platforms in healthcare that have emerged out of India even though there is a huge potential to tap the huge mobile teledensity of close to 900 million. We have tapped less than 10% of this, even though healthcare is an important part of the way people live, work and communicate in India. How do we create a similar platform for rural areas, where Internet platforms are not usable due to literacy, access, and affordability challenges? Building on from my work at the Health and ICT Minister’s Panel for Africa in the last decade. The key takeaways from my work in the emerging market with respect to healthcare, ICT and social media is that these business models will be successful only when:

Transparency

The transparency of activities is a key feature in social media; health is a subject affects private provider companies, public administration as well as consumers

Rise of ubiquitous participatory communication model.

Newspapers, urban spaces and television will all be supplemented with interactive social media applications.

Reflexive empowerment.

Healthcare empowerment through social media is mostly reflexive, i.e. it is usually based on a specific issue and temporary coalitions that engage in dialogue on the topical issue.

Personalization/fragmentation versus mass effects/integration.

Practices and services in the web can be tailored and personalized to almost every detail with the help of portable profiles. Simultaneously, social media opens vast potential also for enormous mass effects and integration.

New relations between physical and virtual worlds

Practices induced by social media, e.g. communication, participation, co-creation, feedback and rating, get more common in daily environments and in urban spaces.

Key Drivers to Social Networking

There are 12 key drivers that need to be broadly analysed for developing social networking business models in (see box) in healthcare in India and that can then be exported to other emerging markets. Every business model in social networking in healthcare would pick 2-3 key drivers to disrupt the social networking landscape as described earlier.

Slide4

Creating a Framework for Transformative Business Models in Social Media in Healthcare

Countries like Finland, Singapore are experimenting these models of social media networking for healthcare. There are several analytical tools being used to analyse this networking effect. One such tool is illustrated in the box below:

Slide5

Charting out and exploring the social network relationships

As we are increasingly surrounded by a by a sea of tweets, e-mails, blogs, wiki pages, videos, wall posts and different apps that enable the social networking. It is important for any new business model to map out these relationships to understand where the gaps are in the overall social network landscape (4Es given earlier). 

Not all social media networks include people as nodes. Some include content of interest, such as videos, images, or wiki pages. Increasingly, data from social media sites such as tags, comments, purchasing patterns, and ratings can be used to link related content together into networks. Viewing content as a network can help learners make sense of how individual concepts or experiences fit into a larger whole. They can provide a view that provides perspective on an entire field of knowledge so that information that is most relevant can be identified. The goal is to provide an overview on surgery, many of which can be used to help educate medical students, professionals, and consumers. It may be useful in finding relevant content and its relationship. Companies or educational institutions interested in medical content may use such a map to inform their decisions about what videos to post and how to carve out a unique niche in the existing information landscape. Or they may decide that their solution has a poor selection of videos on the topic of interest

Social Network Map of Surgery on You Tube

Slide6

Case Study: Gram Vaani: Taking Social Media to the Masses

Gram Vaani is voice based social media network accessible from ANY phone (not a smart phone connected to a EDGE or 3G network). They have developed the novel concept of voice based social media, wherein they enable people to express themselves and share information in voice through ordinary phone calls. People can call into our toll-free number and leave messages or listen to messages left by other people (post moderation). It has captive user base of 35,000 families, over 2,000 impressions made per day. This enables

  • bottom-up information sharing where people ask questions and others from the same community help answer these questions, or share stories and experiences, and
  • accountability by giving reports on the performance of government schemes, demanding better performance from local and state social welfare providers, and policy inputs.

Their network in Jharkhand has seen several cases where reports filed by people led to redressal action by the government departments including healthcare, and the platform is also used regularly for information seeking on agriculture, livelihoods, health and education, and even cultural expression through folk songs and poetry. They have ability to run sponsored channels and programs and to incentivize local entrepreneur networks to conduct social marketing. 90% community sourced content which includes local news, interviews and informational services, opinion on topical issues, guided discussions and campaigns, grievances and feedback on government schemes, cultural artifacts including folk songs and poems. 98% of the users of this social media platform is educated class 12 and below. This platform is also very interesting for a vertical health through rural social media application.

Slide7

Summing Up

India is a typical to many other emerging markets where social media has only penetrated the urban and the educated sections of the society, while over a large majority 90% of the mobile population is still not seen the face of the Facebook. Healthcare is now emerging as investments in retail sector have penetrated deeper into India. We need business models that can become the next twitter or facebook in India. Folks like Graam Vaani have demonstrated in a small way that they can bring social media to the mobile connected populations of India and emerging markets. It is time to look at the 4Es of healthcare social media and start building vertical healthcare solutions on top Creating a Socially and Inclusive Social Media in Healthcare in India

What Drove QuoteUnQuote With KK to be India’s Leading Business Podcast to the World?

Why this Blog Now?

I was on a call with Padma Bhushan Awardee Dr. Jagdish Sheth earlier this week to wish him on his 58th Wedding Anniversary. He was the keyman and inspiration behind starting QuoteUnquote . I was updating him on the progress of our of the show. He requested me to share this experience for others to learn and figure out. Hence I am posting this blog.

Visit to the Showroom

In 2008, iPod Mini was launched as a very innovative product by Apple. I was at the Ample Showroom at Forum Mall. The sales person showed me the benefits of iPod Mini that apart from songs there was something call talk shows called Podcasts. I bought the iPod Mini and a Bose headphones. The next 2 years before my I lost my iPod Mini from my car, I was introduced to the world of podcasts. There were no Indian Podcasts back then. So most of the Podcasts I heard during my morning and evening walks were from Harvard, Stanford, MIT and other US Universities on leadership and management.   

The Covid Affected CEO’s Self-Motivational Drive and Mental Roadblocks

Fast forward to April this year, the Covid lockdown and crisis created a sort of a mental road block in the minds of circle of CEOs in India and amongst my peer groups who I was talking with. The uncertainty, lack of experience in crisis management of this sort and driving their people and companies out of this was their deep concerns that they expressed to me one-on-one. This also made me think hard and wonder on the road ahead.

The Vehicle Design Template

One of my weekly board calls with Dr. Jagdish Sheth, I openly shared my feelings and empathy towards my peer group with him. That’s when he recommended to organized a virtual webinar for my peer group of CEOs to which he would address to allay their concerns and provide a road ahead given he was in touch with the PM and other folks in the power center in India. We started off with a Virtual Fireside Chat which he would moderate with a few global thought leaders and himself. That was the birth of our vehicle to address the Indian CEO diaspora. The launch date was set and we burnt our bridges with the world and a brave announcement to invite my circle of CEOs to attend this Virtual Fireside Chat free of cost and openly share their fears.   

The Vehicle Proto Type and Test Drive

 While we set about in motion inviting a few panelist for this Virtual Fireside Chat, we did not have a name of the model. In of our brainstorming sessions we called this QuoteUnQuote. While we could get confirmations with a few thought leaders, their calendar availability led to all sorts of logistics and vehicle assembly issues in our garage production shop. Last minute drop out of our key driver Dr. Sheth, made us think we should abbot the launch or defer it. I took the brave decision to be the back up driver and hosted my dear investment industry Dr. Mark Mobious on QuoteUnQuote. 750 industry CEOs and veterans attended the show. WhatsApp messages poured as feedback from them till late night. It may be believe that the test drive was successful based on the results of the direction it set out the roadblocks in the minds of the CEOs.

