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El Toro Finserve LLP

Why are Indians Losing Sleep? How do We Regulate Sleep?

Why are Indians Losing Sleep

Introduction

There are various sleep guidelines for adults from various experts and institutions that vary from 7 to 9 hours per night, every night. However, as we will discuss here, this is not be adequately being followed and complied by individuals in India and around the world. There are several individual (such as personal, socio-demographic, lifestyle, health) and work related (psychosocial and job) factors that affects and inhibits regular sleep patterns of individuals (see Box).

Factors Affecting Sleep - Lifestyle and health factors
Factors Affecting Sleep – Lifestyle and health factors
Factors Affecting Sleep - Personal and socio-demographic factors
Factors Affecting Sleep – Personal and socio-demographic factors
Factors Affecting Sleep - Workplace psychosocial and job factors
Factors Affecting Sleep – Workplace psychosocial and job factors

In our 2024: Healthcare & Lifesciences Investment Manifesto – Top 40 Future Bets, our bet #39 discussed about Sleep Biology. See 2024 – India Healthcare And Life Sciences Investment Manifesto | Kapil Khandelwal KK for more details. We believed that The traditional “one-size-fits-all” approach to sleep is becoming obsolete and we need to reimagine solutions under “Sleep Biology” given that we all understand the consequences of lack of proper sleep. Our hunch was that Gen Z and Millennian in India are more sleep deprived. This has turned out to be true. Meta analysis of all the research papers on Indians sleep or lack of sleep patterns is in the Annexure 1. Moreover, the recent report from various and our inhouse analysis gives a very grim view of why Indians are losing sleep?

Indian Sleeping Statistics

The chart below summarises the impact of lack of sleep among Indians and some of the causes for it. We will discuss the impact of lack of sleep later.

Indians Sleeping Statistics in a (S)nap
Indians Sleeping Statistics in a (S)nap

India Macro Sleep Economics

Sleep deprivation significantly impacts India’s Human Capital Index (HCI). Chronic sleep deprivation can lead to reduced cognitive abilities, lower productivity, and increased absenteeism. These factors collectively diminish the overall quality of human capital, which is crucial for economic growth and development. The chart below shows the overall impact to GDP for various countries, including India:

Macro Sleep Economics (Impact on GDP due to Lack/Less Sleep)
Macro Sleep Economics (Impact on GDP due to Lack/Less Sleep)

India is at risk of losing of GDP, an opportunity cost, as a nation over losing sleep of its citizens and this will be a huge issue in the future.

How do We Regulate Sleep? The National Sleep Monitoring and Regulatory Authority (NSMRA)

Given the loss of sleep and India’s GDP, there is a need to set up a National Sleep Monitoring and Regulatory Authority (NSMRA). This Authority will be empowered to ensure that there is a proper and enabling environment to assure that the issues emerging out of lack of citizen’s sleep are mitigated. The Authority will align with various health and labour initiatives and regulations prevailing in India. Some of the objectives, though not exhaustive, of NSMRA would be:

Indian Citizen Lifestyle Ethos and Culture

  • Set a consistent wake-up time
  • Limit time spent in bed on activities other than sleeping
  • Do not stay in bed unless asleep
  • Limit the use of electronic devices before bedtime
  • Limit the consumption of substances which may impair sleep quality
  • Address stressful issues long before bedtime
  • Exercise and alignment with

Labour and Employment Laws Modifications

  • Recognise the importance of sleep and the employer’s role in its promotion
  • Commit to build a culture to helping employees achieve better sleep outcomes

Work Environment Regulatory Guidance and Monitoring

  • Minimise variability in working hours and maximize employees’ control
  • Discourage the extended use of electronic devices
  • Address physical workplace risk factors
  • Combat workplace psychosocial risks
  • Provide facilities and amenities that help employees with their sleep hygiene
  • Design and build brighter workspaces
  • Support health workers in providing sleep-related help
  • Encourage employers to pay attention to sleep issues
  • Make use of existing workspace mandates and their enforcement
  • Introduce later school starting times
  • Raise general awareness of the benefits of sleep

Let’s look forward to Healthy India and Wealthy (GDP Opportunity Cost Savings)

