New Healthcare Bills in Parliament in Monsoon Session 2023

Background

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

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

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

The Drugs, Medical Devices and Cosmetics Bill 2023

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

The National Dental Bill 2023

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

The National Nursing and Midwifery Commission Bill 2023

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

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

The National Research Foundation Bill 2023

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

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

The Biological Diversity (Amendment) Bill 2022

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

The Forest (Conservation) Amendment Bill 2023

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

Environment Minister Bhupendra Yadav will be introducing the Bill.

The DNA Technology Bill (Use and Application) Regulation

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

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

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

Digital and Tele Health : An Investors Perspective

My Key Note Address at the TeleMedicon 2021

Prime Minister’s Task Force on Food and Agriculture Reforms

PM Task Force on Food and Agri Reform

The Executive Summary of the Recommendations of Prime Minister (Atal Bihari Bajpayee) Task Force on Food and Agriculture Reform in India presented in November 1998

Also Read Blog: Food And Agri Reforms | Kapil Khandelwal KK

Also Listen Podcast

What’s Next? Operation Himalaya?

Operations Himalaya

Preamble

Operation Ganga was an evacuation operation by the Government of India to evacuate the Indian citizens amidst the 2022 Russian invasion of Ukraine, who had crossed over to neighboring countries. This involved transport assistance from the neighboring countries of Romania, Hungary, Poland, Moldova, Slovakia to reach India. Over 20,000 medical students were evacuated in Operation Ganga. I have been writing and talking about it over the last 10 years. Let me outline the magnitude of the situation at hand. 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. 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. Given the shortage of merit quota seats in Indian medical colleges, students have to migrate abroad for pursuing their medical education. We need an upstream Operations Himalaya in earnest.

Vision for Operations Himalaya

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. The table outlines the future of Medical Education.

What is the Future of Medical Education?
As per the Milbanks Report on the Future of Academic Medicine 2025, there are 3 key trends that are impacting medical education

Digitalization of Healthcare
new science and technology, particularly genetics and IT
speed of internet and digitalization
unimportance of distances
24/7 society
lack of agreement on where healthcare begins and ends

Personalization of Healthcare
rich and poor gap
seeking “wellness” and rise of self-care & sophistication
increasing anxiety about security and ethical issues
emergent diseases

Globalization of Healthcare
gap between what can be done and what can be afforded
increasing accountability of all institutions
loss of respect for experts (more so after the pandemic)
economic and political rise of India and China

Future of Medical Education

There needs to be a top-down vision for expanding the supply of clinical manpower in India which needs to be tied to the healthcare outcomes our healthcare system needs to achieve. The following framework which I presented earlier outlines the process for setting up the vision.

Our Health Markers – Linking Medical Education and Health

In the past I have defined these as the 3 A’s.

Affordability: The Cost and Benefits of Developing Careers in Healthcare in India
Accessibility: Providing trained staff in different parts of India
Assurance: Training to medical professionals meets global standards to perform in any healthcare system

Key Issues: Healthcare Manpower Economics:

It costs approximately Rs 2 crores per seat to set up a medical college for 100 seats in India. While this may be economical, investments in medical colleges and doctor training is a lengthy process; therefore, changes implemented to alter supply do not have immediate effects on the supply of trained healthcare professionals. A recent estimate reveals that as many as 40% of rural posting by trained medical graduates and post graduates in different states in India are not fulfilled. There is a huge shortage of gynaecologists, cardiologists and child specialists in rural hospitals in the government sectors. Hence the government announcement to increase the supply of medical graduates may still not address the accessibility issue. We may end up importing clinical manpower from lower cost destinations if we are not able to produce these cost effectively in India.

