What happens when … a failed healthcare system is opened to FDI

So there are many takers for Indian hospitals.This is very interesting given the fact that India’s healthcare spending as a percentage of GDP (~ 3.9% including private sector, ~1.8% excluding) is one of the smallest in the world whereas it has the second largest population in the world.

In this ‘what happens when’ we explore this scenario a bit. In India the demand is definitely there for healthcare. The supply is skewed towards urban areas and the variance in availability and quality of service is massive, especially when comparing Government run hospitals and private hospitals.

What cannot be argued against is that there is a massive gap between demand and supply with demand far outstripping supply. This gap is likely to further widen as the population ages. This gap, for sure, increases as we move down the wealth ladder.

In theory – investment is supposed to increase the supply (if used to build capacity). But that model works for products more than services. Especially where services are specialised in nature (e.g. MRI scanning, Gamma knife) or require extensive training (e.g. general practitioner, dentist etc.)  or both (e.g. neuro-surgeon, heart specialists, cancer specialists, neo-natal specialists etc.).

Therefore more money in today does not mean more doctors tomorrow. It means higher packages being offered to currently qualified doctors and specialists irrespective of whether they are in the private or public sectors. This would mean an increased demand for a resource in limited supply. In turn, to recoup the higher input costs the hospitals will have to find ways of either increasing their charges, reducing other costs or somehow battle to increase occupancy rates (perhaps by connecting with Health Insurance schemes?). This becomes even more important when we take into account the fact that any investment will require a return. Whether it is over a longer term or short term, fixed or variable.

So it leads to some disturbing conclusions:

  1. Brain drain away from the public sector into the private
  2. Providers sticking to safe markets (e.g. urban areas)
  3. Increased gap between quality and availability of healthcare as the costs rise
  4. Rising inequality in terms of access to healthcare
  5. Increased reliance on insurance to come in and plug the gap between treatment costs and income (insurance – healthcare provider nexus)

To think positively one can look at the silver lining:

  1. It would encourage setting up of integrated medi-cities (treatment, training and research) and expansion of medical education (suddenly all those medical colleges churning out MBBS will have more incentive to expand and improve quality of education – especially if the foreign owned healthcare facilities are more discerning than their local counterparts)
  2. There may be some risk takers driven by new investments, who may want to explore newer markets (e.g. smaller cities, villages) and come up with innovative business models for healthcare delivery
  3. Increased accountability and a driver to improve medical insurance (the US model)
  4. Turning to medical tourism to ‘subsidise’ treatments for locals (in the same way UK universities use foreign students to subsidise home students)
  5. Faster and (hopefully) cheaper access to advanced treatments

In all of this the Citizens of India and the Government will have to make sure that they act as watchdogs to make sure FDI does not result in exploitative practices or long term mis-alignment of the healthcare system in India.


Data Analysis: Dengue Disease Prediction

Delhi suffers from an annual dengue epidemic between the months of July and October. It is only the cooler and drier weather at the start of November that stops the mosquitoes that spread this disease.

The year 2015 was a bad year for dengue and all kinds of records were broken. Thankfully due to increased awareness the death toll did not set any records. In fact it was not as high as it could have been (in my view even 1 death is high!).

So I wanted to try and see if there is a relation between Rainfall and Dengue cases?

Also to see if there is any way of predicting the number of Dengue cases in 2016?

I used the historic data available from: http://nvbdcp.gov.in/den-cd.html
and MCD (Delhi).


Year, Rainfall, Cases

2006, 618.70, 3340

2007, 601.60, 548

2008, 815.00, 1216

2009, 595.50, 1154

2010, 953.10, 6259

2011, 661.80, 1131

2012, 559.40, 2093

2013, 1531.40, 5574

2014, 778.60, 995

2015, 1123.10, 15836

Rainfall vs Dengue
More rain – more water logging leading to more opportunities for mosquitoes to multiply. Therefore there must be some relationship between Rainfall and the number of Dengue cases. Given the dramatic growth of Delhi over the last five years we restrict going as far back as 2010.

Using the available data for rainfall and dengue cases if we fit a straight line and 2nd degree polynomial we get Diagram 1 below.
dengue_rainfallDiagram 1: Rainfall vs Dengue Cases.

We see that for a linear model there is a clear trend of higher number of cases with increasing rainfall. The R-Square value is 0.35 (approx) which is not a good fit but it is expected given the fluctuations.

What is more interesting is the 2nd degree polynomial which gives a R-Square value of 0.94 (approx) which is very good. But this could also point to over-fitting.

Another way of interpreting it is that there is a ‘sweet-spot’ for dengue spreading rapidly. If the rain is below a certain amount – there is not enough water around for dengue vector (mosquito) to breed. If there is too much rain then also there is lack of ‘still’ water to allow mosquitoes to breed.