Annexure 1

Sr No. Author Study Design Participants Group Sample Size(n) Age(Mean+SD)
/Age Group		 Assessment Tool Sleep Disorder Addressed JBI
Score (0-10)
1 H. K. Aggarwal et al., 2017 Cross sectional study CKD stage III to V patients 200 50.11+13.99 PSQI  Insomnia 7
2 S. Ahmad et al., 2013 Cross sectional study Adults with CKD 104 54.17+12.96 ISI, STOP-BANG  Insomnia 9
3 Jain et al., 2017 Cross sectional study Type-2 diabetes patients 50 48.25+19.05 ISI  Insomnia 7
4 Dahale et al., 2020 Multicentre cross sectional survey Elderly patients attending PHCs 1574 68.6+6.3 ISI  Insomnia 8
5 Uvais et al., 2021 Cross sectional study Nurse and other staff 347 29.12+6.85 ISI  Insomnia 7
6 Panda et al., 2012 Observational cross sectional study Healthy subjects accompanying patients 1050 35.1+8.7 ESS, PSQI RLS,
Insomnia		 9
7 Shivashankar et al., 2017 Cross sectional study Healthy participants 16287 42.03+12.43 Sleep Habbits questionnaire, ESS  Insomnia, EDS 6
8 Katyayan et al., 2019 Cross sectional study Healthy subjects 850 44.68+10.44 ESS, BQ, STOP
BANG 		 Insomnia 8
9 Dewan et al., 2022 Questionnaire-based survey study Dental students 1115 21+1.8 SLEEP-50
questionnaire (that had 50 questions)		 OSA,
Insomnia		 6
10 Jain et al., 2020 Cross sectional study Students University of Rajasthan and affiliated colleges 954 23.81+3.72 ISI  Insomnia 7
11 N. Kumar et al., 2022 Cross-sectional study General People 1596 39.76+13.1 Standard questionnaire RLS,
Insomnia		 4
12 Khan et al., 2018 Epidemiological study Adult population of a district 1700 39.4+13.9 ISI, door to door survey Insomnia 9
13 Sreedharan et al., 2016 Cohort study PSG proven OSA patients 152 53.81+12.01 PSG Insomnia, EDS 7
14 Jaisoorya et al., 2018 Cross sectional study General patients at OPD(PHCs) 7017 41.4+11.1 ISI  Insomnia 8
15 Panda et al., 2018 Observational study Patients with definite and probable ALS 40 56.6+9.4 ESS, PSQI  RLS,
Insomnia		 6
16 Mondal et al., 2018 Observational cross sectional study Psychiatric outpatients 500 42.2+15.3 ISI  Insomnia 7
17 Jain et al., 2014 Prospective study Traumatic brain injury patients 204 33.34+12.9 ISI  Insomnia 6
19 Naik et al., 2021 Prospective observational study Patients aged >18 years with laboratory- confirmed COVID-19 1234 41.6+14.2 Interviews conducted by trained residents Insomnia 7
20 Tomar et al., 2018 Cross sectional Post-traumatic brain injury patients 100 35.07+12.88 ISI, PHQ-9  Insomnia 9
21 A. Kumar et al., 2021 Cross-sectional study Patients with chronic liver disease 131 48.7+12.31 PHQ-9, PSQI  RLS,
Insomnia		 8
22 Devaraj et al., 2013 Cross sectional Patients with a recent Myocardial Infarction 44 57.5+10.44 PSG, ESS, BQ OSA,
Insomnia		 8
23 Ramakrishnan et al., 2012 Descriptive study General patients visited sleep centre 1765 All age patients PSG OSA,
Insomnia		 6
24 N. Kumar et al., 2021 Cross-sectional study Parkinson’s disease  832 66.9+18.39 Online survey with validated questionnaire RLS,
Insomnia		 6
25 Jasti et al., 2018 Cross-sectional study Parkinsonism patients 168 65.3+12.8 PSQI, ESS, PDSS-
2 		 OSA, EDS,
Insomnia		 7
26 Kishan et al., 2021 Cross Sectional observational Chronic heart failure patients 103 62.65+11.8 ESS,  STOP-BANG,
BQ		 OSA 7
27 Shanmugam et al., 2015 Cross-sectional prospective observational study CKD patients 302 All age patients BQ OSA 7
28 A. Singh et al., 2021 Cross sectional study Type 2 diabetes patients 149 63.42+12.31 STOP-BANG  OSA 9
29 Viswanathan et al., 2017 Cross sectional study Type 2 diabetes patients 203 54+8 AHI OSA 6
30 Malik et al., 2017 Cross sectional study Type 2 diabetes patients 62 60.82+11.34 PSG OSA 8
31 Goyal et al., 2018 School-based cross- sectional School students 1346 6.81+2.18 SRBD scale OSA 9
32 S. K. Sharma & Sreenivas, 2010 Cross sectional study Middle aged urban Indians  in South Delhi 351 43+13.2 PSG OSA 8
33 S. K. Sharma et al., 2010 Cross sectional study Individuals of either gender aged 30-65 years 365 47.5+13.8 Validated questionnaire, PSG OSA 7
34 Shailly Saxena, 2006 Observational cross sectional study Individuals above 18 years of age 1188 44.27+10.79 Sleep questionnaires OSA 7
35 Joseph et al., 2020 Cross sectional study Pregnant women 214 27.2+4.7 STOP-BANG,  ESS  OSA 5
36 Choudhury et al., 2019 Cross sectional study Rural community of Odisha 200 50+16.3 BQ  OSA, EDS 6
37 Pinto et al., 2018 Observational cross sectional study Adult population  321 39.43+15.6 ESS, Modified BQ OSA 8
38 K. Aggarwal et al., 2021 Cross-sectional and observational study Undergraduate college students 493 20.3+1.53 PSQI OSA 7
39 Agrawal et al., 2011 Cross sectional study Patients with and without OSA 272 45.29+8.96 PSG OSA 8
40 Surya Kant, 2019 Prospective observational study Patients of Pulmonology Outpatient Department 48 All age patients PSG OSA 6
41 Anand et al., 2021 Cross sectional prospective study Children with Down syndrome 53 7.4+3.47 PSG OSA 4
42 Nanaware et al., 2006 Retrospective study Suspected sleep disordered breathing children under 18 years 56 11.5+5.13 PSG OSA 4
43 Kaswan et al., 2021 Prospective cross section Diabetes mellitus patient 362 55.7+10 STOP-BANG,  ESS  OSA 9
44 Devaraj et al., 2017 Prospective cohort Patients underwent non-cardiac surgery 182 48.9+14.41 PSG,  STOP-BANG  OSA 9
45 Lorenzoni et al., 2019 Observational cross sectional study Obese children 45 10.5+0.75 PSG OSA 6
46 Dixit et al., 2018 Cross sectional study Adult patients of bronchial asthma 50 48.16+14.9 PSG OSA 6
47 Tripathi et al., 2019 Cross sectional study Elderly completely edentulous patients 183 62.5+1.97 PSG, ESS  OSA 9
48 Reddy et al., 2009 Cross sectional, community based study Middle-aged urban of South Delhi 2505 47.5+13.8 PSG OSA 9
49 S. K. Mahajan et al., 2021 Cross sectional study Patients with acute coronary syndrome  66 57.7+11.1 PSG OSA 8
50 Prasad et al., 2017 Comparative study Subjects who underwent polysomnography at sleep lab 210 46.5+13.7 PSG OSA 8
51 Kamgo et al., 2022 Prospective observational study Interstitial Lung Disease patients 41 55.5   10 PSG OSA 6
52 R. Kumar et al., 2013 Cross Sectional observational Patients with asthma and COPD 400 35.8   7.9 ESS, BQ OSA 8
53 Sehgal et al., 2016 Cross sectional study Patients with metabolic syndrome  50 47.1   6.6 PSG, ESS  OSA 6
54 Nair et al., 2022 Cross sectional study Patients with sleep disordered breathing 142 49.7   14.6 Level 1 PSG OSA 10
55 Priyadarshini et al., 2017 Observational cross sectional study Obese patients seeking bariatric surgery 27 42.4   10.5 PSG, ESS, BQ OSA, EDS 7
56 Nattusami et al., 2021 Cross sectional study Patients with stable COPD 301 59.6   10 PSG, ESS  OSA, EDS 10
57 Shoib et al., 2017 Cross-sectional study Patients suffering from depression 182 54.89   12.93 PSG OSA 10
58 Utpat et al., 2020 Prospective observational study Interstitial lung disease patients 100 56.44   20.52 PSG OSA 9
59 Bhaisare et al., 2022 Prospective observational study Diagnosed lung cancer patients 30 55   8 PSG, ESS  OSA 8
60 Agrawal et al., 2013 Cross sectional study Patients of ASA I-III scheduled for elective surgical procedures under anesthesia 204 42.7   15.08 STOP-BANG  OSA 7
61 Kaul et al., 2001 Cross Sectional observational study Primary sleep disturbances patients 60 46.36   7.89 PSG OSA 7
62 Jain & Sahni, 2002 Prospective observational study Children adenoidectomy and/or tonsillectomy 40 8   3.15 PSG OSA 6
63 Ghosh et al., 2020 Cross sectional study Population study 1000 47   13 BQ OSA, EDS 7
64 Tripathi et al., 2018 Cross Sectional observational study Non-obese male subjects 120 45   7.8 PSG OSA 5
65 P. Singh et al., 2022 Prospective study Coronary artery disease patients 100 35.14   4.35 PSG OSA 7
66 Dubey et al., 2018 Cross sectional study Male Driving License recipients 542 31.8   13.2 STOP-BANG   OSA 9
67 Mathiyalagen et al., 2019 Cross sectional study Patients attending a non-communicable disease clinic 473 51   11.34 Pre-tested semi- structured questionnaire OSA 10
68 M. Kumar et al., 2021 prospective cross- sectional study Patients with cirrhosis 1098 48.3   10.5 PSQI, ESS  OSA, EDS 10
69 Rohatgi et al., 2018 Preliminary study Patients suffering from schizophrenia spectrum disorder 43 32.2   10.1 Berlin Questionnaire OSA 8
70 L. Ahmad et al., 2020 Prospective, cross- sectional hospital- based study Adolescent patients who reported to Orthodontic OPD 213 16   3.4 STOP-BANG   OSA 9
71 Selvaraj & Keshavamurthy, 2016 Cross sectional study Parkinson’s Disease patients 50 57.16   6.6 PDSS, ESS  OSA 6
72 Bhagawati et al., 2019 Cross-sectional study Patients with CKD who were >18 years of age 300 47.58   15.04 IRLSSG rating scale RLS 10
73 Pinheiro et al., 2020 Cross sectional study Type-2 diabetes 210 56   13.5 IRLSSG rating scale RLS 6
74 R. Gupta et al., 2017 Population based door to door study Subjects 18 and 84 years in Himalayan and Sub-Himalayan region 1689 35.2   10.9 Cambridge-Hopkins RLS diagnostic questionnaire RLS 9
75 Rangarajan et al., 2007 Cross-sectional, questionnaire-based study Adult residents of Bangalore 1266 49.4   24.4 Face-to-face interview, IRLSSG scale RLS 7
76 Bellur et al., 2022 Cross-sectional observational study College students 4211 18   1.48 PSQI, ESS  RLS 7
77 Joseph et al., 2022 Cross-sectional study General population of Mangalore 202 29   13 PSQI  RLS 6
78 R. Gupta et al., 2012 Cross sectional study Patients who presented with insomnia or leg pain 653 39.86   12.8 IRLS Hindi version RLS 7
79 Halkurike- Jayadevappa et al., 2019 Prospective observational study Adult patients with cirrhosis 356 48   25.6 IRLS scoring system RLS 9
80 Bhowmik et al., 2003 Comperative study Hemodialysis patients 121 34.5   11.1 Predesigned questionnaire RLS 5
81 R. Gupta et al., 2018 Cross sectional observational study Patients with opioid use disorder 19 30.2   10.4 Predesigned RLS 6
82 Bathla et al., 2016 Cross sectional study Patients undergoing hemodialysis 194 54.5+15 Face-to-face interview, IRLS questionnaire RLS 7
83 A. Gupta et al., 2017 Prospective study Stroke patients 346 54.87+12.03 Pre-structured sleep questionnaire RLS 9
84 Velu et al., 2022 Cross sectional study Patients with End-stage kidney disease 148 44+14.5 ESS, PSQI  RLS, EDS 10
85 R. Gupta et al., 2013 Cross sectional observational study Subjects presenting to psychiatry OPD with complaints of depressive illness 54 35.58+33.22 MINI-Plus Interview, IRLSSG criteria RLS 9
86 Raj & Ramesh, 2021 Cross sectional study Patients diagnosed with Tuberculosis 206 41+16.2 PSQI, ESS  RLS, EDS 6
87 Raj et al., 2019 Cross-sectional study Type 2 diabetes  patients 102 56.88+10.98 ESS  RLS, EDS 7
88 Kaur & Singh, 2017 Cross-sectional study College students 1215 19.5+4.7 ESS  EDS 4
89 A. Singh et al., 2017 Prospective cross sectional study Subjects with age groups ≥ 25 years 1512 42.6+11.2 ESS, face to face interview EDS 5
90 Roopa et al., 2010 Cross sectional study Random subjects aged 20-76 from Chennai Urban Rural 358 43.7+12.7 Standard validated questionnaire EDS 8
91 Krishnaswamy et al., 2016 Prospective study Bus drivers working in Karnataka State Road Transportation Corporation 180 41.4+9.3 ESS  EDS 6
92 Ghante et al., 2021 Cross-sectional study Postnatal women 225 25.16+3.98 ESS, PSQI  EDS 7
93 Dey et al., 2020 Cross-sectional study Doctors from all the clinical department 100 35.32+6.21 PSQI, ESS  EDS 8
94 Venkatnarayan et al., 2022 Cross sectional observational study OSA patients 100 49.5+13.3 PSG EDS 5
95 Shoib et al., 2022 Cross-sectional study OSA patients 182 54.89+12.89 PSG, ESS  EDS 6
96 Samanta et al., 2013 Cross sectional observational study Patients of cirrhosis 100 49.1+11.4 PSQI, ESS  EDS 5
97 P. Sharma et al., 2016 Cross-sectional study Patients with schizophrenia 100 30.63+8.7 PSQI, ESS  EDS 7
98 Sreedharan et al., 2021 Prospective study Patients getting admitted for coronary artery bypass surgery  120 60+11.5 STOP-BANG   EDS 7
99 S. Mahajan et al., 2012 Cross sectional observational study Patients on maintenance hemodialysis for >3 months 47 37.1+13.1 ESS  EDS 5
100 Kadam Y, Patil S, Waghachavare V, Gore A, 2016 Cross sectional study College students from an urban area 900 19.3+1.5 Pre tested self- administered questionnaire EDS 6