The Licensing Issues

One of the editors of a leading media house who had attended the QuoteUnQuote published a summary of our talk without any due reference and credit to QuoteUnQuote. This made me furious. Given the media industry’s blatant misuse and misrepresentation, I called up the Managing Editor of Business Standard and worked out a 4-episode deal to publish in their newspaper to further amplify the content from our virtual shows.    

Further Test Drives

While Dr. Sheth was freeing up his calendar, we went on with a few more test drives with the Gallup Chairman, who I had built up friendship since 2004 when he visited India to make an acquisition and start Gallup India. He had to apologize last moment as he was called on a major TV channel in the US to announce President Trumps approval rating. His replacement, Mohammad Younis, the Editor-in-Chief at Gallup filled up the shoes of the Gallup Chairman and the audience expectations. Dr. Jagdish Sheth followed up with his talk which further delighted the audience and built confidence in the CEOs.

The Virtual Vehicle Model Development and Configuration – Autonomous or Automatic or Manual Gear

By June 2020, the starving event management industry and its corporate sponsors had found a way to engage with their target audience virtually and blatant spamming of emails, SMS and WhatsApp on a daily basis for invites started pouring in. The personal time pressures, work demands and virtual webinar fatigue started to set in with my peer CEOs who yet sent out messages through their executive assistants on the next event to block their calendars. We were just not prepared to run our prototype in its current form to compete with the well-oiled big buck event management industry. On the other hand, requests started pouring in from the PR agencies to take their clients on our panel. This was not the intent or the drive with which we had started out. Our vehicle prototype design needed a drastic remodelling and a new drive. Back to the drawing board.

Uber or Ola?

The Indo-China relations escalations and PM’s Atmanirbhar bugle call was the back drop on which we set out for a model redesign. Uber was an American business model in India while Ola (I was an investor in Taxi For Sure seed stage) an Indian business for Indian, let us believe that our core audience was still the Indian diaspora and an Indian Ola-like though-leader with a global unicorn stature would better empathise with our audience in these increasing complex times rather than a foreigner Uber-like global thought leader to give an outside in view and perspective to issues . After several discussions with my CEO friends and those in advertising, PR, digital media, affirmed our belief that a desi podcast show giving the anytime, anywhere, anybody, anyways and anything experience is the way forward and would be available on-demand like the app-based taxi service to our core audience and also extend to the wider secondary audience.

Does Brand KK’s has the Audience Permission and License to Drive?

Our next challenge was who will be the host to anchor the show. Given the preoccupation of our initial star host, we zeroed into some of the celebrity hosts from the TV channels to take the mantle. However, their exclusivity to their TV Channels or other virtual events did not yield us any potential star anchor. The issue boiled down to can KK do it and carry it forward. It made me wonder if I am capable and would the core audience accept me or see it as a platform that would be a bragging of KK. Internally, I had to search what were my bragging rights to qualify for a successful show host if the podcast had to move ahead and the time pressures and demands on me. I had chaired industry bodies forums which has delivered the Biotech Ignition Grant Policy, Agri Reforms, Social Impact and Financial Reforms. After a few calls with my mentors, CEO club buddies, the consensus was that I should anchor and continue with the shows. After a few YouTube videos on podcasting and inputs from Spotify CEO and his team, I finally took the plunge to create the podcast. Now what do we call it?

Vehicle Brand and Launch

After a few creative iterations and ensuring continuity of QuoteUnQuote the consensus was to name the podcast QuoteUnQuote with KK with KK as the anchor host. For any new vehicle launch you need a you need a celebrity to premiere it. Given the Indo-China cross-border escalations at its peak, I called my dear friend Parag Khanna to come for the show which he gladly consented. The podcast show was launched with a huge India and International acceptance. Given the topic Parag carried, the first podcast delivered us over 1 million impressions. However the intent was for Indians by Indians. Here came the next challenge, how to market and go to more Indians?

Setting Up Indian Vehicle Distributors

There are many Indian podcast platforms. We went and tied up with Aawaz and Zee5 for hosting the show. Over the next few episodes the impressions multiplied 100x for each episode. Potential speaker requests and content request feedback started pouring in.

Periodic Maintenance of our Vehicle and Fuel Top-Up

Blessed with a strong analytics team and a Chief Evangalist Officer, our podcast vehicle came into the garage for drive-worthiness and fuel-top up. Every podcast show gave us insights on how the drive has been and what shifts in the gears are required. Armed with all the information and details from the last 10 episodes, our calendar for the next year and the drive for the 2021 was announced to the world and CNBC-TV18.

The Key Take Aways for any New Podcast Vehicle Launch

The dialogue from Dirty Movie, “Films work on 3 things, entertainment, entertainment, entertainment. However, for podcasts, my dialogue is, “Podcasts drive on 3 things, Content, Context and Commentator.”

KK on CNBC-TV18

Healthcare for All: Money for Nothing!

KK at Tedx Gateway

In 1998, we solved the food security in India as part of the Prime Minister’s Task Force on Food and Agri. We gave the PM the slogan

“Kisan Ugaye, Janta Khaye, Aur Desh Aage Badh Jaye”

20 years hence, India is facing a impending health crisis. This crisis is already so huge that moving forward would take away 25% of the household incomes due to people suffering from health aliments and lack of proper medical intervention. You may google on Kapil Khandelwal to get to many of my articles in public domain to get more details of what I am saying is to the magnitude of 25 lakh crores per annum.  Hence to achieve our target of $5 trillion economy, we would have to actually target $6.5 trillion. An uphill task!

The Government has announced world’s largest Universal Health Insurance Scheme last year to mitigate the risks. It’s still early days and supply side capacities need to be build to service this incremental demand for healthcare services which are cheaper, better and faster to address. The world and the jury out there is witnessing this to come to its conclusion on the outcomes.

Unlike food security, health security is a more local and systemic long-gestational issue to solve the different at the factors of production such as land, labor, capital at a macro level. While each of the factors could by itself become a Tedx presentation. Let’s look at the high-level each of the issues and the break-away from the past to a new healthcare revolution in India.

At a global macro perspective of India, at 1.35 billion population, India constitutes ~18% of world’s population. From here things become a bit trickier. We have world’s 21% disease burden. Ie. One sixth higher proportion of people falling sick.

Coming to land, We have only 2.4% of world’s land mass so like intense agriculture on land, we have to be intensive in land usage for all activities. We would need approx 0.01% of our urban land usage for health and well being purposes which are currently not adequately provided by our cities and town planners. Hence land availability is critically sensitive.

Talking about labour, as far as healthcare is concerned, India stats become adverse.  To adequately treat that, we are approx 13.5 million hospital beds short. This is not accounting for the 1/6th incremental disease burden our population carries. On the clinical manpower shortages, we just have around 8% of the total global labour force of doctors, nurses and healthcare workers to address the 20% of the global disease burden we carry with our people. We are short by 5 lakh doctors, 20 lakh nurses and 30 lakh short of other health workers. Fortunately, we are a net exporter of nurses to the world so we have to also back fill the gaps of nurses leaving out of India for those remaining in India. 

Coming to the capital to address these gaps, we require close to Rs 30 lakh crores or $430 billion to come to the global average of hospital beds. Another Rs 2 lakh crores or $29 billion is required to build capacity for healthcare manpower. Therefore the total investment is approx $460 billion. To give you the magnitude, 165 countries in the world had a GDP of less than $460 billion in 2018. Or spending all what RBI currently has in its forex reserves on healthcare and becoming what Pakistan is struggling today or the scenario when Manmohan Singh took over as Finance Minister in 1991. A financial health crisis of sorts! The education and health cess

Why do we spend this all $460 billion now? We can drip feed the country to fund this? There is a saying “9 men cannot make a baby in 1 month”. Similarly, students enrolled into medicine today will add incrementally to the workforce in next 4 years.  The silver lining is that this capacity building spend would lead to $1.45 trillion of additional incremental to the GDP after 5 years as 1 incremental bed capacity creates 28 jobs over its lifetime. In other words healthcare economy in India as a standalone would itself be #16 nation in terms of GDP.