The ‘sweet spot’ seems to be rain at a certain level that tapers leaving enough amount of ‘stagnant’ water for mosquitoes to breed.


Growth of Dengue over the Years

Diagram 2 shows the growth trend of Dengue over the years. In 1996 the dengue epidemic broke all records. In 2015 it broke all records once again. If we were to plot the number of cases over the years we see that the graph is steadily marching upwards.

If all other factors remain constant we should see about 6000 cases in 2016. 


Diagram 2: Dengue growth rate over the years.

This is a very simple analysis of dengue. There are lots of other variables that can be added (for example – growing population, temperature profiles, regional variance). But I wanted to show how even simple analysis can produce some interesting results.

Another important point I wanted to highlight was the lack of easily accessible data on diseases and epidemics. If we had better data then public health initiatives could be better targeted to combat such occurrences.

Ab baat pakki…. the deal is fixed…. X 4

The second season of Swayamvar starring Rahul Mahajan is currently the number one TV show of  India. The show is supposed to end on the 6th of March and this time they have promised us a marriage!

I like this program because it blows away some serious concepts in marriages. At the same time it exposes the dark side of human nature.

In last nights episode he travelled to meet the family of the first girl (Harpreet Chhabra). Harpreet’s family members were obviously treating it is if a boy had come to meet the family for her marriage. They asked him whether he has any ‘demands’ [for dowry]. Did they realise he was on camera being view by half of India? Even if he wanted something would he have said so on air? Women activists would be buring his effigy all across India if he had. But this shows that dowry is still a big issue.

Now the second point: usually when marriage is being discussed between two families it is usually between TWO families! The process is quite sequential.

 In this case he has to visit three other families who are expected to discuss marriage equally seriously! He has to interact with girls at individual level as if SHE is the one, which is impossible at the deepest level. The problem is that this can be taken in two ways:

1) Either he is really good at compartmentalising emotions and such deep interactions… which means there is full scope for other women in his life, perhaps even after marriage.

2) He has already made up his mind and all this is acting.

But this show has made bride hunting similar to buying a house where you have multiple deals going on at once. A new concept indeed in marriages. Will this be used by families to parallelise bride hunting? Make it more efficient? Especially keeping in mind, like good houses, brides are in short supply?

The multi-Billion Dollar Scam: Selling unsustainable dreams…

The real estate sector is booming in India. Areas just outside the four metro cities have seen land rates shoot up like a NASA rocket.

A textbook case is the suburb of Gurgaon touching the southern border of New Delhi. Till 10 years ago it was a dusty under-developed area with bad infrastructure. It was not a hot favourite for house-hunters and real-estate developers. How can I say all this? I had relatives living in that area and have been visiting them since I was 11-12 years old. I have seen that area develop as I was growing.

Then came the multi-national corporations, the call centers and the big brandnames. These were followed closely by the shopping-mall culture and a major empowerment of the young working Indian. All this meant that within a short span of time on a 4 km stretch of the Meherauli-Gurgaon road there were 6 shopping malls standing shoulder to shoulder.

While individually these were no where close to their western counterparts, taken together they formed a solid block of shops surrounding on of the busiest roads connecting Gurgaon with South Delhi. Within months the Meherauli-Gurgaon road became a nightmare for regular commuters. Being stuck in traffic for hours became normal.

Yet the property prices in Gurgaon kept increasing. New real-estate projects started springing up all over the place. There were buildings but no roads. Homes but no water or electricity. The boom was fueled by the ITeS boom in India and rise of home loans where young professionals starting their first job were able to buy flats and land. People made a lot of money selling dreams.

But what is the reality? Infrastructure is still trying to catch up with Gurgaon. Non-existant transport facilities are being supported with a new metro system. But what about water?

What about sustainability?

A crore’s worth of property is not of any use if you do not get water when you want to have a bath or electricity when you want to sleep. While power shortage can be removed (if your children are lucky then maybe in their lifetime) what will we do about water?
Study sees dramatic drop in Indian groundwater – longterm prospects are anything but bright for a good supply of water.

With a declining water table, unpredictable rains the long term forcast for Haryana points towards it becoming an extension of the Thar desert.

What will happen to the billion dollars worth of real estate? The investment in our future will be equal to a pile of sand?

Lack of sustainable development and blind destruction of the natural shield that is Haryana does not give a solid foundation to any kind of long term investment (for e.g. property investment).

The above factors make the real estate boom in India a bubble waiting to burst. When this bubble bursts a lot of people will be left with shattered dreams.

Few people though, will be left with a load of money they made selling unsustainable dreams.

Why not us?

Netherlands from air looks like an island. Instead of roads in between fields they have canals. The entire country is built on water.
UK is famous for its BAD weather. It is cold and damp.