Source: Systematic Review of Prevalence of Sleep Problems in India: A Wake- up Call for Promotion of Sleep Health by Karuna Datta, Anna Bhutambare, Hruda Nanda Mallickfd

Note: CKD: Chronic Kidney Disease, OSA: Obstructive sleep apnea, RLS: Restless Legs Syndrome, EDS: Excessive daytime sleepiness PSQI: Pittsburgh Sleep Quality Index, PHC: Primary Health Centre, ESS: Epworth Sleepiness Scale, ISI: Insomnia Severity Index, PSG: Polysomnograpgy, PHQ-9: Patients Health Questionnaire, BDI: Beck Depression Inventory, BSA: Berlin Sleep Apnea, BQ: Berlin Questionnaire, PDSS-2: Parkinson Disease Sleep Score-2, AHI: Apnea Hypopnea Index, SRBD: Sleep Related Breathing Disorder, COPD: Chronic Obstructive Pulmonary Disease, PDSS-III: Parkinson Disease Sleep Score Part-III, IRLSSG: International Restless Legs Syndrome Study Group, IRLS: International Restless Legs Syndrome severity scoring, MINIPlus: Mini International Neuropsychiatric Interview Plus, JBI: Joanna Briggs Institute

2025 Healthcare and Life Sciences Investment Outlook

2025 Healthcare and Life Sciences Investment Outlook

Mankind versus ChatGPT: Our Caveat for 2025

For the first time in AI’s and mankind’s history, the line between what is human and what is AI-driven technology is increasingly blurring, we are witnessing that ChatGPT and other OpenAI models, can influence the rates of false negatives and false positives in various healthcare and investment applications including algorithms that make investment calls based on future predictions. We have been making annual healthcare and life sciences investment predictions since 2013 with 95% accuracy except during the Covid pandemic years. It seems that ChatGPT itself is turning out to be a black swan event for the algorithms which are predicting the future so accurately in the past. As ChatGPT becomes mainstream, we need to understand the “Confusion Matrix” (see chart below) that will ensure with the power of AI and ChatGPT versus the humans in the future as more and more AI-generated content and analytics proliferates the world in 2025 and beyond. 

Confusion Matrix for AI ChatGPT and Human Predictions
Confusion Matrix for AI ChatGPT and Human Predictions

As industries including, Healthcare and Lifesciences is adopting AI very rapidly for delivering healthcare and so do the Banking and Financial Services, investment managers using AI-driven algos for investment calls. We would need to take cognizant of the False Negatives and False Positive that would elevate the risks and mitigate accordingly. We have included AI as one of the factors in our 2025 Outlook, India Healthcare and Lifesciences Investment Heatmap.

2025: Heal the World – From Geo Politics to Socio Politics

In our 2024 forecast last year we included Geopolitics for the first time in our investment heatmap as the signals were emerging as early as mid-2023. While 2024 witnessed global geopolitics upheaval with regime changes through democratic elections and other means with over 60 wars and armed conflicts ongoing around the world, we were seeing signals of slowdown in growth and investments in Q12024 itself. As a result, as we exited 2024, the growth and investment climate slowed down significantly.

The broad global theme for 2025 is “Heal the World” for better outlook for 2026 and beyond.  If we are able to heal the world with robust socio political agenda it would turn out to be the future prosperity of mankind.

2025: India’s Healthcare and Lifesciences Innovation and Business Models

India was also not insulated with the global geopolitics impact. In 2024, there was ~50% decline in capex and investments in the sector.  We expect 2025 to continue to be a weak year for investments in the sector. After our general elections, there were uncertainties in our region and further slowing of investment and capex cycles on the back of global slowdown. Healthcare is a big creator of employment and it should not slow down any further in 2025.

Since Q12024, the signals were towards robust investments in early stage innovations and growth in new age business models which we have been labelling as “cross-domain” investment ideas. In March 2024, we released 2024 – India Healthcare And Life Sciences Investment Manifesto | Kapil Khandelwal KK covering key 40 bets that will be an opportunity to invest in the sector that will witness an upside beyond the market returns for the sector over the next 5 years. This will accelerate the investments that was with USD 857 million in 2024 to reach a unicorn status of over USD 1 billion in 2025. Fortunately, this is the only segment witnessing positive growth in investments in 2024 and continues to attract robust growth and investments. 

Hence, we have made attempts to analyse International ‘Geo Politics’ as a separate factor and bolt-on-top of our algo predictive models to adjust our heat map for 2024 to accurately predict whether the heat is on in our 2025 Investment Heat Map.

The wave of optimism for 2025 in Indian healthcare and life sciences stems from the following:

  • Over half of Indian consumers are increasingly curious to understand their body and well-being by ‘listening to their body’. Innovators and start ups are exploring this opportunity to scale up their ventures.
  • Many of the start-ups of the Pre Covid India Stack in healthcare are either pivoting to including AI tech or will perish as AI goes turbo. We are expecting around 450 such start ups at this stage of AI upgrade.
  • Agentic AI effectively turbocharges the Do It For Me (DIFM) healthcare economy. Early adopters include GenZ and Millennials (approx 50% of Indians) users who will have their own bots or AI agents helping them choose products and execute transactions in adoption of healthcare products and services as the line between what is human and what is technology will be blurring. Competition will tick-up as starts-ups grow.
  • “AI for All is not All” as consumers are getting more consumerised for their health needs. AI cannot solve it all for all of Indian consumers healthcare needs. These include Gen X and Seniors (approx 44% of Indians) are skeptics and late adopters. This innovative products to serve these cohorts is key.
  • New business models/incubation for investments are emerging (see our 40 Future Bets in Healthcare 2024 – India Healthcare And Life Sciences Investment Manifesto | Kapil Khandelwal KK) that are cross-domain and will be a potential USD 50 billion addition to India’s GPD in next 5 years.
  • Healthcare real estate will also explore cross-domain concepts to fit consumer needs.
  • Wellness is now an ‘Avatar’ that is experiential and connects with other lifestyle domains such as beauty, cosmetics, travel, tourism, hospitality, food, technology, wearables tech, work environment and many more. Holistic innovation in experiential longevity is emerging.
  • Alternative therapies are now body rejuvenation biohacks that traditional and alternative medicine and wellness cannot provide or fulfill completely and which health fascism fuels. Indian GenZ and Millennials are leading this change.
  • New age innovative medical integrative DIFM models will be a push for medical and wellness tourism repositioning for India medical tourism.
  • In 2024, the BSE Healthcare Index was one of the standout performers, delivering an impressive 40% year-to-date (YTD) return. This trend continues in 2025.
  • The valuations have come back to realistic levels to peak by 2026-27.
  • Private hospitals are now aggressively embarking on increasing bed capacity after a phase of consolidation in 2024.
  • M&A and buyouts are expected to continue to be buoyant.
  • Healthcare real estate are expected to launch and kick off innovative cross-domain formats.

The 2025 India Healthcare and Life Sciences Investment Heat Map is as under:

2025 India Healthcare and LifeSciences Investment Heat Map
2025 India Healthcare and LifeSciences Investment Heat Map

Healthcare Financing

With mental health needs and healthcare fascism at its peak, newer products and services for financing longevity and healthy lifestyle for the Gen Alpha and Gen Z are emerging. Cross domain models of business are emerging to address the needs to finance consumers needs to such emerging products and services. 