Therefore to achieve this the new slogan should be:

“Kisan Ugaye, Janta Khaye, Kisan aur Janta Swasth Rahe, Aur Desh Aage Badh Jaye”

How do we achieve this all?

We need a total disruption and reenvisioing to way things are done in healthcare while still minimizing the scarce resources such as land, labour and capital but derive the maximum impact. Before I start outlining my plan, let me make my customary caveats and limitations and disclaimers:

  1. I am not God nor his Massiah
  2. Political, economic, sociological, technological factors and assumptions are all favourable towards achieving this disruption
  3. Human race does not become stupid enough to become self destructive that health and well being of others and self is no longer a priority
  4. I am leveraging my experience in setting up various disruptive healthcare business models in the past to scale this
  5. My current experience to manage India’s first healthcare infra fund

Let’s get started:

Healthcare labour and skill acceleration, I had in one of my articles on human capital in healthcare estimated we need atleast 1000 Infosys, TCS hard brick and mortar like campuses near the cities that can work with clock speed in churning the talent pipeline. Our investments in new age AR/VR technologies in healthcare skilling and up skilling shows that medical and judgment errors are reduced before actual on the job-training to be right skilled for clinical positions from day 1.

Based on our investments in India’s first asset-lite day-care surgery chain, and here is the 80:20 rule. 80% of all elective healthcare, ie healthcare that is not an emergency or urgency is delivered out of the top-16 most populated cities of India. It is in these cities we see high concentration of highly-skilled and specialised medical labour force as well as infrastructure which is world class and cutting edge is present. Currently, catchment for these places is around 150-20 kms. Data from Ayshman Bharat on the residence city of the patient and the target treatment facility delivering care is yet no available for us to reaffirm the care for the bottom 250 million population of India.  Next 10 years we require this to extend to 30 cities. We need to set up stand alone acute and urgent care centers across all districts and taluks which would be feeders these 30 cities medical hubs

Tech enabled emergency, drones, telehealth, home health monitoring infrastructure with 5G connectivity have to be developed. I can go on this. However this would by itself be another Tedx talk by itself.

Coming to capital. Perpetual cheap cost of capital is the need for the healthcare industry to accelerate development of healthcare infra. Monetising existing infra is the only way forward to provide this essential capital. Moreover new age construction and build technologies which develop hospital are available outside India be its adoption is very low here. Around $20 billion of FDI can flow to India very quickly provided the enablers are given to the investment manager and incentives to the investors.

This is the excerpts of my talk delivered at Tedx Gateway on 20 July 2019

KK at Tedx Gateway

Ending Endemics: My Learnings from Eradicating Polio from India

My Paul Harris Fellow Medal

Ending Endemics: My Learnings from Eradicating Polio from India

Background

The rumors, fake news and experts comments around Covid Vaccination has pitched. In China, the mass sentiment is that their Covid vaccine is not effective and is just a placebo. While in India there are concerns on the efficacy of the vaccines under development and their safety. As a result our Hon. Prime Minister, Narendra Modi has to address the nation around this issue. There was a similar safety concerns around the pulse polio program in Tamil Nadu and Karnataka back in 2010 which was being organized by Rotary International. A few kids has some effects from the polio drops in the adjoining district of Bangalore, Hosur in Tamil Nadu. I was part of the Rotary which was planning the campaign for polio to ensure that there was a maximum turn out. The rumours and fears of the people in Hosur would have an impact on the turn out in the bordering districts of Tamil Nadu near Bangalore.

Our Strategy and Learnings

Back then the power of social media such as Facebook, WhatsApp was not effective medium to reach to the rural masses. Our challenge was to communicate effectively with every household which had children in immunization age in our state on the safety, benefits and turning out for the polio drops. As Rotary was a not for profit organization supporting this initiative, we had limited budgets for the campaign. The jugaad we used was SMS to every mobile subscribers in the state. Airtel, Vodafone, Idea, Tata Docomo, Spice Telecom, Reliance Mobile Circle CEOs were reached out to provide pro bono three broadcast SMS, free of costs to support the Rotary Polio initiative. All the mobile operators except Reliance Mobile agreed to support the campaign. Through the broadcast SMS, we communicated with the masses on informing the safety and need for polio drops for the children; it was free of cost; inform on the date of the polio program; reminder on the polio program one day before and on the date of the program. The result of this SMS campaign was over 99% coverage and turnout in Karnataka for the polio drops for the children. While Tamil Nadu had around 80% turnout.

Armed with this information, I visited Planning Commission office in New Delhi on one of my visits and met with Dr. Salma Hamied and Dr. Jagendra Haldea. I urged them to make free broadcast SMS mandatory for polio program for all states of India through the mobile operators. This request was accepted and sent to the Ministry of Telecom and actioned immediately. Through this process, India was declared Polio free on 27 March 2014 by World Health Organisation. I was honored by Rotary International with Paul Harris Fellow Medal for organizing and pushing the campaign.

Ending Endemics of Covid in India: Getting the Covid Vaccination Program Logistics in Place

The Numbers

As per my estimate, on the demand side, around 800 million Indians will be covered in the Covid immunization program. I am assuming that there will be a boster dose also. Hence we would require around 1.6 billion in two phases along with the allied materials such as gauge, syringes, swabs, etc to be provided for distribution to every nook and crany of India. Unlike the polio drop which the Rotary volunteers could easily deliver, this program will required trained volunteers in delivering injectables. My estimate is that we would require any where between 50 million trained volunteers in injecting the vaccines throughout India. These need not be medical professionals. On the supply side of the four key vaccines under development for India, Serum Institute, Cadila, Bharat Biotech and a few others would be able to deliver around 1 billion doses through their ramped up manufacturing facilities. The issue is the last mile linkages and cold chain required to reach the masses. Around 10 key states have ready excellent cold chain and warehousing and reefer facilities. These constitute around 68% of India’s eligible population for Covid immunization by April of 2021. The challenge will be for the other states which would need to be ready by April 2021 in the cold chain logistics.  

Busting the Myths: Communication Mediums

During Covid, we have implemented Covid Bots on the National Health Mission’s program through WhatsApp. It was a struggle to get the policy change in WhatsApp as there was no such policy in WhatsApp in March 2020 at the beginning of the pandemic. India was the first country in the world to get the approval to go ahead from WhatsApp headquarters to implement such Covid Bots. I would like to personally thank WhatsApp India and Facebook India Government Affairs teams to be able to push this with their global headquarters to get a policy out and obtain such approvals for roll out of such CovidBots. These Bots can be upgraded to answers queries on the Covid Vaccine program to be rolled out in March 2021 rather than the operators replying to the queries on the normal 104 helpline. We already have the policy in place for the mandatory SMS in place. This would give us reach and coverage to around 800 million eligible population of India for the Covid immunization.   