Both countries today are counted amongst the worlds most developed countries.
People will point to their colonial past as the source of their wealth. But these countries did not always have these colonies. The colonies were built up with strength and resolve. It is not easy to conquer and command people halfway around the world.

These countries had similar problems as India. Problems related to oppression of poor, caste system, superstition, domination of religion and wars.

As time passed the fate of these countries diverged from that of India. We became the shoe on their foot. The diamond in their crown.

What could be the reason?
Maybe it was the lack of a global point of view?
Maybe it was something to do with looking for short term riches over the long term benefit of the people.
Maybe dictatorship and rule of kings went on for a decade longer than it was supposed to?

Maybe the politicians and industrial elite took over from the rulers of old to exploit people? But the same happened to Germany that to not once but twice.

What could it be then?
Could it then be the inability of India to control its population growth? It could certainly be a major factor. Bigger the car more powerful an engine it needs. Furthermore more passengers on board lesser is the efficiency of the engine.

Where to go from here?
Start a one child policy like China?
Or better educate people so that they understand the advantages of a small popultation?

Evidence from Kerala indicates the second option is just as good (if not better) than the first. Kerala’s population growth stands around 1.8 which is similar to that of China but a whole lot less than the National average for India.
Kerala also boasts of 99% literacy.

This means education has a clear link with population growth which in turn has a major effect on economic and civic growth of the country.

If the equation is so simple again I ask… Why not us?

A Day at the Registrar’s Office

One would think a Registrar’s Office where probably crores worth of property changes hands every day life is pretty dull and weighed down under thick dusty files. But no! Any place where big things happen (like people buying their first house or probably registering their last will) can be anything but dull. In fact it is full of stories!

One would wonder why is the place not clean and how come people who can spend lakhs to buy a property do not have civic sense to use a dustbin. Why don’t the civic authorities have common sense to put dustbins in a place visited by hundred of people a day!

There was a large group of young Army jawans there to register their wills. People who don’t have control over their destiny. I wonder how it must feel to write out your will knowing that it might be used soon.

There were photographs I took, some sad, some funny and some fascinating.  There was life in all its glory. Intersection of different life-flows. All in all it was a very interesting day out at the crossroads of life.

Stone slab announcing the installation of computers at the govt. office!

Stone slab announcing the installation of computers at the govt. office!

Heaps of Garbage..

Heaps of Garbage..


Patterns on water..

Patterns on water..


Indian Foreign Policy – Himesh Reshammiya Style

‘Jhalak dikhla jaa’ (show me a glimpse) is one of the most popular songs sung by Himesh Reshammiya.

These days India seems to be taking their foreign policy decisions based on the above song. Few days ago I saw a news item on NDTV which talked about how India was concerned that US was getting closer to Pakistan. The major reason for this was that over the last month or so the Indian Government had been busy with the General Elections. During that time Pakistan had been busy warming up to the new US administration.

When the Indian politicians suddenly woke up to this fact towards the end of the election process they appeared desperate to see a glimpse of US engagement and interest in India.

As one big drama ends the next one is about to begin, the Indian politicians are  singing ‘jhalak dikhlaa jaa’ for the new US President.

The Fact of Indian Elections

Every conflict has three sides. The side which won, the side which lost and the side which sits on the side to watch the conflict to take all possible advantage.

During the current election period we find parties in power taking fire from parties which lost the last election. The loosers blaming the winners for the almost continuous sorry state of affairs in India. The winners in turn blaming the losers who were in power previously. This blame game has no end unfortunately.

In all this one critical fact never gets highlighted: the amount of time a government gets to plan and implement development work.

Is it right for Congress to blame BJP which was previously in power? Is it right for the BJP to blame the Congress? Is four/five years enough time for the party in power to prove itself?

Given the slow speed of the Indian state machinary any project typically takes a long time to be planned and completed. Especially if the project spans multiple states (like the National Highway Project).

Take the Delhi Metro Project for example: The plan for the metro was passed, guess when? Maybe you thought 1980s or 1990s? No way! The concept of the metro was finalised in the 1960 Delhi Master Plan. The legal framework was setup in 1978 (the Metro Railways (Construction of Works) Act) (see this). When did the construction start? 1998. I guess that is why the Metro project is considered to be a miracle.

In my view each Government should be given at least a 6-8 years period to plan and implement projects before cursing them. We have seen how bad governments are when it comes to handing over and giving credit.

The situation is even worse when it comes to State-level projects. Uttar Pradesh is famous for this. Key infrastructure projects stop and start based on which Government is in power.

Then what is the fight and posturing about? Can any Government claim that they are the masterminds behind development projects when each major project has its roots in history? I don’t think so.