2025 Outlook: Moderate

  • What may go wrong: false claims by online influencers, right pricing, reach and penetration to consumers, improper lifestyle based consumer segmentation, business volatility in some NBFCs, newer regulations on consumer credits by RBI, lower consumer spending and financing, outstanding credit cards debt
  • What’s going right: AI intervention and solutions, lower interest rates,

Medical Education

Medical education content is no longer the marker for better valuation and funding. The market has flipped to buyers’ market. The investors are no longer entering into opportunities at the current valuations and will lead to rerating downwards. Need major reforms in the medical education sector.

2025 Outlook: Low

  • What may go wrong: lower student enrollment, regulatory issues, new emerging careers in industry, accreditation and learning models, international players and competition
  • What’s going right: AI-generated content creation, immersive content, stable valuations

Med Tech Innovation and Life Sciences Discovery and Clinical Development

Trump Administration and the US BioSecure Act will be a positive. India has to enter the big league of biologics with global partnerships as Chinese firms will face headwinds. Cross domain innovation with AI is the key to leapfrog in the global race. Also India needs to reinforce its success in Covid vaccine development to reignite confidence in India. Expect a major IPO.

2025 Outlook: Moderate

  • What may go wrong: over dependence on Chinese players, slower reverse brain drain transition of drug hunters from US, low qualified life sciences professionals pool, lower grant funding, no further sops in the 2025 finance budget
  • What may go right: emerging social innovation models, market appropriate solution development, native AI models

Pharma and Therapeutic Solutions

Volume growth in the domestic markets, US generics price erosion, with the softening of input costs, ongoing decoupling of supply chain with China and currency depreciation to continue in 2025, will improve the margins very marginally.  The companies with strong cash positions will increase capex and also buyouts and M&A activity. Not any major name IPOs expected.

2025 Outlook: Moderate

  • What may go wrong: Slower China decoupling of supply chain, continuing US generics markets prices decline, potential increase in tariffs by the US under Trump regime, increased APIs prices, continuing domestic market volume degrowth, no further sops in the 2025 finance budget
  • What may go right: US BioSecure Act to favour India, increased R&D spend, new products pipeline, newer capex cycles, multi-year high in US active drug shortages

Healthcare Providers

Capacity creation will now be around 2500 beds in tier 2 and 3 cities. Funding cycles improve as internal accurals improve for fresh capex and capacity expansions and inorganic expansions. Expect a few IPOs, buyouts and exits via secondary sale.

2025 Outlook: Hot

  • What may go wrong: margin pressures, supply and demand mismatch in micromarkets, lower medical tourists arrivals, rising valuations, stable margins
  • What may go right: asset-lite models, launching into new medical tourism markets

Healthcare Insurance

Payors are seeing insurance penetration grow since the Covid pandemic. Newer markets in the GenZ and Millennials cohorts and geographically tier-2 and 3 cities are the essential for growth. Bundled products and services for health and wellbeing is the key. AI modelling will assist in accurate underwriting of risks. Agentic AI entry to change the solicitation and selling customised bundled products.

2025 Outlook: Hot

  • What may go wrong: bundled product for consumer needs, product approvals, risk mitigation for new products, consumers need for longevity, agentic AI to connect consumers, payors and providers for seamless services
  • What may go right: Consumer demand, reduced loss ratios, AI fraud detecting agents

Health Retail

Anti-digital trend is catching up with consumers expecting analogic human to human touch for consuming healthcare products and services in cross-domain settings which is now perceived aspirational and desirable. Many digital business models need to tweak their phydigital presence mix. Its back to innovative traditional health retail settings.

2025 Outlook: Hot

  • What may go wrong: failing to provide the human to human touch points, talent for new age health retail settings, anti-digital pivoting, wrong business model assumptions
  • What may go right: exits in failed business models, profitability focus, phydigital presence

Wellness

The past wellness definition is no longer relevant. New age ‘Gen-Z’ed wellness business models and innovation is emerging which brings in the cross-domain experiential products and services. Redefinition of wellness is the key and will show case the future winners. These innovations will fuel India’s new age wellness tourism too.

2024 Outlook: Hot

  • What may go wrong: regulation, talent and skills in cross domain products and services, micro market segmentation, faster beta testing, new mass market business models, spurious social media channels, fake outcome/claims
  • What may go right: Gen Z micro segmentation, wearables, biosensors, newer phydigital formats

Alternative Therapies

Redefined by cross-domain influences, emerging tech, wearables, biosensors, cutting-edge innovation in life sciences with other domains fueled by GenZ experimentation with new biohacking and health fascism expressions. It is going to be the next destination of value care in healthcare emerging from real need and experience of consumers for Do It For Me (DIFM) healthcare.

2025 Outlook: Hot

  • What’s going wrong: regulations, consumer education and confidence, clinical research, new product development, new mass market business models, repeat sales, spurious social media channels, fake outcome/claims, wrong Gen Z role models, developing phydigital formats
  • What may go right: discretionary consumer spending, newer cross-vertical innovative business models, mainstream complementary treatment, wearables, biosensors

Moving Forward

2025 will be a pivoting year for mankind, healthcare and investing as AI for All is not All.

Happy investing and stay strong!

Media Coverage

M&A, Buyouts in Healthcare to Remain Coverage in VC Circle

M&A, Buyouts in Healthcare to Remain Coverage in VC Circle

2025 India Healthcare and LifeSciences Investment Outlook Coverage in Express Pharma Feb 2025

2025 India Healthcare and LifeSciences Investment Outlook Coverage in Express Pharma Feb 2025

A Very Heavy and Weighty 2025 New Year Resolution!

A Very Heavy and Weighty 2025 New Year Resolution!

2025 New Year Resolutions

It’s that time of the year when we make New Year’s Resolutions. This year’s number one resolution that tops the chart is healthy diet and weight loss which is being wished by 51% of the people. Next is wishing for wealth which is wished by 21%. Finally comes spending quality time with friends and family which is wished by 14%. This is much lower this year post covid lockdown. Is there any correlation to the obesity trends in India with the New Year’s Resolutions for 2025?

Obesity Trends in India

Body Mass Index (BMI) scale is used to indicate if one is obese or not. The different classifications are as unde for India. Please note that this is not the same for other countries which may vary or are higher:

  • Normal BMI: 18.0-22.9 kg/m²
  • Overweight: 23.0-24.9 kg/m²
  • Obesity: ≥25 kg/m²

The prevalence of obesity has been increasing, with nearly one in four Indians now considered overweight. Approximately 24% of women and 23% of men aged 15-49 are classified as overweight or obese in India. Obesity rates are higher in urban areas (30% of men and 33% of women) compared to rural areas (19% of men and 25% of women).

Dietary Trends in India

The Economic Survey 2023-24 noted unhealthy diets and rising rates of obesity need to be tackled urgently to improve health parameters, in order to reap the gains of the country’s demographic dividend. Citing the Indian Council of Medical Research’s (ICMR) latest dietary guidelines, published in April this year, it notes the fact that 56.4% of the total disease burden in India is due to unhealthy diets. The ICMR report observes that the upsurge in the consumption of highly processed foods, laden with sugars and fat, coupled with reduced physical activity and limited access to diverse foods, exacerbate micronutrient deficiencies and overweight/obesity problems.

Correlating Obesity, Diet and 2025 New Year’s Resolutions

There seems to be a positive correlation between the weight loss and what people wishing to achieve in 2025 with respect to their diet and weight. These are many reasons for this correlation. These could be:

  • Calling for ill-Health: Obesity leads to chronic inflammation and impact longevity (listen to podcast on longevity https://open.spotify.com/episode/19pvPEE7f5UGgzJyXSlLsS?si=5f06687dfcf64232). Over the years, the body’s organs don’t function as effectively as they should. Damage to the pancreas, for example, leads to diabetes; damage to the heart leads to cardiovascular disease; and damage to the brain leads to dementia. And even if someone loses weight, the damage is not irreversible. (The liver is the only organ that can regenerate itself.) Obesity is also linked to many cancers, musculoskeletal problems, depression and obstructive sleep apnea. Some of the co-morbidities with obesity and overweight people include:
    • Chronic Kidney Disease
    • Type 2 Diabetes         
    • Cardiovascular Disease
    • PAD (Peripheral Arterial Disease)
    • Alzheimer’s  
    • Heart Failure
    • MASH (Fatty Liver Disease)

Sounds very alarming for increasing healthcare costs!

  • Better Employability: As per the National Health and Family Surveys, obese and over weight people have issues with their employability and their ability to work. This is tied to their overall health and their physical abilities. Hence being fit and normal BMI works in their favour.
  • Lifestyle, Fashion and Aesthetics: One of the most fundamental drivers of behavior is the desire to look attractive. Sales for personal care and beauty products easily exceed USD 25 billion by 2029, and sales for apparel reach USD 550 billion by 2029. This is a very aspiration segment. (listen to podcast: https://open.spotify.com/episode/36TCAlD1gglGXoWJtDa27o?si=09dd617d77434985). A significant number of Indians are unhappy with their weight and body image. A study involving participants from 65 countries found that Indians have lower body image satisfaction compared to many other nations.