Medical education is supposed to be overseen by the different Councils of India, which is responsible for ensuring the quality of both the infrastructure and the professors at India’s medical institutes and also provide assurance that they meet the global standards. Since demand is high, it is difficult for schools to retain faculty over the long term, which creates a lack of continuity in both the school’s practices and its policy. The plethora of new and underequipped medical schools will create more doctors and healthcare professionals on paper, but will lower the quality of the doctors produced, further exacerbating the preexisting shortage. So, while attempting to alleviate a shortage of doctors, India has managed to create a completely new crisis on top of the preexisting one – the shortage of teaching professionals in these medical collages. Various estimates put this somewhere between 75,000 to 100,000 trained teachers and professions currently.

Finally,

Mere policy announcement for opening up more medical colleges in India is not the panacea for solving the shortages in the supply of healthcare professionals and the people to train healthcare professionals. It is time we look at the issues holistically and plan for the future by going upstream towards the Himalaya from the current emergency evacuation of Operation Ganga!

https://open.spotify.com/episode/5SwlhKl1MYBEMM95usMh2U?si=e51b6fa5d2974e6d

Also Listen Podcast on Russia-Ukraine Conflict

Also Read Article published in my Column – A Dose of IT published in Deccan Chronicle and Asian Age – 14 February 2011

Rs 1 Crore crores Human Capital Impact – A Generation Lost

My presentation at the 21^st World Quality Congress a fortnight ago just highlighted the human capital impact due to healthcare and education in India. A whopping Rs 92,28,230 crores to the Indian economy at net present value! This is like creating over 1500 TCS or Infosys or Wipro in today’s size overnight in our economy.

Let us understand, although India has 18% of world’s student population that is the largest in the world, its policy and direction on higher education, including medical and health sciences sector is not clearly articulated towards inclusive development. Regulation, size of funding to this sector, both public and private is one of the key determinants of India’s ability to generate wealth (GDP). Moreover sectorial priorities and directions in sectors such as health sciences, infrastructure if not clearly addressed could create future crisis in the economy and further impede economic growth.

On the demand side, we already know that India contributes to 18% of world’s population, however its share of world’s disease burden is 20%. Hence to treat the increased disease burden, India requires incremental human capital of doctors, nurses and other health workers. But the issues get very grave for India. We have around 8% of world’s doctors, nurses and health workers. Hence we may have to create more human capital in healthcare to treat India’s disease burden. What’s more, of the Rs 490,000 crores we currently require for skills repair to make the current human capital coming out of our colleges and universities, approximately 25% of this is to the medical and nursing schools make the graduate doctors, nurses and health workers job ready.

On the supply side, there are competing careers options and sectors that await the aspirants that are entering the colleges and universities to take up courses. Using the Lev and Schwartz model for human capital valuation, we evaluated the value of different careers in health sciences versus other sectors. What is interesting is that a nurse who decides to work in India human capital value would be Rs 19 lakhs while a surgeons with a master’s degree is around Rs 1 crore. Other non medical sectors are equally attractive in terms of their human capital value. Hence the issue for India is how do we make this attractive for aspirants to take up medicine as a career. While shortage in supply of doctors, nurses and health workers in the economy will obviously push up their human capital value, knowing the disease burden of India. However, we will lose a whole generation of boomers!

But all is not lost for India. Our enrolment ratio in higher education is 12% and is half of China’s at 24% of all students passing out of secondary schools. Hence even to match China’s enrollment, we would create a total human capital of Rs 1 Crore crores using the same valuation model at higher education level. To meet this potential, we need to be opening over 25 colleges everyday for the next 3 years in the brick and mortar world!

We will again fail to create such huge capacity in the real brick and mortar world as we have under supplied the infrastructure sector due to the boom in other sector in the last decade. Hence the only option left behind for the present generation to graduate through higher education is through ICT (online) world. Over the last 5 years there have been many ventures that have come forward looking at the wider opportunity in the ICT space for medical education. However the key barriers have been the regulatory and accreditation agencies that have slowed down the mass adoption.

It is time that we wake up to the huge human capital potential awaiting India. If we fail to deliver, we not only diminish this human capital over Rs 1 Crore crores, but the increased disease burden that I wrote about in my earlier column would cost us over Rs 25,00,000 crores of diminished human capital potential!

