Healthcare for All: Money for Nothing!

Kapil Khandelwal @Tedx Gateway Unplugged
Kapil Khandelwal @Tedx Gateway Unplugged

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

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

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

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

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

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

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

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

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

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

Therefore to achieve this the new slogan should be:

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

How do we achieve this all?

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

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

Let’s get started:

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

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

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

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

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

Kapil Khandelwal @ Tedx Gateway Unplugged
Kapil Khandelwal @ Tedx Gateway Unplugged

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