Meeting and Beating the 2025 New Year Resolutions

Like any resolution, the compliance to any New Year Resolution is very low. Coming to managing ones weight reduction, the compliance is even lower. The level of compliance with weight loss programs among Indians varies widely. Several factors influence this, including cultural attitudes towards weight, accessibility to resources, and individual motivation.

  • Cultural Attitudes: In many parts of India, there is a cultural acceptance of larger body sizes, which can affect motivation to lose weight.
  • Accessibility to Resources: Access to weight loss programs, gyms, and healthy food options can be limited, especially in rural areas.
  • Individual Motivation: Personal commitment and motivation play a crucial role. Many individuals start weight loss programs but struggle to maintain long-term adherence due to lifestyle challenges and lack of support.

With such low levels of compliance and issues surrounding it, what has the healthcare industry done to find solutions to the weighty problems?

Healthcare Industry’s Invasive and Non Invasive Solutions to Obesity

There are several invasive and non-invasive solutions to obesity reduction. Here’s a brief overview of both:

Invasive Solutions

  • Gastric Bypass Surgery: This procedure involves creating a small pouch from the stomach and connecting it directly to the small intestine. This bypasses a large part of the stomach and some of the small intestine, reducing the amount of food you can eat and absorb.
  • Gastric Sleeve Surgery: Also known as sleeve gastrectomy, this surgery removes a large portion of the stomach, leaving a tube-like structure. This limits the amount of food you can consume.
  • Adjustable Gastric Banding: A band is placed around the upper part of the stomach to create a small pouch that holds food. The band can be adjusted to control the amount of food intake.
  • Biliopancreatic Diversion with Duodenal Switch (BPD/DS): This complex surgery involves removing a portion of the stomach and bypassing a significant part of the small intestine. It reduces the amount of food intake and nutrient absorption

Invasive surgery is expensive and not affordable by many. Also, this has to be followed up with non-invasive and other cosmetic surgery later on.

Non-Invasive Solutions

  • CoolSculpting: This technique uses controlled cooling to freeze and destroy fat cells. The body then naturally eliminates these dead cells over time.
  • SculpSure: A laser-based treatment that targets and heats fat cells, causing them to break down and be absorbed by the body.
  • Kybella: An injectable treatment that destroys fat cells under the chin, improving the appearance of a double chin
  • Emsculpt: This procedure uses high-intensity focused electromagnetic energy to induce muscle contractions, which can help reduce fat and build muscle.
  • Lifestyle Modifications: Diet and exercise remain fundamental. Behavioral therapy and support groups can also be effective in managing obesity

Each method has its own benefits and risks, and the best choice depends on individual health conditions, preferences, and goals.

GLP-1 The Magic Pill for Obesity

During 2024, a hype has been created over social media, celebrities both in Bollywood and Hollywood about GLP-1 (glucagon-like peptide-1), the wonder drug and magic pill for weight reduction. For the scientifically advanced beings, brief overview of the mechanism of action of GLP-1 (Glucagon-Like Peptide-1):

  • Secretion: GLP-1 is secreted by the intestinal L-cells in response to food intake.
  • Receptor Binding: GLP-1 binds to its receptors located in various organs, including the pancreas, brain, stomach, and heart.
  • Insulin Secretion: In the pancreas, GLP-1 enhances glucose-dependent insulin secretion.
  • Glucagon Suppression: It suppresses glucagon release, which helps lower blood glucose levels.
  • Gastric Emptying: GLP-1 slows gastric emptying, promoting satiety and reducing food intake.
  • Neuroprotection: It has neuroprotective effects and may improve cognitive function.

For the least scientifically advanced beings, GLP-1 works in reducing the food appetite and the weight of a person by 15-20%. In addition, GLP-1 also works on other co-morbidies such as

  • Diabetes Management: GLP-1 agonists are medications that help lower blood sugar levels by increasing insulin secretion and decreasing glucagon release. They also slow down gastric emptying, which helps control blood sugar spikes after meals.
  • Weight Loss: These medications are also effective for weight loss. They work by reducing appetite and increasing feelings of fullness, which can lead to reduced calorie intake and weight loss.
  • Cardiovascular Benefits: Some GLP-1 agonists have been shown to provide cardiovascular benefits, such as reducing the risk of heart attack and stroke in people with type 2 diabetes.
  • Potential Kidney Benefits: Emerging research suggests that GLP-1 agonists may also have protective effects on kidney function.
  • Parkinson, Alzheimer’s and Dementia: Early clinical research is showing effective results in patients with neuro issues with a lower risk of the cognitive issues (such as memory loss) that are often an early sign of dementia.
  • Addiction Management: This is still very early and GLP-1 is being tested on animals and showing positive results on addiction to alcohol and nicotine.

Statutory Warning:

All drugs have side effects, and the GLP-1s are no exception. The most common ones are gastro-intestinal problems, for example diarrhea. In addition, the drugs cause the loss of lean muscle mass, which is particularly concerning for the elderly. Moreover, newer formulations or the next generation of GLP-1 are also being researched and will circumvent the side effects.

GLP-1 in India

In India, several GLP-1 (glucagon-like peptide-1) receptor agonists are available for the management of diabetes and obesity. Here are some of the notable ones:

  • Liraglutide: Marketed under the brand name Lirafit™ by Glenmark Pharmaceuticals, this drug is used to improve glycemic control in adults with type 2 diabetes.
  • Semaglutide: Available as an oral formulation, this drug is marketed by Novo Nordisk India and is used for diabetes management.
  • Exenatide: Another GLP-1 agonist used for diabetes treatment, though specific brand names in India may vary.

I am also informed that there is a venture working on GLP-1 extracted from plants peptides under development.

As for me, I am wishing that 2025 will bring in more innovation in GLP-1 solutions which are more effective!

Happy New Year 2025!

Deny, Depose, Defend – Assassination of a CEO – Making of A New Suspense Serial?

Deny, Depose, Defend – Assassination of a CEO – Making of A New Suspense Serial?

Celebrity Assassinations Inspired by Books and Literature

The US has several cases of Presidents and celebrities who have been murdered where the assassin was motivated by a written books and literature and that became the inspiration and the motive to kill someone who is well known. Some of them include:

  • John Lennon’s Assassination: Mark David Chapman, who assassinated John Lennon in 1980, was heavily influenced by J.D. Salinger’s novel The Catcher in the Rye. Chapman was found reading the book at the scene of the crime and later claimed that he identified with the protagonist, Holden Caulfield.
  • Ronald Reagan’s Assassination Attempt: John Hinckley Jr., who attempted to assassinate President Ronald Reagan in 1981, was obsessed with the movie Taxi Driver and its protagonist, Travis Bickle. The character’s actions in the film were inspired by Arthur Bremer’s diary, which was later published as a book.
  • The Assassination of Robert F. Kennedy: Sirhan Sirhan, who assassinated Robert F. Kennedy in 1968, was reportedly influenced by the novel The Secret Agent by Joseph Conrad. The book explores themes of political violence and assassination.
  • The Murder of Rebecca Schaeffer: Robert John Bardo, who murdered actress Rebecca Schaeffer in 1989, was found with a copy of The Catcher in the Rye. This book has been linked to several other high-profile crimes.
  • The Columbine High School Massacre: Eric Harris and Dylan Klebold, the perpetrators of the Columbine High School massacre in 1999, were influenced by Stephen King’s novel Rage. The book, which King later allowed to go out of print, tells the story of a high school student who takes his class hostage.

Nothing comes to my mind about such killings in India, except those inspired by Religious Scriptures.

How can Written Books and Literature be an Inspiration or Prime Motive to Kill?

There are several studies and scholarly articles that explore the influence of books and other media on real-life crimes and killings and their motives. Here are a few key points from the research:

  • Media Effects on Violence and Crime: Research has shown that exposure to violent media, including books, can increase aggressive behaviour and attitudes. However, the direct link between media violence and actual violent crime is more complex and less conclusive.
  • Copycat Crimes: Some studies focus on the phenomenon of copycat crimes, where individuals mimic criminal acts they have read about or seen in media. This includes crimes inspired by books, movies, and even news reports.
  • Psychological Impact: The psychological impact of media on individuals can vary. Factors such as personal susceptibility, mental health, and environmental influences play significant roles in how media content affects behaviour.
  • Case Studies: Specific cases, like the ones we discuss here (e.g., John Lennon’s assassination), are often analyzed to understand the motivations behind such crimes and the role media might have played.

The points highlighted above address the complex relationship between media consumption and real-life actions.