It’s all about the quality of human capital we produce and how we produce it that will matter for this generation that is passing us in India. This is the biggest scam that none of our future generations in India will forgive us as Indians.

Budget 2022: When is Healthcare’s Amrit Kaal Coming?

Budget 2022

Preamble

On 1 February 2022, our Hon. Finance Minister presented her fourth budget in the Parliament and introduced the “Amrit Kaal” in Point 4 of her speech, “we are marking Azadi ka Amrit Mahotsav, and have entered into Amrit Kaal, the 25-year-long leadup to India@100. Hon’ble Prime Minister in his Independence Day address had set-out the vision for India@100.”

Point 5 of the Budget Speech outlined the vision for Amrit Kaal, “By achieving certain goals during the Amrit Kaal, the government aims to attain the vision. They are:

Complementing the macro-economic level growth focus with a micro-economic level all-inclusive welfare focus,
Promoting digital economy & fintech, technology enabled development, energy transition, and climate action, and
Relying on virtuous cycle starting from private investment with public capital investment helping to crowd-in private investment.

The Finance Minister has envisioned to develop ‘sunrise opportunities’ such as artificial intelligence, genomics, and pharmaceuticals to assist sustainable development and modernise the country. However, this is more on the supply side industrial development. But the core issue of healthcare infrastructure is not addressed. Envisioning the Indian population which we would like to be a healthy one by 2047 when we enter India@100. I believe that Budget 2022 missed out a huge opportunity in envisioning Healthcare 2047! Here are my reasons.

Current Undergoing Transformation in Healthcare

The country has undergone a tough time during the pandemic. The Government has played its enabling role in ensuring the supply chain disruptions with China does not lead into a health crisis of sorts. On the other hand, the funding of Covid-Vaccine and immunization has ensured that the country emerges quickly into an endemic phase of Covid pandemic. While this was going on, there was strengthening and upgrade of the digital health infrastructure. The pandemic has also taught lessons to the private healthcare delivery ecosystem to restructure their business models and ensure that there is a push toward lower costs healthcare delivery models. These transformations have demonstrated India’s resilience in its healthcare systems to face emergency situations like the current pandemic.

India’s Amrit Kaal’s Population Demographics

As the chart below demonstrates that India’s population by 2047 will be shifting towards middle age bulge. Over 300 million (~19% of the total population) will be senior citizens by 2047. Our dependency ratio will be around 40%. These 40% will be in the tax paying bracket which will provide the then Finance Minister in 2047 the revenues to spend for different welfare programs including healthcare.

India's Population Pyramid Shifts to 2047 — India’s Population Pyramid Shifts to 2047

Lessons from Elsewhere in the World

In early 2000, I was involved in restructuring the healthcare systems of Saudi Aramco. Being the largest oil producer in the world, the company had been underfunding the pension and healthcare benefits of their employees who were going to be retiring in the future. The financing of these healthcare benefits created a financial crisis of sorts which have to be funded.

USA has also being facing such challenges when its baby boomers have now become unproductive senior citizens and their total healthcare bill is currently 18% of their GDP.

Vision for India’s Amrit Kaal Healthcare Delivery to Avoid Maha Kaal

As per current estimates, our country requires USD 400 billion of investments in healthcare infrastructure on our current demography to meet the global norms. There are no allocation in the current National Infrastructure Pipeline (NIP) funding for healthcare. Therefore much of the investment will be private sector driven in the future for healthcare infrastructure.

Such experiences elsewhere in the world remind me that our Amrit Kaal in 2047 does not end up as Maha Kaal of our Amrit Kaal where we would have to look up to Indian Gods who were invoked to end the situation. There have been several demands in the last few budget to accord infrastructure status to the healthcare industry. The current budgetary allocations to healthcare all though increasing has not been sufficient to build capital formation for healthcare infrastructure in the country. From the current 2.5% of GDP, there needs to broaden the spend on healthcare. We need the real picture of the input and outputs in healthcare. With the current GST regime of zero tax on healthcare services, we are not able to gather the real value of healthcare in the country and healthcare should be under minimum GST slab so that there is pass through benefits of the inputs that are set off. This will lead to a lot of transparency and provide real hard estimates of healthcare spend of the country.