For more details on Covid Vaccine Race and More: Please visit the Podcast Ending Endemics: The Future of Healthcare QuoteUnQuote with KK – Kapil Khandelwal (KK)

PHF Medal

Beyond the Farm Bill – Setting the Agenda for the Next Generation of Food and Agri Reforms in India

Farm Bill

Introduction

In 1998, when I was part of the Prime Minister Atal Bihari Vajpeyee’s Task Force on Food and Agri Management Policy, we present set of recommendations that would transform the sector and affect the overall food security of India. The 70-page report outlined the issues across the agri value chain. To align the country, we gave the slogan to the Honorable Prime Minister:

“Kisan Ugaye (farmer grows)

Janta Khaye (population feeds)

Aur Desh Aage Badh Jaye” (and the country advances)

The current Farm Bill which is being politically contested is just addressing one part of the overall agri value chain. Back then in 1998, over INR 55,000 crores of agri produce is wasted every year due to inadequate infrastructure to the latest estimate of INR 44,000 crores. This is hardly a dent over the last 22 years in curbing the loss of farm produce. Over the last 70 years of independent India, the so called ‘middlemen’ have not added value nor reduced the farm produce losses. However, this is not the purpose of my blog today. There were several recommendations that were put forth and accepted by the Government in 1998. Unfortunately, the political and administrative will and intent was missing. I would like to recall some of the key recommendations that would need to form part of the Next Generation of Food and Agri Reforms in India.

Setting Agenda for Next Generation of Food and Agri Reforms in India

India’s current agri output is around USD 300 billion and provides food security for one season. There are several items on the agenda to double this output to around USD 500 billion by 2030. These include reducing the number of Ministries and Departments that manage the agri value chain, to setting up the Next Green and White Revolution to increase productivity to global norms, investment in smart infrastructure and digitization of agriculture, funding agriculture, food processing to enable farm to fork, agri labour reforms amongst a few. Let’s discuss the important agenda items one by one.

Super Food and Agri Ministry

In the current Government, there are following Ministries across the food and agri value chain:

  1. Ministry of Chemicals and Fertilizers
  2. Ministry of Consumer Affairs, Food and Public Distribution
  3. Ministry of Agriculture and Farmers Welfare
  4. Ministry of Food Processing Industries
  5. Ministry of Environment, Forest and Climate Change
  6. Ministry of Animal Husbandry, Dairying and Fisheries

This is still a manageable number from over 14 Ministries in 1998. Compare this with a single Ministry of Agriculture, Fisheries and Food (MAFF) in the UK which manages the administration of the entire value chain.

Next Green and White Revolution in India

In 1998, we had outlined several recommendations that would lead to doubling of the agri productivity to reach global norms in various agri produce per hectare. Over the last 20 years there have been several advances in agri and animal husbandry technology which would need to be rolled out at the farm level to increase the produce on reduced land supply for agriculture due to increasing population pressure. These include agri biotech innovations, precision farming, multi-level farming, organic pesticides and fertilizers and so on. The issue of land fragmentation over the last 20 years have become fairly acute and as time elapses, would accentuate further affecting the productivity. Newer technologies and consolidation to intensify agri on limited land due to population pressure is to be developed. Lastly, the issues of climate and environmental change over the 20 years have become very visible and would need technologies and crop rotation to mitigate agri failures due to climate and environmental changes that are occurring rapidly over the last decade. My work with Department of Biotech (DBT) in setting up the Biotech Ignition Grant (BIG) Policy in 2011-12 was muted to enable innovations in agri biotech and start up to obtain grants to commercialize their concepts and innovation in this area.

Investment in Smart Infrastructure and Digitization of Agricultural Value Chain

There are several developments on the information technology front which has yet to be adopted by Indian agriculturalists. Several product innovation start ups are working on solving some of these issues. We would need to accelerate the adoption as well as new innovation in IoT and remote sensing, big data and artificial intelligence, smaller farm implements for mechanizing small farm holdings, robotics, full stack farm 2 fork digital solutions. In 1998, ITC’s eChaupal was drubbed as an innovative path and way forward for Indian agriculture. Times and technology have advanced by leaps and bounds. Indian agriculture must adopt these quickly and aggressively. This also brings another issue of digital education for the farmers and labourers in upskilling them in these new tools and techniques leveraging deep tech in agri.

New Age Food Processing to Enable Farm 2 Fork

In 1998, several recommendations were made to invest into the food processing and logistics to enable quicker movement of fresh produce from the farm 2 fork. A lot has been done in this front. However, the data on infra investments in this space show a skew towards the top-5 states of India. Another area of innovation is adoption of newer and latest food processing technologies with our ‘jugaad’ innovation including the cold chains and refers. The Covid vaccine distribution cold chain which would be an episodic exercise could be turned to alternative use post endemic in the remotest parts of India to create the linkages of cold chain.

Agri Labour Reforms

Several recommendations have been made to consolidate the farms and contract farmers into co-operatives and social enterprises. One of the steps in the right direction would be the Social Stock Exchange where these social agri enterprises can be listed and be professionally managed with transparent governance and funding. The other issue that is reskilling and employment generation for the displaced labour due to implementation of new age deep tech which would replace manual farm labour. We had recommended around 15% of undisguised labour to be migrated out of agriculture to other sectors for employment. During the Covid Crisis, Rural BPOs have grown over 10-fold, its these ideas for alternative employment generation and reskilling that needs to creatively addressed.

Finally, Funding, Funding, Funding

Apart from the Central and State Government budgetary support to the sector for funding and apex financial institution NABARD, in the last 20 years there were a few focused providers of risk capital to this sector which I can count on my finger tips. These included PE/VC offshoots of large corporate houses with interest in food and agri and multinational agri-focussed banks. I believe the ESG Funds, new age VCs and the Social Stock Exchange Regulations will provide newer players to step into this sector. One of the hang over of the last 20 years had been the accumulated gun-powder that needs to be monitised.

Why Food-Health Alchemy is the Need?

As an investor in core healthcare sector, why am I writing this to set up the discussions on food and agri reforms? Our learning from our investments in nutrigenomics venture was that the new age diseases and syndromes emerging in healthcare is the outcome of what we eat. The food and nutrition consumption basket of Indians has dramatically altered over the last 20 years since my Britannia days. The national well being of Indian population depends on the nutritional outputs from the food and agri sector. Therefore I may now like to alter the slogan which we coined in 1998 to

“Kisan Ugaye (farmer grows)

Janta Khaye (population feeds)

Kisan aur Janta Swasth Rahe (farmer and population remains healthy)

Aur Desh Aage Badh Jaye” (and the country advances)

For more recent update on the issue of Farm Bill and Agri and Agritech Reforms listen to QuoteUnQuote with KK – Kapil Khandelwal (KK) and Mark Kahn on The Future of Agriculture: AgriTech and Government Reforms

Sustainability Heat Map of State-level Digital Health Initiatives in the New Normal in India

Preamble

The Covid Crisis has opened up many digital health initiatives by many State Governments as a crisis management initiative. Over 300 such initiatives were launched by various State Governments across India for management of Covid as part of their charter for health management. As we shift to the new normal, many of these efforts by the State Governments would either shut down or pivot into general health management initiatives. We caried out an exercise to create a sustainability index on whether they would continue or not.