A New Novel and A TV Serial in the Making

“Delay, Deny, Defend: Why Insurance Companies Don’t Pay Claims and What You Can Do About It” by Jay Feinman is an exposé on the practices of the insurance industry. Feinman, a legal scholar and insurance expert, argues that insurance companies often prioritize profits over policyholders by employing strategies to delay, deny, and defend against claims. Some of the excerpts from his book include:

  • Systematic Denial of Claims: Feinman explains that the denial of valid claims is not an occasional error but a systematic practice designed to maximize profits. Insurance companies often delay payments, deny claims without proper justification, and force claimants into lengthy litigation processes.
  • Historical Context: The book provides a historical overview of how these practices developed over time. Feinman traces the evolution of the insurance industry and highlights key changes that have led to the current state of affairs.
  • Consumer Impact: Feinman shares numerous stories of individuals who have been unfairly denied claims, illustrating the real-world impact of these practices on policyholders. These stories highlight the financial and emotional toll on those affected.
  • Legal and Policy Recommendations: The book offers practical advice for consumers on how to protect themselves when dealing with insurance companies. Feinman also outlines necessary legal reforms to prevent future abuses and improve the insurance system.
  • Call to Action: Feinman urges consumers, lawmakers, and regulators to take action against these unfair practices. He emphasizes the need for greater transparency and accountability within the insurance industry.

Overall, “Delay, Deny, Defend” serves as a critical examination of the insurance industry, providing valuable insights and actionable advice for consumers and policymakers alike.

Assassination of the United Healthcare CEO – An Inspired Killing?

On Wednesday 4 December 2024, Brian Thompson, the CEO of United Healthcare, was shot at targeted fatal on a midtown Manhattan sidewalk. This has sent shock waves in the industry in the US. Brian Thompson was not an ex-US President in a Presidential race, but yet he was targeted. Well, Brian managed over USD 250 billion healthcare insurance business of the United Healthcare. Hence, he would be in a Presidential status of a smaller country than the US. It seems that Brian Thompson’s assassination, could have been inspired and linked to a 2010 book titled “Delay, Deny, Defend: Why Insurance Companies Don’t Pay Claims and What You Can Do About It” by Jay Feinman. Police found shell casings at the crime scene engraved with the words “deny,” “depose,” and “defend,” which closely resemble the themes of Feinman’s book.

This blog is not about the condolences to the dead corporate executive, but the change in the mentality of the killers to attach corporate executives.

Industry Achievements of Assassinated United Healthcare CEO

Brian Thompson had several health insurance industry accomplishments and led several specific initiatives during crises that showcased his strategic and compassionate leadership:

  • COVID-19 Response: During the COVID-19 pandemic, Thompson spearheaded initiatives to expand telehealth services, ensuring that patients could access healthcare safely from their homes. He also implemented support programs for frontline healthcare workers, providing them with necessary resources and mental health support.
  • Telehealth Expansion: Recognizing the need for remote healthcare solutions during the pandemic, Thompson accelerated the rollout of telehealth services. This initiative allowed patients to receive medical consultations and care without risking exposure to the virus.
  • Support for Frontline Workers: Thompson introduced programs to support frontline healthcare workers, including mental health resources and financial assistance. These measures were crucial in helping healthcare professionals cope with the immense pressures of the pandemic.
  • Regulatory Compliance and Advocacy: Thompson effectively managed regulatory challenges by working closely with policymakers. He advocated for policies that would benefit both the company and its members, ensuring that UnitedHealthcare remained compliant while continuing to innovate.
  • Cybersecurity Enhancements: In response to increasing cybersecurity threats, Thompson prioritized investments in advanced security technologies. This initiative aimed to protect sensitive patient data and maintain trust with members and stakeholders.
  • Public Relations Management: Thompson handled public relations crises with transparency and accountability. For example, when faced with criticism over healthcare costs, he addressed concerns openly and implemented solutions to improve member satisfaction.

These initiatives highlight Thompson’s ability to lead effectively during crises, ensuring that UnitedHealthcare could navigate challenges while continuing to provide essential services and support to its members and employees. I had met Brian briefly in Minneapolis in 2016 when he was not the CEO of United Healthcare. He came out to be a compassionate and a visionary. But why would someone want to kill him?

Reforms in the US Healthcare Industry Emerging out of “Delay, Deny, Defend”

Based on the events, the wider question to be asked is what needs to be done that Healthcare Executives are not targeted. Here are some of my thoughts coming out of Jay Feinman book. Let me inform the readers here, that I am no expert on the US Healthcare System. I am replaying some of the points Jay Feinman suggests several key reforms to address the systemic issues within the insurance industry to create a more equitable and transparent insurance system, ensuring that policyholders receive the coverage and support consumers are entitled to:

  • Enhanced Regulatory Oversight: Feinman advocates for stronger regulatory oversight to ensure that insurance companies adhere to fair practices. This includes stricter enforcement of existing laws and the introduction of new regulations to prevent the delay, denial, and unjust defense of claims.
  • Transparency Requirements: He calls for greater transparency in the insurance claims process. This would involve clear communication from insurers about the reasons for claim denials and the criteria used to evaluate claims.
  • Consumer Protection Laws: Feinman suggests the implementation of more robust consumer protection laws to safeguard policyholders. These laws would provide better recourse for consumers who are unfairly denied claims and ensure that they receive timely and fair settlements.
  • Penalties for Unfair Practices: He recommends imposing significant penalties on insurance companies that engage in unfair practices. This would serve as a deterrent against the systematic denial of valid claims and encourage insurers to act in good faith.
  • Support for Legal Reforms: Feinman supports legal reforms that make it easier for consumers to challenge unfair claim denials. This includes simplifying the process for filing complaints and pursuing legal action against insurers.
  • Public Awareness Campaigns: He emphasizes the importance of public awareness campaigns to educate consumers about their rights and the tactics used by insurance companies. This knowledge would empower policyholders to better navigate the claims process and protect themselves against unfair practices.

All I can imagine is that the assassin was denied healthcare that he was entitled to by United Healthcare and he thought it as an extreme step to redeem it with the life of the top honcho of United Healthcare CEO.

We will wait for the investigators and police to apprehend the killer and figure out the real motive. But for the time being, Jay Feinman’s book is now going to be a best seller and material for dramatization into a TV serial or a movie.

I am deeply shocked and my sincere condolences to those who feel the loss of Brian Thompson.

Ministry of Sex – Undemographic Dividends?

Ministry of Sex – Undemographic Dividends

Preamble

Various Industry Bodies are working with Niti Aayog for the Viksit Bharat@2047 policy recommendations. Mine was on the Amrit Kaal for healthcare for all by 2047. Parts of the thinking has been outlined in some our my blogs and podcasts. Read Amrit Kaal : Budget 2022 | Kapil Khandelwal KK.

But an interesting announcement by Russia came across my eyes and it makes me wonder on the timing and its effectiveness. Recently, Russia announced a new Ministry – The Ministry of Sex. The title of the Ministry may sound obscene, but its objectives are not to regulate illicit sex in the country. I can understand that is part of a broader effort by Russian authorities to reverse the country’s demographic decline, due to the fatalities suffered by the Russian in the ongoing conflict with Ukraine. In 2024, Russia’s birth rate is approximately 11.108 births per 1,000. This represents a slight decline from the previous year.

Let’s understand the objectives of this new Ministry in Russia and similar initiatives around the world and in India to improve their demographic dividends.

World Crude Birthrate
World Crude Birthrate

What is Ministry of Sex?

Russia’s Russia aimed at addressing the country’s declining birth rate. The idea is to create a dedicated government body to coordinate various efforts to boost the population and birth rate to derive demographic dividends in the future. Some of the proposed measures include:

  • Turning off the internet and lights between 10 PM and 2 AM to encourage intimacy among couples;
  • Financial incentives for first dates, with the government paying up to 5,000 roubles (around ₹4,395);
  • State-funded wedding nights in hotels, with expenses covered up to 26,300 roubles (around ₹23,122); and
  • Compensation for stay-at-home mothers for household chores, which would count towards their pensions.

Let us understand if such measures can lead to increase in babies in Russia.

Key Drivers of Increasing Birth Rate of a Country

Russia is not alone as a country that is witnessing the decline in the population due to birth rate. See Map.

While Russia’s measures to regulate couples to encourage more sex and babies in the short-term is laudable, the key drivers to improve the birth rate of a country are dependent on multiple factors addressing various social, economic, and policy-related factors. Here are some key drivers:

  • Economic Stability and Growth: Economic prosperity can encourage higher birth rates as families feel more secure in their financial future.
  • Affordable Childcare and Education: Providing affordable and high-quality childcare and education can reduce the financial burden on families and make it easier for parents to balance work and family life2.
  • Parental Leave Policies: Generous parental leave policies, including paid maternity and paternity leave, can support parents during the early stages of child-rearing.
  • Housing Policies: Affordable housing can make it easier for young families to establish a stable home environment, which is conducive to having more children.
  • Healthcare Access: Ensuring access to comprehensive healthcare, including reproductive health services, can help families plan and support larger families.
  • Work-Life Balance: Policies that promote flexible working hours and remote work options can help parents manage their professional and personal responsibilities more effectively.
  • Social and Cultural Support: Creating a family-friendly culture that values and supports parenthood can encourage higher birth rates. This includes community support systems and positive societal attitudes towards families.
  • Financial Incentives: Direct financial incentives, such as child allowances, tax breaks, and subsidies for families with children, can alleviate some of the economic pressures associated with raising children.
  • Education and Awareness: Promoting awareness about the benefits of family planning and providing education on reproductive health can empower individuals to make informed decisions about having children.
  • Social Media Blackouts: This is a new one coming from Russia. Reducing social media chatter and addiction can improve sexual health and sex.