Assuming by 2047 our dependency ratio will be lower than today. Which means that the total taxpaying population in 2047 may be same as today or even lower. There needs to be a plan to ensure that current taxes from the current population who will become senior citizens by 2047 will be underfunded like in the examples that I have mentioned below, leading into a budgetary crisis.

In all earnest, given the current constraints the current budget 2022 could do so much for healthcare. But now that the Amrit Kaal is out of the bag, there needs adequate focus to healthcare to avoid healthcare Maha Kaal in 2047 when we enter India@100.

Who is Twitter to Adjudicate Life Sciences Opinion?

Preamble

I had written in my blog Ban Twitter | Kapil Khandelwal (KK) last year as Twitter refused to follow Indian regulations and also muzzle certain sections of religious and political voices and opinion from India by banning or suspending their twitter handle. Under the leadership of the New CEO, Twitter seems to be adjudicating opinion on Life Sciences and that too experts. The latest controversial account suspension is of Dr. Robert Malone.

Who Is Dr Robert Malone? Robert W Malone MD (rwmalonemd.com)

Malone is the father of mRNA vaccines. mRNA is the same technology used in COVID vaccines by Pfizer, J&J, etc in the US. He has served as an adjunct associate professor of biotechnology at Kennesaw State University, and he co-founded Atheric Pharmaceutical, a company that was contracted by the U.S. Army Medical Research Institute of Infectious Diseases in 2016. Malone has long been an outspoken critic of the global COVID vaccine rollout, warning of the risks of a rushed release and saying normal procedures have not been followed throughout the process. He has been crusading to stop vaccines from being mandated for children, and to stop corruption in the government and the medical-industrial complex and pharmaceutical industries.

He had over half a million followers on his Twitter account. On 27 December 2021, his account was permanently suspended for not adhering to Twitter’s Covid 19 misinformation policy.

He can still be followed via his substack page.

Muzzling Divergent Scientific Opinion on Social Media

As this pandemic is playing out, the so called official expert spokesperson of the US Government have been proven time and again how wrong they have been in guiding the public. In fact on of the experts and advisor to the US President, had gone on to rubbish the work of our scientist at IIT Delhi who published that they discovered four insertions in the spike glycoprotein of the Covid-19 virus which they say are not present in other coronaviruses. These experts have been using social media to guide or misguide the masses. As a result, the public opinion on the official experts is now suspect and individuals now want to assess both sides of the scientific views before excessing their personal judgement.

Twitter does not possess scientific material peer reviewers to state whether a certain scientific opinion is valid or not. It can at most highlight as not peer reviewed by a wider scientific community. This sort of baning scientific expert opinion is a dangerous trend. In future, the big-pharma can short change the scientific community’s opinion by muzzling their voices and views on social media. For the individuals who are interested in knowing the scientific voices will have to now put pressure for a much open, unbiased social media to allow for alternative scientific views to emerge.

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

Background

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

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

Notable Failures

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

Google Health

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

IBM Watson Health

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

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

UK NHS Spine Program

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

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

African ICT and Digital Initiatives

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

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

Why will India succeed?

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

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

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

Also read: Digital Health | Kapil Khandelwal (KK)

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

Google Health is not going to be there anymore.

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

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

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

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

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

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

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

Google Health, RiP!

Should Indian Government TikTok Twitter out?

Jack Dorsey in India 2018

Preamble

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

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

How Important is India for Twitter

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

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

Global Social Media Manipulation by Country

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

Atma Nirbhar of Twitter – The Koo

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

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

Covid Apartheid-Complete State-level Nationalisation of Hospitals?

Covid Apartheid

Covid Apartheid-Complete State-level Nationalisation of Hospitals?

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?

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!