Approach and Methodology

We carried out a nationwide survey on the Covid-based digital health initiatives. The information was collected through State Health Missions, State Health Department, their websites, doctors connect and various reports. Out of the 300 and more initiatives, we narrowed down to around 75 key initiatives across the States. An analysis of the functionality of these digital health initiatives by the State Governments can be categorized into eight broad categories. These are:

  1. Home Quarantine Tracking         
  2. Travel/Tracking
  3. Covid Chatbot  
  4. Covid Testing   
  5. Telemedicine   
  6. Drones/Robots/Surveillance/Tracking         
  7. Health Worker Management        
  8. Information/Fake News

These initiatives were accessed for their sustainability heat map on the following parameters:

  1. Digital applications
  2. Master data and architecture
  3. Pivotability
  4. New normal use cases
  5. Costs and capital for sustainability
  6. Management in the new normal
  7. Private sector partners
  8. Techno-commercial viability
  9. State regulatory issues
  10. Best practices for Covid management
  11. Others

State Covid Initiatives Sustainability Heat Map

Based on the analysis, we have drawn down a heat map as shown below:

image
Source: EquNev Capital Analysis

Our Conclusions

Based on our heat map, we see only 15% of the current applications that can sustain in the new normal. While we understand that these digital health initiatives were hastily drawn up in early-April 2020, the state health budgets and other issues to get these applications off the ground to create quick citizen impact, over the longer-term such digital health initiatives need to be thought through for a longer time frame as was discussed in my podcast The Promise of Digital Health: For Everyone, Everywhere. QuoteUnQuote with KK – Kapil Khandelwal (KK)

However, this time frame was a solid testing ground for how successful can digital health be in various states of India as healthcare is a state subject. Based on the information, Digital Health in India, holds promise.

Our Recommendations on the Working Group Report on Inclusive Regulatory Framework for Social Stock Exchange (SSE) in India

Cover Letter to SEBI Social Stock Exchange Working Group

Shri Ishaat Hussain

Chairman, SEBI Social Stock Exchange Working Group

Plot No. C 4-A , G Block, SEBI Bhavan, Bandra Kurla Complex, Bandra East,

Mumbai – 400051

Dear Sir,

Re: Our Recommendations on the Working Group Report on Social Stock Exchange (SSE)

At the outset we would like to congratulate you and the working group and the SEBI team along with the external agencies that have worked on drafting the regulations for the SSE for the nation. We believe that a SSE would lead to widening the investor base and also bring to fore the impact investments into this country. We had been involved in discussions with SEBI even before the formation of the working group and provided inputs on what should be the nature of the regulations to guide the investments in the healthcare industry in India.

We are India’s first healthcare infrastructure fund under SEBI AIF-II regulations. We propose to list our fund as a Healthcare REIT. We have therefore focused our note on the issues with respect to healthcare only. As healthcare is a social infrastructure, we and our limited partner and investors believe that a regulation from the SSE and its inclusive definition would go a long way in bringing to the fold of the investment ambit healthcare infrastructure which is being operated under trusts and societies. In addition, we believe that the measurement of impact for healthcare is not only primary but also secondary level. As part of our note we have outlined our recommendations which would be inclusive in nature and would appreciate be considered into the working draft recommendations.

Our review and recommendations for the draft regulations are under the following heads:

  1. All encompassing definitions of operators/players in the social sector
  2. Increased definition of scope of impact which are acceptable by ESG and impact investors
  3. Sustainability and limitations of grants and aids for social projects
  4. Wider inclusion of Alternative Investment Funds (AIF) and relaxations of various limitations under SEBI AIF Regulations
  5. GST waivers and set offs for the social sector like healthcare infra
  6. Regulations for social sector ventures for social credit rating
  7. Sale and lease back for infrastructure under the trusts and societies for asset monetization
  8. Listing and trading norms for wider market participation on the SSE including market making
  9. Participation of CSR funds into healthcare infra
  10. Special purpose vehicles (SPVs) listing of healthcare PPPs with community and social impact
  11. Regulations for pivoting from for profit to not for profit and vice versa and exit for failed ventures
  12. Other regulatory issues

Further, this note may not have been possible during the times of Covid, with inputs and efforts put in by our limited partner who are multilateral agencies, impact and ESG funds, sovereign

funds and several family office investors from India and abroad. We would like to also mention the efforts of our legal counsels Khaitan & Co, Mr. Siddharth Shah, Mr. Divaspati Singh and Mr. Anindya Roy who have worked in compiling the recommendations together into this note. Along the way, I had spoken with several institutions and industry bodies, both in impact and healthcare, in the country for their views. I thank them for their candid views and observations in framing the guidance to this note.

Once again, thank you all for your time and contributions to giving this nation a strong and robust social investment regulations, guiding path and the way forward. I would appreciate if we can be given a chance to discuss the various points outlined in our note.

Awaiting your response.

Stay Safe

With Warm Regards,

Kapil Khandelwal

Toro Finserve LLP

Managing Partner

Preamble

The establishing of the Social Stock Exchange in India (SSE) is a positive step in the creation of a vibrant capital markets for the social sector. The Working Group Report published by SEBI for the public consumption and response has been reviewed by us and we offer our feedback which we have taken from our investors (some of them are impact and global multilateral funding agencies). We would like to offer our recommendations and inputs for consideration.

Healthcare in India with focus on the Charities and Impact Organisations      

India lags behind on several parameters on SGD-3. One of the reasons is the lagging investments in healthcare infrastructure and spending. On the issue of donor led spending, the participation by donors and external agencies in healthcare has increased from 0.01% of GDP in 2009 to 0.03% of GDP in 2016. The overall healthcare investments through PE/VCs in India is around USD 5.3 bn till June 2018 making it the third largest sector after ICT and BFSI sectors.

Of the total hospital beds in India, 40% of the hospital beds in India are provided by Government (and allied organisations), approximately 5% of the beds are charitable and or subsidized in medical colleges teaching hospitals. A large proportion of these charitable beds are in urban areas which are provided by for profit sector in lieu of concessional land. A recent press report stated that in Mumbai around 89% of the charitable beds earmarked for not-for-profit remained unoccupied during Covid-19.

An article publish in VC Circle by Toro Finserve LLP estimated the healthcare spend on the BoP in India which could translate through the social ventures servicing this population is estimated to be around $1 trillion by 2025 across all products and services for healthcare. The expected healthcare investments to be around $275-350 billion in infrastructure gap funding. The addressable social ventures that would qualify to be listed on the SSE would potentially deliver an annual turnover to be around $5 billion on a conservative basis.

The above estimates would remain elusive unless an inclusive regulatory framework is adopted for the social stock exchange in India and is an attractive proposition for our impact and ESG investors from abroad which is attractive for them to participate.

Over and above, the impact to SGDs and incremental social healthcare capacity creation in India, an inclusive regulation will also lead to:

  • Direct and indirect employment in the healthcare and allied infrastructure creation sector
  • Provision of long-term, perpetual capital to the healthcare infrastructure development
  • Economies of scale of many operators platforms to take them to IPOs and provide investor liquidity
  • Increased investment in newer innovation and clinical solutions to provide healthcare cheaper, better and faster
  • Adequate investment in technology to provide digital health and create smart hospitals
  • Reduced costs and improved quality of healthcare delivery to the masses without any burden on the healthcare operators to repay bank and NBFC debts
  • Creating of Healthcare REIT/InvIT as a separate investment asset class for channelising domestic and foreign investment which has been lagging for the last 4 years despite positive policy initiatives

Inclusive Regulatory Framework for Social Stock Exchange

Our review and recommendations for the draft regulations are under the following heads:

  1. All encompassing definitions of operators/players in the social sector
  2. Increased definition of scope of impact which are acceptable by ESG and impact investors
  3. Sustainability and limitations of grants and aids for social projects
  4. Wider inclusion of Alternative Investment Funds (AIF) and relaxations of various limitations under SEBI AIF Regulations
  5. GST waivers and set offs for the social sector like healthcare infra
  6. Regulations for social sector ventures for social credit rating
  7. Sale and lease back for infrastructure under the trusts and societies for asset monetization
  8. Listing and trading norms for wider market participation on the SSE including market making
  9. Participation of CSR funds into healthcare infra
  10. Special purpose vehicles (SPVs) listing of healthcare PPPs with community and social impact
  11. Regulations for pivoting from for profit to not for profit and vice versa and exit for failed ventures
  12. Other regulatory issues

All encompassing definitions of operators/players in the social sector

The current definitions as given in the report delineates between not for profit and for profit. There are no shades of grey (hybrid models of business) in the draft regulations.