Addressing these factors comprehensively can create an environment that supports and encourages higher birth rates in a country. Let’s compare these with some of the measures taken by some of the countries to increase their birth rates in their country.

Birth Rate Increasing Measures by Country

Here are some examples of countries that have taken measures to increase the birth rate in their country by encouraging couples to have more babies.

Country Measures Other Unique Measures
Singapore ·        Financial incentives

·        Housing benefits

·        Extended parental leave

 ·        Promote dating events and matchmaking services to help singles find partners
Japan ·        Subsidized childcare

·        Parental leave

·        Financial incentives

 ·        Community programs to encourage social interaction and dating among young people
France ·        Generous family policies

·        Extensive parental leave

·        Subsidized childcare

·        Financial incentives

 ·        France has the most generous family policies in the EU to promote family welfare

·        Free education and healthcare for children
South Korea ·        Financial incentives

·        Community programs for parental support

 ·        Financial support for fertility treatments

·        Policies to improve work-life balance and family and family-friendly workplaces
Hungary ·        Financial incentives

·        Tax benefits

 ·        Loan waivers for having multiple children

·        Subsidies for housing and car purchases
Greece ·        Tax benefits

·         

 ·        Subsidies for childcare

·        Payments for new parents
Poland ·        Financial incentives ·        Known for its “Family 500+” program,

·        Monthly payments to families for each child

Anti-Measures That Accelerate Ministry of Sex Type Initiatives Around the World

There are several anti-measures or counter trends that are accelerating the Ministry of Sex type of initiative around the world in the future to provide incentives people to marry, starting a family. Some of them, though not an exhaustive list are as under:

The #MeToo Awakening:

The #MeToo movement has contributed to a broader cultural shift that affects how people view and approach relationships, which in turn may be impact birth rates, although it is early to establish a co-relation. In the U.S., there was a notable drop in the number of babies born in 2017, with an estimated 3.84 million births, down by more than 100,000 from the previous year. This decline has been partially attributed to the “romantic reckoning” following the #MeToo movement. The societal changes after the #MeToo has many counter trends. These include:

  • Increased Awareness and Caution: The movement has heightened awareness about consent and respectful relationships. This has led to more cautious and deliberate romantic interactions, which has delayed relationship progression and family planning of the past.
  • Shift in Social Dynamics: The emphasis on addressing and preventing sexual harassment has changed how people approach dating and relationships. This shift can lead to more thoughtful and slower relationship development, potentially delaying decisions about marriage and having children.
  • Economic and Career Considerations: The movement has also highlighted gender inequalities in the workplace, prompting many women to focus on their careers and financial independence before considering starting a family.
  • Psychological Impact: For some, the movement has brought up past traumas and led to a reevaluation of personal priorities and relationships. This can influence decisions about marriage and parenthood.

Influence of Wokeism:

“Wokeism,” can influence birth rates in several ways. These include:

  • Changing Social Norms: The emphasis on social justice and equality can lead to shifts in traditional family structures and roles. People may prioritize personal development, career goals, and social activism over starting a family.
  • Economic and Career Focus: With a strong focus on addressing systemic inequalities, many individuals may choose to invest more time in their careers and financial stability before considering marriage and children.
  • Gender Equality: The push for gender equality can lead to more balanced domestic responsibilities and career opportunities for women. This can result in delayed family planning as both partners may focus on their careers.
  • Environmental Concerns: Wokeism often includes a strong environmental component, with concerns about overpopulation and sustainability. Some people may choose to have fewer children or none at all to reduce their environmental footprint.
  • Support for Diverse Family Structures: There is greater acceptance of diverse family structures, including single parenthood, cohabitation without marriage, and same-sex parenting. This can lead to different timelines and approaches to family planning.

BirthStrike Like Movements:

BirthStrike is a movement founded by Blythe Pepino in 2019, primarily in the UK, to raise awareness about the severe threats posed by climate change and how these threats influence decisions about having children. BirthStrike members, who are mostly young women, publicly declare their decision not to have children due to fears about the future impacts of climate change. BirthStrike helped to humanize the climate crisis by connecting it to deeply personal decisions about family planning. BirthStrike has played a significant role in bringing attention to the existential threats of climate change and how they affect personal decisions about having children. It underscores the deep connections between environmental activism and individual life choices. Some of the impact are:

  • Psychological and Social Impact: BirthStrike provided a platform to express their anxieties about the future and find solidarity with others who share similar concerns and also starting the family. This collective action also served as a form of protest, aiming to pressure governments and corporations to take more decisive action on climate change.
  • Broader Influence: BirthStrike is part of a larger trend where environmental concerns influence reproductive decisions. Similar movements, like Conceivable Future in the U.S. and No Future No Children in Canada, also highlight the intersection of climate anxiety and family planning.

Technoference:

The interference of technology in personal relationships, can have several indirect impacts on birth rates:

  • Relationship Quality: Technoference can lead to decreased relationship satisfaction and increased conflict. When partners feel neglected due to excessive technology use, it can strain the relationship, potentially leading to lower levels of intimacy and connection. This strain can reduce the likelihood of couples deciding to have children.
  • Reduced Communication: Constant interruptions from technology can hinder meaningful communication between partners. Effective communication is crucial for resolving conflicts and making joint decisions, including those about starting a family.
  • Increased Stress and Anxiety: The constant presence of technology can contribute to higher stress and anxiety levels. This can affect mental health and overall well-being, making individuals less inclined to consider having children.
  • Work-Life Balance: Technology often blurs the boundaries between work and personal life. The pressure to be constantly available for work can reduce the time and energy couples have for each other, impacting their decisions about family planning.
  • Parent-Child Relationships: For existing parents, technoference can affect the quality of interactions with their children. Parents distracted by technology may be less responsive and engaged, which can impact their desire to expand their family.

The Divorce Pandemic:

The trend of increasing divorce rates, often referred to as the “divorce pandemic,” has been influenced by several factors:

  • Economic Stress: Financial instability, exacerbated by the COVID-19 pandemic, has put a strain on many marriages. Job losses, reduced income, and economic uncertainty can lead to increased marital conflict and, ultimately, divorce.
  • Changing Social Norms: There is less stigma associated with divorce today compared to previous generations. This shift in societal attitudes makes it easier for individuals to consider divorce as an option when facing marital difficulties.
  • Later-Life Divorces: Known as “gray divorces,” the rate of divorce among adults aged 50 and older has surged. This trend is partly due to the baby boomer generation, who are more likely to seek divorce later in life compared to previous generations. This is impacting younger generations to evaluate marriage as an option.
  • Pandemic-Related Stress: The COVID-19 pandemic has intensified existing marital issues for many couples. Lockdowns, quarantine measures, and the stress of managing work and family life from home have contributed to a rise in divorce rates.
  • Personal Growth and Independence: There is a growing emphasis on personal growth and independence. Many individuals, especially women, are more financially independent and feel empowered to leave unsatisfactory marriages.

The Dating Apps Raps:

Digital dating apps have significantly transformed the landscape of romantic relationships. but they also come with several negative impacts, including people finding the right choice for the younger generations and delay in finding a life-long relationship to settle down and start a family. These include:

  • Mental Health Issues: Frequent use of dating apps can lead to mental health problems such as anxiety, depression, and low self-esteem. The constant exposure to rejection and the pressure to present an idealized version of oneself can be damaging.
  • Superficial Judgments: Dating apps often encourage users to make quick judgments based on appearance. This can lead to superficial connections and a focus on physical attributes over deeper compatibility.
  • Addictive Behavior: The design of many dating apps, with their swipe-based interfaces, can be addictive. Users may spend excessive amounts of time on these apps, which can interfere with their daily lives and relationships.
  • Ghosting and Rejection: The ease of ending communication without explanation, known as ghosting, is common on dating apps. This behavior can be emotionally hurtful and lead to feelings of insecurity and mistrust in the process.
  • Harassment and Safety Concerns: Many users, particularly women, report experiencing harassment, unsolicited explicit messages, and other forms of inappropriate behavior on dating apps. This can create a hostile and unsafe environment and mistrusts for the future relationship.
  • Decreased Relationship Satisfaction: Some studies suggest that relationships formed through dating apps may have lower levels of satisfaction and stability compared to those formed through traditional means. The abundance of choices can lead to a “grass is greener” mentality, where users are always looking for a better match.