I think we should be honest with ourselves and evaluate the parties based on what NEW things they did. What new initiatives were put in place? We should never go by the chest-thumping and shouting as politicians try and take credit.






Hulla of Indian Elections!

The movie Hulla (2008) talks about how noise leads to a man loosing his peace and stability.

Indian politicians seem to be trying to do the same to the masses. Trying to confuse the people with noise so that they loose their capacity to think and vote. This ensures that the real issues get clouded in the noise.

Which ever channel you turn to, whatever election issue may it be (from Terrorism to Economic Slowdown) the discussion starts out quite calmly with the various people from different parties (the standard on NDTV being BJP, Congress and the Left) looking all cool and calm.

The anchor introduces the people and the topic.

Then the anchor puts the first question to one of the representatives. That is when the whole group of ‘politicians’ starts shouting at one another like a couple of sulking teenagers.

Usually it is the party in power vs party wanting to be in power which, sometimes, is almost the same as party in power vs party which WAS in power 5 years ago!

What we see is discussions on all issues, big or small, reduce to a shouting match with the anchor trying to guide the discussion. The attempt to guide is as affective trying to divert a flood with a straw!

All the noise, all the fighting, all the personal and political battles being fought on air while the real issues are being ignored. No one is going to admit failing and no one is going to give an inch.

What happens then? A stalemate. No discussion and no one party either gets questioned by the public or needs to defend itself.

I wonder if this is something that all sides have implicitly agreed on. To create a noise screen to drown out the REAL questions.




Property Cases in New Delhi…

Money is the root of all evil and money is at the root of property. Whether it is a house or a flat. Skyrocketing prices of real estate in Delhi has ensured that the worst side of human nature is exposed in family relationships.

How does a typical property case start?

It starts with a family with multiple real brothers/sisters, a property, a doubt in the ownership and usually a builder interested in the property (if it is a house and not a flat).

The various children have ego issues with each other and within themselves. This includes jealousy for the other persons success and simple greed. If that is not the case then a builder comes along who wants that property and doesn’t want to pay full price. He plants the seed of greed in one of the siblings head.

Then one of the brothers/sisters files a suit of partition against his/her siblings. Usually only those people are made party to the suit who have a right in the property and have not explicitly signed away that right.

The person filing the case becomes the plaintiff and the person(s) against whom it is filed are defendants.

Obviously to file a case one has to go to a lawyer.  Not many lawyers are going to tell you not to file a case and settle it outside the court. Most lawyers are going to tell you that your case is winnable. The person filing the case is already pumped up and aching to go. Ego rules the brain.

Property cases are good because they take a long time and provide a lawyer with regular income.

The real fun and games begin once the notice is served to the defendants. Especially if they happen to be neighbours. This activates the ego of the defendants. All ties are broken. No one goes to the other persons house and obviously every move is treated with utmost suspicion. From that day all communication takes place through the lawyers.

Initially the plaintiff is really pumped up. Comes to each hearing. Then as the case gets more complicated with the defendant’s lawyer throwing punches and mixing up things a single case gives birth to multiple cases in different courts.

This obviously reduces the enthusiasm of the plaintiff but stil the ego is there. So he starts coming only for the crucial hearings (which happen once in 3-4 months). All this while both the lawyers are pretending to be gearing up for the fight of their life. This also ensures their clients that yes things are progressing.

As months turn into years and a grand tour of the courts of Delhi begins for both the sides, enthusiasm starts waning and the egos start getting crushed. Then only the most important hearings are attended.

After 4-5 years the ego of both the sides is completely crushed. That is when the lawyers start whispering about a compromise. A property case, while giving decent money over a few years, is a bit like a milk giving animal. There comes a time when you can make more money by slaughtering the animal and selling the meat than by milking it. Lawyers are usually expert at recognising this. They know if a compromise takes place they will get a lump sum of cash which would be at percentage of the property value.

It takes about a year for both the lawyers to bring the parties on to the table for a compromise. The most common compromise is everyone gets equal share. Once a compromise has taken place the plaintiffs move the court to pass a compromise decree under Order 23 Rule 3 of the Civil Procedure Code of India.

This puts the courts seal on the compromise. It is not a ‘decision’ by the court so it does not preclude further litigation thru ‘res judicata’.

Once the compromise is achieved and all the paperwork is done and over with the lawyer will do a bit of show off in front of the other side to convince their client that they managed to do a brilliant job and that they were in complete control all the time. Furthermore they will show that it was their side who were sensible and generous therefore decided to give a share to the other side.

All in all in any kind of a case one must always remember:

The judge, the lawyers and the legal staff are all actors.

The courtroom is the stage.

The case is a drama.

The poor people caught up in litigation are the hapless victims/spectators who see their fortunes rising and falling without having any control on the acting or the script.

So remember… before you file a case make sure you have tried talking to the other person.