We would like to submit that the definition of a social enterprise should ideally, seek to select a class or category of enterprises that are engaging in the business of “creating positive social impact”. It is our belief that the definitions should be all-encompassing requiring all social enterprises, whether they are FPEs or NPOs, to state an intent to create positive social impact, to describe the nature of the impact they wish to create, and to report the impact that they have created; and the differentiation should not be solely on the criteria of muted returns. There can be various hybrid models created by combining characteristics of both an FPE and an NPO. In our view, the current distinction as provided in the report does not afford enough flexibility to encompass all such possible models. The parameters of what constitutes a ‘positive social impact’ should be inclusive in nature and only by taking such a holistic view of the SSE could we hope to address the issue of the funding gap that this mechanism is expected to resolve. Given the ambiguity around the definitions, the SSE regulations must provide standard definitions to determine whether the model will predominantly provide space for non-profits or for-profit organisations or other hybrid structures.

For example, even schedule VII of the Companies Act uses the words “activities which may be included by companies in their Corporate Social Responsibility Policies” to indicate a list of exhaustive items which may be consider within the ambit of CSR activities by companies. In comparison, both the SASIX in South Africa and Singapore’s Impact Investment Exchange – prescribe social impact to be measured by the outcome in the community and not on muted returns.

In our view, the SSE should have a clear definition of what constitutes a ‘social cause’ and a ‘socially responsible’ act. The definition should also be dynamic to accommodate events that may emerge, such as Covid-19, or cyclone, that would require area-specific funds. We would further submit that the SSE should allow the listing of various assets encompassing a wide array of sectors such as healthcare, education, food, healthcare assets, colleges, schools, minimum development goals etc. This would inject a much needed impetus to overall social development by providing additional fund raising options in these sectors. It would also allow existing investors to offload their assets by listing on the SSE and utilise the money for other viable purposes ensuring a wholistic growth in the economy. Therefore, it is our submission that the ambit of social impact should be kept as broad as possible delineating between FPEs and NPOs, in order to truly enable holistic social development.

Increased definition of scope of impact which are acceptable by ESG and impact investors

Investment into healthcare social infrastructure not only creates bed capacity for population health management and impacting SGDs, but creates various axis of social impact for the Indian economy. These include the following when considering the direct and indirect impact of investment in healthcare infrastructure development that have been accepted by many of our ESG and impact investors as benchmarks:

Table deleted from here due to confidentiality reasons

We therefore submit that the scope of primary and secondary impact to the community needs to be defined into the draft report

Sustainability and limitations of grants and aids for social projects

During my work with the health and ICT Ministers’ Panel for Africa, one of the key fundamental drawback felt by the Governments was that 95% of the projects initiated by donors through grants and aid failed to sustain themselves through the self-funding by the communities once the donor’s grants and aids completed their tenure. The issues project completion and impact post grants and continued funding became very critical. Another issue was the measurement of the impact post exit of the donors. Social healthcare infrastructure project need sustainable upfront funding which need to be closed else projects would not complete

Hence, the scope of grants and aids should be tied to the overall project costs and operations till viability is establish. The regulations need to provide tighter norms for projects funded through grants and aid and not be allowed to kick off till funding closure is announced.

Wider inclusion of Alternative Investment Funds (AIF) under SEBI Regulations

The current draft talks about the AIF -1 Social Venture Capital. As India’s first healthcare infrastructure fund, we are registered under AIF- 2 regulations. We propose to exit the investments we make in for profit and not for profit and select hybrid models with impact in hospital infrastructure, we would like to understand the split between and investment criterial for listing of Social Healthcare REITs on SSE and for profit healthcare REITs on the NSE. We have evaluated the Singapore model. It creates flexibility on price discovery and is not so water tight.

It is submitted that even Category II AIFs may invest in social sectors and cause overall social impact and therefore even such AIFs should be allowed to be listed on the SSE. Here it is our submission that the regulators should consider either designing a general framework of pooling for this purpose which will apply across all regulations, whether AIFs (Cat1, 2 or REITs), or in the alternative create a special class of AIFs for social impact. from a regulatory point of view, that a new category of AIF structured similar to a ‘social venture fund’ may be introduced – the criteria for determination of which would correlate with its positive spillover effects on the economy. Such new class of AIFs should have the benefits of pooling coupled with the flexibility of investing in an identified asset and should be free from the limitations of diversification norms otherwise applicable to other AIFs.

AIFs have the potential to become the best source of additional capital to undertake the desired projects in the social sector given the overwhelming need for additional capital in such sectors in India. To reiterate, under the SEBI AIF regulations, Category I and II Alternative Investment Funds are prohibited from investing more than twenty five percent of their investible funds in one Investee Company. Which is restrictive in itself in the context of social upheaval as it does not provide the flexibility to invest more capital in a single project as may be required. We would humbly request for this restriction to be relaxed in case of a Cat I or Cat II AIF which is eligible to be listed on SSE or provide an exemption from the aforementioned 25% limit to the new category of AIFs specifically designed for this purpose.  

GST waivers and set offs for the social healthcare infra

The current draft has discussed on tax holidays and waivers for social ventures and their investors under the Income Tax Act. Social healthcare infrastructure also attracts GST across the value chain which is being incurred by the social healthcare ventures. However there is zero GST on healthcare for the final services being delivered to the community and is currently not offsetable. As a result the entire burden falls on the social healthcare venture operator and its donors if the final services to the community is fully subsidized.

From the social healthcare infra creation, in the current Goods and Services Tax (GST) regime of charging non-offsetable tax on rent from social healthcare operators makes the cost of funding prohibitive and reduces the net fund in hands of hospital operators to create incremental bed capacity by almost 20% in the country. GST on rent is virtually not offsetable because healthcare operators are exempt from charging GST to its patients / customers and that therefore, is a major roadblock for hospital operators to raise long-term affordable finance to create additional bed capacity in the country. Adequate policy measures need to be introduced to streamline the GST regime for financing healthcare infrastructure through sale and lease back transactions in India in line with bank and NBFC debt which do not attract any GST tax on financing healthcare infrastructure.

We submit that GST offset on the healthcare and allied services increases the burden to the operator and donors and needs to be removed as part of the tax recommendations in addition to the direct taxes recommendations provided by the draft regulations.

Regulations for social sector ventures for social credit rating

Banks and NBFCs do not consider the social and community impacts while providing debt finance to social sector healthcare operators. Our Healthcare REIT/InvIT model considers and ensures these impacts while investing into social sector healthcare operators through the sale and lease back modus of financing healthcare infrastructure. A change in the rating methodology for social sector infrastructure like healthcare is required to be considered for social healthcare ventures.