There are around 20 countries which are experiencing negative population growth. Moreover, more than 100 countries and territories have fertility rates below the replacement level of 2.1 births per woman. While India is still not at that cusp of replacement level of 2.1 births. But it is certain that a Ministry of Sex measures are required for more than 50 countries given their demographics. However, some of the countertrends could accelerate this even faster. 

Rebooting Age: Long-Living India

Rebooting Age : Long-living India

Podcast

QuoteUnQuote with KK and Dr. Deepak Kumar Saini, Convener, Longevity India and Professor, Dept. of Developmental Biology & Genetics Indian Institute of Science (IISC), discuss Bet #3 on anti-ageing tech and products that is going to be a major trend in the next 5 years. Why is it so? 

As 50s is the new 30s now. Present Genx and seniors would like to reverse age or age slowly. By 2047, over 300 million Indian would be Senior Citizens and our dependency ratio will be around 40%. Indian would like to extend their lifespan 20% to 50%. But the trick here is to ensure that the end of life after prolonged life is a quick process rather than a prolonged decline. 

Indexation and Canons of Taxation: Have We Learnt Anything from Angel Tax?

Indexation and Canons of Taxation: Have We Learnt Anything from Angel Tax?

Preamble

In my Macroeconomics Course in College, I was introduced to the Canons of Taxation are principles that guide the design of a fair and efficient tax system. Adam Smith, in his book *The Wealth of Nations*, introduced four fundamental canons of taxation:

  • Equity: Taxes should be proportional to the taxpayer’s ability to pay. This means that individuals with higher incomes should pay more taxes than those with lower incomes.
  • Certainty: The tax amount, payment time, and method should be clear and certain to the taxpayer. This helps in planning and reduces the chances of arbitrary taxation.
  • Convenience: The tax system should be convenient for taxpayers to comply with. This includes the timing and method of tax payments.
  • Economy: The cost of collecting taxes should be minimal. The tax system should not be overly expensive to administer.

Modern economists have expanded these canons to include additional principles such as productivity, elasticity, simplicity, and diversity.

However many Governments around the world, including India do not follow these Canons of Taxation and make the taxation more complex rather than simplistic. From an investor point of view, the latest Budget for FY 2024-25 is one such instance where the Ministry of Finance has demonstrated one case of positive and one case of negative principles of canons of taxation. From an investor point of view, on the positive side, the Budget has abolished the Angel Tax and on the negative side, the Budget has abolished the indexation applied on Long-Term Capital Gains (LTCG) for computation of LTCG by reducing the LTCG rate from 20% with indexation to flat 12.5%. Let’s discuss this in detail.

Angel Tax Abolition  – Positive Canon of Taxation

When late Finance Minister and President of India Pranob Mukherjee, introduced the Angel tax in 2012, the justification given was that it was to prevent money laundering through inflated valuations. However, most start ups are valued higher than fair market value. Most angel investor would value these angel investments looking at the future growth potential and at the time of investments, these start ups had no or low revenues and profits. It is but obvious that the valuation methodologies would be higher than the market value. The angel tax had several significant impacts on startups in India:

  • Valuation Challenges: Startups often faced difficulties in justifying their valuations to tax authorities, leading to disputes and potential tax liabilities.
  • Investor Hesitation: The tax created uncertainty and risk for angel investors, making them more cautious about investing in early-stage startups.
  • Cash Flow Issues: Startups had to allocate funds to cover potential tax liabilities, which could otherwise have been used for growth and development.
  • Administrative Burden: The process of proving fair market value and dealing with tax assessments added to the administrative burden on startups.
  • Stifling Innovation: The overall environment of uncertainty and additional financial strain could stifle innovation and discourage entrepreneurship.

With the abolition of the angel tax in 2024, the startup ecosystem is expected to benefit from increased investor confidence and a more supportive regulatory environment.

Conclusion

The Angel tax did not pass the Canons of Taxation test and met its stated objectives. After lobbying for many years it is now abolished.

Removal of Indexation on LTCG for Sale of Real Estate

In the current budget, the Finance Ministry has removed the indexation benefit for calculating long-term capital gain (LTCG) on non-financial assets (including property). It has also lowered the LTCG tax rate to 12.5% (from 20% previously). The government has clarified that the removal of indexation benefits will not be applicable to old properties held before 2001, which would continue to get indexation benefits. This move is unlikely to impact the end-users who sell their existing house and reinvest in a new house (LTCG is not applicable). However, it will impact investors who would sell their house (investment) and reinvest in other asset classes.

Now the statement coming from the Finance Secretary in the media is that the new LTCG tax regime is in favour of the taxpayer as it lowers the LTCG burden. However,

this is not the case. Let is analyse this in detail.

Indexation on LTCG

There is an adjustment to the cost of acquisition of real estate of offset the inflation. Since 2001 onwards is the time frame when the new LTCG tax regime will impact the taxation, the following chart shows the indexation with 2001-02 as 100.

Indexation for LTCG Since 2001-02 Till Date
Indexation for LTCG Since 2001-02 Till Date

Assuming that an investor bought the property in 2001-02 at INR 100, the indexation benefit will be that if sold in 2024-25 it will be valued at INR 363, that is a multiple of 3.63x and this will be the cost that will be deducted from the sale consideration for computation of LTCG on the profit on the sale of the property. Now this benefit has been removed and a flat rate of 12.5% of sale consideration. This change has its own pros and cons and debunks what the Finance Secretary talked to the media about the new LTCG tax regime. Let’s see the different scenarios and time frame and the tax burden under the two LTCG tax regime.

INR 100 Asset @ 5% pa Appreciation Illustration

INR 100 Asset @ 5% pa Appreciation Illustration
INR 100 Asset @ 5% pa Appreciation Illustration

Clearly, the investor pays more LTCG when the indexation benefit is removed with lower tax rate of 12.5%.

INR 100 Asset @ 10% pa Appreciation Illustration

INR 100 Asset @ 10% pa Appreciation Illustration
INR 100 Asset @ 10% pa Appreciation Illustration

The investor only gains to pay less tax if the property is held for 10 years and more and appreciates in value @10% pa. Therefore we can conclude that the impact on relatively shorter-term investments (<5 years) where market price growth is <10% p.a. is negative. Conversely, the impact of this new regime would be neutral/marginally beneficial for investments with longer holding period (>10 years) and where property price appreciation is at >10% p.a.

It’s a Bummer

As a healthcare real estate fund, the social infrastructure like hospitals do not appreciate > 10% pa. Also the investment and exit timeframe would be <5 years. This means that there is additional tax burden for the investors. However, we are not the only institutional investors who are impacted with this change in LTCG tax computation. The recent change in LTCG tax computation bring about many questions around the cannons of taxation and many more. These include:

  • Healthcare real estate in India is one of the most costliest in the world and hence its relative attractiveness reduces for international investors towards India due to the additional tax burden.
  • There should have been exceptions allowed for funds and institutional investors for their existing investments in property sector to allow for the projected returns. Any new investments could have been based on the new LTCG tax proposal. This will allow for certainty of gains and returns to the investors in their current investments.
  • There are doubts in the minds of the investors about the stability of the LTCG tax regime if they are tweaked in the name of lower tax burden which is totally not true.
  • The secondary sale of the property by investors may alter the exit process by the investors in terms of time and valuation to match the increased LTCG tax burden suddenly imposed under the new regime.
  • The real valuation of the property may be tweaked with cash in the transaction to lower the LTCG tax.
  • Other creative accounting practices may be introduced to capitalise on the property inflate their costs to offset the loss due to increased LTCG tax burden.

To conclude, the new LTCG tax regime on property is not a positive one and does meet the canons of taxation and is not going to meet its objectives like the abolished Angel Tax.

Bharatvarsh – Pilgrim Nation: The Land of Spiritual Wellness Travel

Bharatvarsh: The Destinations for Spiritual Wellness Journeys

Podcast

QuoteUnquote with KK and Dr Devdutt Patnaik, India’s top mythologist and author discusses on our bet #our Bet #22 on mythological/pilgrimage wellness/health that is going to be a major trend in the next 5 years from our 2024 India healthcare and lifesciences investment manifesto. Devdutt, clears the issues on Bharatvarsh, sprituality, spiritualism, the Great Indian Pilgrimage, destinations across Hindu, Jain, Buddhist followers, ancient practices and modern beliefs. He also discusses various emerging counter trends around non-traditional spirituality, conspirituality amongst the extreme rightists and wokes, fake narrative emerging out of AI and ChatGPT and how belief systems are being altered around practice of spirituality and religion.

Excerpts

What is Spirituality?
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How is Bharatvarsh defined by Politicians, Pilgrims and Vedas?
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