We therefore submit that the draft should recommend setting of separate rating guidelines for social ventures in India by the credit rating agencies for various instruments being used by the social ventures

Sale and lease back for infrastructure under the trusts and societies for asset monetization

As per our industry estimates around INR 75,000 crs of healthcare infrastructure is the dry gun powder that needs upgrade and expansion funding is residing on the trusts and charitable societies in India. These healthcare operators are currently financing their growth by using funds raised via:

  • Loan Against Property (Hospitals) from Banks (cheaper, limited amount, short tenure, not for debt averse operators)
  • Land Acquisition / Development finance from a Financial Investor (expensive and limited)

A new model of financing growth for such operators has opened up since SEBI announced the REIT / InvIT regulations (cheaper, cleaner and control neutral). This enables the hospital operators to monetize its “dead” hospital infrastructure assets and raise perpetual capital to fund its future growth opportunities. This is done via sale-lease back model where the operator sells the hospital infrastructure to a professional property investor while also signing a long-term lease to ensure business continuity. This enables the property investor to earn rental income while it provides the Hospital Operator with perpetual and affordable source of capital and becoming asset-lite – a win-win situation for all parties concerned.

REITs also have certain listing limitations under the current regulatory regime – which should be relaxed in the event they become eligible to be listed on the SSE. The SSE should also enable debt, equity or perpetual debt instruments to be listed through SPV structures.

Listing and trading norms for wider market participation on the SSE including market making

Under the current AIF regime, units of close ended AIFs are allowed to be listed on stock exchanges subject to a minimum tradable lot of one crore rupees. In light of our recommendation for a separate category of AIFs, the listing for such category of AIFs should be allowed with the minimum tradeable lot for such AIFs being made smaller, in region of 10 – 15 lakhs instead of the more cumbersome 1 crore requirement. The AIF may also hold assets directly, i.e. hospital assets through a single AIF and units of such AIF will get listed. It is humbly submitted that an SPV created for such purposes is listed then in additional to equity listing, perpetual bond listing should also be allowed at the SPV level.

Participation of CSR funds into healthcare infra

Please note that the same asset that engages in ‘for profit’ ventures to initiate social impact may also consider raising CSR money at a ‘for profit’ bond / equity interest.  It is submitted that clear guidelines should be introduced on how CSR funds can be deployed via SSE.

Under the current CSR regime (as per the Companies Act) there is no provision for one company’s CSR monies to be combined with and added to monies of other companies CSR, i.e. there is no concept of pooling and/ or co-participation under the current regime. For example, if the resources of various companies could be pooled together in partnership with the government and other creditable NGOs, the impact could be manifold. Where NGOs and corporates can bring in quality, but scaling is possible only with the involvement of the government. This co-participation may be in the form of cash or in the form of valuable knowledge sharing / experience or personnel that one company may benefit from others. Smaller companies may benefit greatly from such overall changes to the regime given the 5 percent limit on overheads stipulated by the government. Smaller CSR spenders can only deploy a limited amount in the form of administration expenses and hence the sample size of projects they can invest in are much lesser in number and quantity. This often leads to sub-optimal allocation of funds, with a disconnect between capital deployment and on-ground realities.

Therefore, while the CSR regime currently encourages collaboration between companies to help avoid duplication of managerial efforts, infrastructure, personnel amongst other factors, it does not explicitly mention / allow ‘pooling of funds’. We humbly submit that a minor modification in the act could address this aspect. We believe that pooling CSR spends of companies can unlock a myriad number of opportunities in addressing India’s most pressing challenges in the social sector.

SPVs listing of healthcare PPPs with community and social impact

As member of the Planning Commissions’s PPP Committee for Healthcare Infra under UPA -1 chaired by Dr. Hamied and Haldea, several recommendations were given to fast track PPP in Healthcare. However, the issue of concessioning and operating costs of providing community healthcare to the masses has been the bone of contention. The recent Orissa PPP bids front ended by IFC has failed to elicit bidders due to the same reasons.

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 LP investors as the PPP policies have failed to garner interest.

The current National Infrastructure Pipleline published in Dec 2019, 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. Many of our multilateral funding agencies who are also LPs in our fund would like to participate in the social healthcare.

Innovative SPV structures need to be created where the concessions can be funded by the multi lateral agencies and ESGs for the impact to the communities while the Central and State Governments exit their assets to private operators. These SPVs can be listed on the SSE and actively traded or subscribed to by these LPs.

The government should consider creation of such hybrid impact models involving private-sector partnerships to provide critically-needed health infrastructure.  For profit models may be considered even in this sector which is lagging behind for want of funding from interested LPs. The bid evaluation process in PPP / concession agreements may be relooked at in order to require more concrete bids showing higher levels of commitment from lenders and to eliminate bids that are not in line with commercial projections. An alternative may be for governmental bodies to exit foible projects and letting the operator / agencies pool / fund the concessions through SPV structures. Such SPV structures with underlying PPP projects may be listed on the SSE platform for turnaround and subscribed to by willing investors thereby achieving a turnaround of otherwise stagnant developmental projects.

Regulations for pivoting from for profit to not for profit and vice versa and exit for failed ventures

There have been many instances in the past where social healthcare ventures in trusts which could not be sustained by the promoters and settlers of the trust/societies (see case study) to for profit business models due to various business models, strategic and sustainability issues. The current regulations are fairly prohibitive and do not consider pivoting from not for profit to for profit business models as a going concern. The current draft does not consider these scenarios nor make any recommendations on these exits.

We request that the draft regulations look into provisions for pivoting the business models from for profit to not for profit and vice versa and frictionless exit regulations need to be drafted for a going concern scenarios.

We would like to further submit that LPs should be allowed to exit in the event social ventures are not sustainable for their businesses. Otherwise such models become less lucrative and newer LPs may not participate in such models given the inflexibility around it. Therefore, there is a need to provide a flexible mechanism to allow LPs to exit, be it from a ‘non-profit’ to a ‘for profit’ model or vice versa.

Other regulatory issues

Thin capitalization rules

SPVs / acquisition companies are set up in India to raise money (through debt or equity) for the purposes of financing the said acquisition. While restrictions on debt financing of acquisitions still exist, India has seen a steady increase in the use of innovative financial instruments to fund such acquisitions. Thin capitalisation refers to the situation in which a company is financed / leveraged through a relatively high level of debt compared to equity.

Current IT Act provisions restrict the payment of interest by an entity to its ‘Associated Enterprise’ to the extent of 30% of its earnings before interest, taxes, depreciation and amortization (EBITDA) or interest paid or payable to associated enterprise, whichever is less.

In view of the non-deductibility of the interest expense beyond the de minimis threshold as stated above, investors investing through perpetuity debt instruments, do not have access to such an exemption. It is our humble submission that this exemption be allowed for SPVs with a higher debt component, which are eligible to be listed on the SSE satisfying all relevant criteria.

Flexibility in order to get CSR funding

In the event an FPE is converted into a NPO, such organization should be allowed access to CSR funding and this should be expressly mentioned under the SSE regulations.

Relaxation on listing requirements of REITs

We request that the current considerations which are otherwise applicable around listing of REITs be relaxed to an extent in the event of such REIT being eligible to be listed on the SSE. Such considerations include restrictions on minimum subscription amounts (INR 50,000), minimum tradable lots (200), minimum value of such REIT assets (i.e INR 500 cr) etc. The restrictions for example, may disallow listing of REITs focussed on the hospital sector on the SSE in the event such minimum criteria are not met. Relaxation of these norms would allow for a more holistic growth of the sector by allowing much wider participation and garnering more interest from investors. Similar to our recommendation in relation to AIFs, the regulator may also consider carving out a separate type of REIT for this purpose.

Case Studies for Consideration

Deleted from here for confidentiality reasons

 

Conclusion

Fostering widespread engagement among investors will be vital to raise adequate capital to fund projects in social sectors. Some of the suggested incentives will be important for both market participants willing to invest and social purpose organisations which are willing to get listed. The wide-reaching economic impact of COVID-19 has resulted in a surge of areas where investments can be made. As envisaged, in order for SSE to be a platform to facilitate raising of capital in such sectors for them to recover and turn-around from the crisis, these measures would only assist in driving more engagement from the relevant market players and ensure that the objectives behind formulation of SSE is met. We therefore request your kind consideration around the suggested recommendations outlined in this note.

From Telegraph Road to US$50 Billion Digital Health Silk Road

Digital Silk Road

Preamble

There have been very positive developments for Indian healthcare on the digital front. First, the Indian Telemedicine Guidelines and then the National Digital Health Mission (NDHM). From various think tanks and industry bodies there have been various numbers been project on the incremental value that these will create for the Indian economy. While it is wishful to conjecture the US$ 250 billion dollar impact, what hums in my mind is the Dire Straits famous 14-minutes “Telegraph Road” song. At that time, Mark Knopfler was reading the novel The Growth Of the Soil by the Nobel Prize winning Norwegian author Knut Hamsun and he was inspired to put the two together and write a song about the beginning of the development along Telegraph Road and the changes over the ensuing decades. Using the same analogy, the development of India’s Digital Health Silk Road is feasible on the back of the physical and human healthcare infrastructure. So let’s tune in to my song!

Song Intro – India’s State of Wild-Wild West Healthcare Underdevelopment

India is a country of paradoxes for healthcare infrastructure. India has 18% of world’s population. However, it has around 18% of world’s diseases burden which is increasing. To service this diseases burden, this increasing disease burden, India has only 2.4% of world’s land mass and needs approx 0.01% of world’s land usage for health and well-being purposes. On the clinical manpower supply, India has 1% of world’s lab techs, 9% of world’s health workers, 8% of world’s nurses and doctors. To level up India to the global average, the total investment is approx $460 billion now (165 countries in the world had a GDP of less than $460 billion in 2018). (see Tedx talks My Presentations – Kapil Khandelwal (KK) To address the country’s healthcare needs within the constraints of capital, land and clinical manpower, homegrown solutions are required. At per capita healthcare spend of INR 4116 (USD 55), India’s per capital spend is growing @ 22% pa. However, India is amongst the lowest 4 countries (ranked 129) in the world on healthcare spend as per Oxfam’s latest Commitment to Reducing Inequality Index 2020 at 4% of GDP (against the globally recommended 15% of GDP).

Song Pre-Chorus – Healthcare Gold Rush to the Wild West due to Covid

Let’s set the context under which there has been an accelerated push for healthcare digitization in India. The Great Covid Lockdown. Elective healthcare were down by 70% across the board due to lockdown and priority to Covid affected. The healthcare industry started rumbling and requesting Government to come out with a bail-out package of over INR 50000 crs. Doctors needed to restart their practice through work from home or anywhere. The decade-long deadlock on the telemedicine act between Medical Council of India (MCI) and the Ministry suddenly cleared. There was a mutual agreement to develop the telemedicine road and to regulate the gold rush road to telemedicine in India.

Song Verse – New Digital Health Regulations

The actual verse of the telemedicine regulations in India was announced by the Niti Aayog and the MCI. The Prime Minister in his verse of Independence Day speech also announced the National Digital Health Mission (NDHM). The draft verse of the digital health regulation was available for the general public to review and critique. This was the back drop to the crescendo of the industry chorus on the digital health in India and the opportunity it offered.

Song Chorus – Industry Estimates and Reports

With the regulatory verse out in the public, the industry voice chorus on the real impact to the Indian economy initiated. One industry report estimated the pace of digital healthcare can unlock USD 200 to 250 billion in next 10 years in terms of primary and secondary impact to the nation’s economic value. These value-creation in the march to the wild west will be on three key roads:

  • Road 1: From episodic care to wellness-oriented care
  • Road 2: From volume-based to value-based healthcare
  • Road 3: From siloed systems to streamlined processes

While such stratospheric estimates at a Concorde-neck supersonic speed of the digital health silk road to the Wild West is great for headlines for the chorus, let’s not fool ourselves with the history of what the retail (brick and mortar) and ecommerce underwent in the past decade which went super sonic with investments and valuations on digital retail commerce in India. I have been writing about various issues and roadblocks to digital health path in my various columns which are available at My Library – Kapil Khandelwal (KK)

Song Bridge/Solo – My Estimates on the Investments and On Ground Reality and Impact

For any song chorus there is also a bridge/solo that makes the real sense. Here is my view of the chorus. The last decade received around USD 500 million in different ventures of digital health which were cut-past healthcare business models of the West. The current technology spend on these is around USD 500 million per annum. For the USD 250 billion impact on the ground to be realized a straight forward deep healthtech investments of around 5% (around USD 12.5 billion) is to be right away with a gestational lag of around 3 years on a conservative 2x on valuations return and not on revenue growth. In other words, all the sum total of early stage VC money raised in 2019 globally will have to be directed to India and that too in healthtech. A tough ask and a pipe dream.

Let’s also focus on the available data sets which is the oil to run the digital health motorway in India that we currently have. Currently, India’s data sets on healthcare is of the Telegraph road era. These include information on radiology, EMR, labs, meds, monitoring, doctor exam, nurse observations, claims data, billing and transactions. This data set is available for the Bharat Stack 1 (the elite-12% of India’s population). The real driver for the growth is the Bharat Stack 2 (the next billion of India’s population) and 30-odd points of healthcare data (not under the current NDHM regulations) which will make the digital health silk road truly a reality. An incremental investments of USD 18 billion in deep tech ventures in next generation digital health ventures to create a true high-speed digital health motorway of the future.

Therefore to land the stratospheric Concorde of the chorus that were singing, we require a total of USD 30 billion of tech investments on the word go. Where is that sort of money? We still don’t know where this money raised will be invested and that is not the point we are belabouring. Taking that cue, we have been tracking around 150 healthtech ventures in our annual healthcare and life sciences investment heatmap on digital. We will need to create 10000s of ventures that can create the depth and width of healthcare apps for the next billion today!

Song Outro – The Rhythmic Orchestration of Capacity Creation in Physical and Digital Healthcare

While most songs orchestra fade and end abruptly, this India digital health silk road would need a different Outro to its song. On a conservative basis, we estimated that the overall India digital health silk road opportunity is valued conservatively at USD 50 billion as it currently stands with the different constraints in our physical and technology healthcare delivery system. This is on the back of three key multiplier effect on the Indian healthcare economy:

  1. Increasing per capita spend on health and well being of the next 1 billion population as disposable incomes goes up moving from the informal sector to formal sector in next 10 years
  2. Incremental 1/6th disease burden our population carries as compared to world due to the genomic make up and ageing population in next 10 years through alternative healthcare delivery models
  3. Emerging alternative digital healthcare delivery models that would play on the shortages in the physical delivery system as penetration and acceptance of mobile first delivery of healthcare services become mainstream and productivity of the clinical manpower is augmented by healthtech

Money for Nothing – Covid Vaccines for Free

Another Mark Knopfler hit which talks about the excesses of a rock star and the easy life it brings compared with real work. Between the Independence Day announcement and the Bihar elections manifesto announcement, there seems to be shift in the focus and the priorities it seems from our Rock Star Prime Minister. The Government would not have the funds to spend on the Digital Health Silk Road if it spends its budget on providing free Covid Vaccines to the masses.

Only time will tell how the orchestra and the song of the great India digital health gold rush will play out!

Excerpts of this blog published as an article in VC Circle: