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An implicit bias that all of us have is that we are incredibly advanced.
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This is undoubtedly true if we look at the past.
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Science is amazing, technology has changed our lives, the internet is so cool, our nanajis
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fufaji did not have tiktok, can you imagine?
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But while it is true that we are more advanced than we have ever been, it is equally undeniable
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that 200 years from now, humans will look back and find us so, so primitive and backward.
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Again, this is a lesson we can learn from the past.
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In the 19th century, 200 years ago, there was no germ theory of disease and a common
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treatment for many ailments was bloodletting.
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That is just crazy, those guys were so backward, and surely, in light of what is to come, so
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For example, decades later, public policy specialists could look back on these times
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and say OMG, these guys had no clue of public policy, these guys had no clue of economics,
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Indeed, one specific field in which we don't need hindsight to say we are floundering,
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indeed it's evident that we are floundering today, is healthcare.
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Different countries have tried different approaches to this, no one has solved it, it's messed
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up everywhere including in advanced countries like the USA and UK.
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Do we know how to fix it?
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Are we constrained by dogmas of the past in fashions of the present?
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It's like bloodletting.
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Welcome to the Scene on the Unseen.
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My guest today is Amrita Agarwal, who is regarded by many people I respect as one of the most
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insightful thinkers on Indian healthcare.
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Amrita began as a standard issue consultant working in Bain for a few years after studying
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at IIM Ahmedabad, but she soon felt consulting wasn't enough, she wanted to tackle bigger
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And what can be a bigger problem than Indian healthcare?
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She worked with the Gates Foundation for a few years, understood the field, applied first
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principles thinking, looked at the data from India, studied practices from around the world
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and realized that everyone was getting the problem statement wrong.
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She is no longer at the Gates Foundation, but she is still engaged with this larger
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problem and in our conversation today, shared not just her insights into healthcare, but
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also into consulting, philanthropy, the science of longevity and the power of sunscreen.
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Terrific discussion all around, but before we get to it, let's take a quick commercial
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Do you want to read more?
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I've put in a lot of work in recent years in building a reading habit.
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This means that I read more books, but I also read more long-form articles and essays.
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There's a world of knowledge available through the internet.
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But the problem we all face is, how do we navigate this knowledge?
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How do we know what to read?
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How do we put the right incentives in place?
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Well, I discovered one way.
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A couple of friends of mine run this awesome company called CTQ Compounds at CTQCompounds.com,
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which aims to help people up-level themselves by reading more.
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A few months ago, I signed up for one of their programs called The Daily Reader.
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Every day for six months, they sent me a long-form article to read.
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The subjects covered went from machine learning to mythology to mental models and marmalade.
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This helped me build a habit of reading.
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At the end of every day, I understood the world a little better than I did before.
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So if you want to build your reading habit, head on over to CTQCompounds and check out
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New batches start every month.
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They also have a great program called Future Stack, which helps you stay up-to-date with
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ideas, skills, and mental models that will help you stay relevant in the future.
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Future Stack batches start every Saturday.
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What's more, you get a discount of a whopping 2,500 rupees, 2,500 if you use the discount
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So head on over to CTQCompounds at CTQCompounds.com and use the code Unseen.
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Amrita, welcome to The Scene and The Unseen.
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So, there's a quote whose provenance is sort of disputed.
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It's supposed to be by a guy called Rollo May.
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The opposite of courage is not covered, it's conformity.
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And when I think of a lot of people I know, and certainly you, it kind of seems to be
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the case because when you get inside a field, it is incredibly tempting to sort of just
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go along with whatever the conventional thinking is, to not fight the consensus, especially
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can be affected by it, you know, where you stand depends on where you sit, etc, etc.
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And therefore, I always admire people who think in an independent way and buck that
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particular trend and think hard about the field they're in.
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And when it comes to economics, I think of people like Land Pritchett, who's been blazing
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such a path while, you know, development economics has moved in a completely different and kind
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You know, our mutual friend Ajay is a similar kind of person.
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And in the context of healthcare, I certainly think of you like that, but we'll, you know,
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double click on the details of public health and healthcare later in this episode.
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But I just want to first begin with the general sort of question that, you know, is it something
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that you have to push yourself to do or is it something that just comes automatically
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that, you know, is conformity the default which you have to fight against, or if you
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are a freethinker, you just are a freethinker and that's okay.
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Thank you, Amit, with easy questions to begin with.
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When I think about myself, I have not necessarily thought of myself as a rebel.
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But at the same time, I do not think I'm looking for conformity either.
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I'm looking for understanding, I'm looking for truth, and I'm looking for meaning.
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And I feel some of it is how I grew up with values and some of it is there's been a yearning
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inside of me to understand things and for it all to mean something.
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I think that's what drives me.
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And also, what are we moving towards?
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And then coldly looking at it, and that's, I think, intrinsic nature to me once I fixate
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on whatever is, which is meaningful, I will be ruthless about it.
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So I will look at every evidence in a cold, calculative manner, while the meaning is driven
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by heart, but the pathways to it is driven by my mind and logic and rationale, at the
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same time, leaps of faith, but in a calculative, risk-taking manner.
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So I feel like in a way, you know, you have an episode on chess, which is out, I feel
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like a chess player and looking at every possibility and looking at the pros and cons and being
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dispassionate about it.
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I feel what helps me is my values, which I grew up with, which is not to think about
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materialistic things or status or very regular trappings we fall into, which may push towards
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But your service, helping others, and meaning helps me be grounded.
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I love what you said about the meaning comes from heart, but the rest of the journey comes
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from mind, because often we sort of make a dichotomy, you know, between those.
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You'll have a phrase like bleeding heart liberal, which indicates all heart and no mind, or
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you'll think of someone who is cold and calculating and does game theory and math, and you'll
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imagine that there is no heart there and it's all calculation.
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And actually, no, I mean, you know, the intensity of the heart dictates the use of the mind
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So if I'm to dig deeper into what, you know, we mean when we talk about heart, would you
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say that that is then A, a sense of purpose in terms of I want to do X, Y, Z, and B, in
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terms of values, that these are the core values that are dear to me, like maybe service, like
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you said, or freedom or whatever the case might be.
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So if I'm to dig deeper on, you know, what are those things that are core to you that
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are coming from the heart, so to say that drive everything else?
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I have evolved over time, and my understanding of my own thought process and emotions have
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It must have started out and as I reflect back in a very personal story, and which came
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from the journey which I took as a child and my family faced, and the sympathy I faced,
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the sympathy I have had for other Indians living in India and living through trying
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times, and I feel it started from a very personal experience.
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But as I have gone along this journey, I have understood values, and I have understood a
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broader thinking, broader philosophy, and I feel like I've evolved.
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So beyond the experience which I had, and therefore trying to give back to society
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and improve things for everyone, there is values and a philosophy, which is around meaning.
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And so it's a bit of an evolution.
#
Let's talk about our journey and that evolution, you know, tell me about your childhood, where
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were you born, where did you grow up?
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I grew up in Jamshedpur, I love my city, and I love to talk about it.
#
I would say my life growing up in Jamshedpur is in two broad streams in my head at least.
#
One is about freedom, and starting from a very conservative place in my ecosystem and
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And the second is this personal health crisis which my family went through.
#
You know, I come from a typical Marwari large family, and growing up I was very aware that
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women were secondary in my ecosystem, as is the case with many such families.
#
But strangely, what happened with me is I experienced freedom, and I was very lucky
#
because part of it was my parents, part of it was the school I was brought up in, part
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of it was Jamshedpur with its unique features, and part of it was I just got plain lucky.
#
So my mother was very conscious that she didn't have freedom, so she would give me permission
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to do whatever I wanted.
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My father wanted us to have a better life, so he ensured that we relocated to the best
#
part of the city, we got admitted to the best schools, which gave me many more opportunities
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Our school principal loved sports, and in a girl's school, to really play sports hard
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core, I played four hours a day for eight years, I played basketball, it's freeing,
#
because physically you really get to challenge yourself, and I do not know how many women
#
I played at school levels, state level, national levels, I got to challenge and train my mind
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to have power over my body and to have power over my emotions, because when you play in
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a team, it's very difficult.
#
So I feel like it was really freeing for me.
#
I also had freedom in a very weird way, because there's not as much pressure as in a girl
#
child, there's no expectation to join the family firm, there's no expectation to excel,
#
so I could choose to study physics or science when the rest of my family was doing commerce
#
and CA, I could choose not to study for IIT because I found it physically too taxing,
#
after two months I gave up, I was like, this is not making sense to me.
#
So it was really interesting way of getting freedom, and then I found freedom in books.
#
I feel like I was oddity, I did not really fit with the conversations around me, and
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perhaps my mind was looking for something more exciting, something more adventurous
#
and grander lives than we seem to live, and I think books were a great escape to figure
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out what was happening in the world, so I got freedom through books.
#
Yeah, so I got a lot of freedom, so that is one track in my mind which has characterized
#
my growing up years in Jamshedpur.
#
Also Jamshedpur, I was just discussing with a friend the other day about her small town
#
experience in Gujarat versus mine, and I realized the multicultural milieu of Jamshedpur is
#
quite interesting, and it brings about freedom from your own community's biases.
#
So I had friends who are Christians, friends who are Bengalis, friends who are Tamilians,
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and it was very, very open.
#
So I think that really again shaped me quite a bit.
#
So that's me being open to exploring things around me, and then there was a whole catastrophe
#
which my family went through when my father was in mid-40s, I must have been 12 or 13
#
He had a big health crisis, his kidneys failed, and we went through a few years of figuring
#
out his treatment, his transplant, and then he's been off and on ill for the last 25 odd
#
So I feel like that was a very interesting phase of life.
#
I can say interesting now as a child, it must have been more difficult.
#
But that made me also understand that lives are quite unpredictable for human beings,
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and the monetary, the physical, and the emotional it takes on the entire family, not only the
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patient is quite substantial, and the effects can last for many, many years.
#
So I feel like that really was deep there inside me, and we were relatively better off.
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We were middle-income, we had savings, we had a network, we had a community.
#
And over the years, I saw many more people come to us, while we had been supported by
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family members, my mamaji and other relatives, I'm really grateful for them, but I saw many
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more people come to my father with their health issues and their problems.
#
And I understood for the people who do not have resources or do not have the knowledge
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or do not have the connections, it is far worse.
#
So having experienced the tough times, I understood for others, it could be even worse.
#
And that is the other value I took away, you know, despite so much challenges in my father's
#
own personal life, he was always ready to help others.
#
And that has really been a strength.
#
He will have days when he'll break down because his body cannot take it anymore.
#
But he will at this age, after 25 years of illness, he will still want to help others.
#
So that's how it was growing up in Jamshedpur.
#
In a way, it's difficult, but in a way, it's very freeing and happy as well.
#
So many things I want to double click on.
#
One of them is that, you know, when I speak to a lot of people between my age and your
#
age, let us say, let me conveniently put us in the same sort of generation and different
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One thing I realized is that their parents, in a sense, and we don't realize this because
#
we've normalized the world as it is, but their parents lived in a different world where they
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had no opportunities and self-actualization was limited and there was really nothing.
#
And a lot of the living that they did, in a sense, was through their kids, like it is
#
very poignant when you say that your mom, who did not experience those freedoms, therefore
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made it a point to give it to you as it were, that your dad wanted to make sure that you
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went to the best schools and got those opportunities.
#
And they may not at that time have seen the changing world that was coming with all this
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But I find that kind of poignant and I find it almost a common theme running through,
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you know, people of that generation who are like the parents of our generation, that,
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you know, it's a severely constrained world.
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You can't possibly know how constrained it is because you don't have a vision of what
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life is going to be 30 years later or what, you know, women in the West, the freedoms
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they may enjoy and etc., etc.
#
But you, you know, there is almost this unarticulated sense that there is a better life and we didn't
#
get it and that's okay, but our kids are kind of...
#
So tell me then a bit about your parents and what part do you think that played in the
#
shaping of you, so to say, you know, beyond the circumstances and we'll come back to that.
#
But just beyond that, what were they like as people, like were there books at home?
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What were the sort of conversations like?
#
Was there a sense at that time that, like you said that you didn't, there wasn't academic
#
pressure on you because you were a girl, but was there nevertheless a sense of what are
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That there's something more at the end of the line than just, you know, getting married
#
We were never a chatty family.
#
I think there was a lot of love, but it was not expressed.
#
There was a lot of support and strength, but we were the strong, silent family to each
#
other, which does happen in India quite a bit.
#
So I always knew I could depend on them, but we didn't really discuss about future and
#
I do remember it being very entrepreneurial.
#
So you know, typical Marwari family, my father had a CA firm, he was the second CA in town,
#
but he also kept experimenting with other businesses.
#
So he would buy a shop and he would try and run a medicine shop on the side.
#
Then he would just keep iterating with other opportunities.
#
So that is again a memory in my mind, which is, you know, business is very normal and
#
it's interesting and one should keep experimenting and trying.
#
And he was successful and respected in the society.
#
What was very striking to me because we didn't discuss it, but I heard from others was because
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he was there for everyone.
#
So that was the recurring thing, which I remember about him.
#
I do not remember him having so much time for us, but I knew that he was trying to be
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there for everyone as much as he could.
#
So that's the kind of family we had.
#
Yeah, so it was not so much getting direct influences at home.
#
It was more observing and experiencing and seeing the values around me and then imbibing
#
And I think a lot of my thinking about the world has been shaped by books actually about
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what do I want to do, what is interesting, what is meaningful, what are the grand questions
#
I feel like that has come more from reading books or as I grew up beyond Jamshedpur to
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college or beyond college to other spheres of my life, I feel like that has been built
#
So I feel like the values are very much almost imbibed and then I have grown in my own sphere.
#
So a digressive question, which could also have come at the end of the episode, but I
#
thought of it when you spoke about your dad's health crisis.
#
It comes back to a conversation I was having just a couple of days ago where I met this
#
friend of mine who runs a think tank slash NGO in Delhi and he's in his late 30s.
#
And I was just telling him that, look, over the last year or so, I've started thinking
#
a lot about aging and there's been that realization that, oh my God, time passes much faster than
#
You begin to realize how little time you kind of have as you grow older and then you begin
#
to realize that the weeks and the months just go by.
#
One of my friends, Gotham John, once told me this, gave me this great line about the
#
days are long, the years are short.
#
But sometimes I feel even the days are short, even the weeks are short, everything kind
#
I remember Jan 1, 2024, I'm thinking, what am I going to do for the year and making my
#
plans for the year and we are already recording this in the middle of June, right?
#
So time moves really fast.
#
And when I said this to my friend who's in his late 30s, who's 28, 39, and he said he
#
felt the same thing and he said he felt it during COVID, people close to him passed away.
#
And he said that, oh my God, you know, that's when I realized that you can't take this shit
#
for granted, that time moves really fast, that everything ends.
#
You know, there was a colleague of his who was also a dear friend of mine sitting with
#
him also in his late 30s.
#
And he said that, you know, when X joined the organization, I told him that, boss, we
#
have to hurry, we don't have time.
#
And that is both in a context of, you know, the nation, the fact that we're losing the
#
demographic dividend, it reverses in 2040.
#
So it's in that context also.
#
But it is also in a sort of a personal context.
#
And I think most of us, the default mode of living, in fact, the mode of living, which
#
we have to adapt if we can live happily, is to assume immortality, to assume ki sab
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theek hai, we are going to live forever.
#
You got to like, you know, just chill.
#
I think someone's, there's some quote to the effect of, you know, live as if you're
#
going to die tomorrow, but learn as if you're going to live forever, something to that
#
effect, I forget the exact thing.
#
And our default mode is to just, and some people have this all their lives, that, you
#
know, they don't step back and take that perspective and, you know, get intense about living as
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So do you think that, you know, a health crisis like that, did that for some of you, like,
#
maybe that's why your dad, perhaps he was always a helpful person, but that could be
#
one spur for him to try and help others because you realize that in life, a lot of the stuff
#
that you otherwise prioritize, like wealth and all that doesn't really matter so much.
#
It's people and relationships and all that.
#
And for you, do you think that that was, that there was, you know, a shift there or, you
#
know, what's your perspective been like?
#
I can clearly see why in many cases, such a health crisis could be a cry for shifting
#
But I feel like in my family context, I saw that growing up, it came from my grandfather
#
when I speak to my father about it, my grandfather was like that.
#
My father was, you know, he had, they were five brothers and two sisters, but he felt
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always closest to his father.
#
And this is what I also saw with my mom's side of the family.
#
Again, my mamaji and my naniji, extremely helpful and, you know, oriented towards helping
#
So I don't think crisis per se shifted that narrative.
#
What did make it, you know, what highlighted things for me was really that despite your
#
own problems, you were able to rise above that.
#
You were still able to maintain your value system and look beyond everyday pain, which
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you were having or everyday crisis you were having to try and rise above that.
#
So I feel that got magnified in my mind.
#
Tell me about the stuff you were reading, like you spoke about how, you know, the grand
#
questions came through books as it were.
#
So what kind of kid were you?
#
You know, what were your obsessions?
#
So to say at that early age, like I'm really talking, you know, before you go to college
#
and all of that, at that early age while you're growing up, what is naturally drawing you
#
Everything I could get my hands on, you know, it was a small town and we were not a family
#
It was me laying my hands on to anything I could grab and I do confess I was quite enterprising.
#
So if one of my relatives had, you know, one of my uncles had a library, I would manage
#
to get books which I should not have gotten at that age.
#
And I would make friends with the school librarian, she's an amazing teacher, and she would take
#
me shopping with her for the school library.
#
I had a nice barter system going in the school because I could read very fast.
#
So I would read three books a day.
#
So I would borrow from a friend, read it quickly during the classes, lend it to another friend
#
in exchange for another book, read that during the classes, do that another third, second
#
exchange, take that home, read it.
#
So I had a very nice barter system going for many, many years where I would have bought
#
three books in total in all those years.
#
And between the library and my friends and some of the other libraries I had access to,
#
I managed to have a very nice gig going for myself.
#
So I feel like I wasn't restricting myself to what kind of books I wanted to read.
#
I was just desperate to escape into a more fun, adventurous, exciting world.
#
I feel like a few things, you know, a lot has faded.
#
The usual Alistair McLean adventure and spy thrillers were there.
#
But I remember reading this book called Strong Medicine, Arthur Haley, when I was in sixth
#
standard or seventh standard.
#
And I don't know if it was age appropriate, but I got it from someone's library.
#
And during a wedding, I remember that's what I did.
#
I just sat in the corner and I read the book.
#
And it did leave a very strong impression in my mind about the pharmaceutical industry,
#
So it was not a very deliberate reading.
#
It was whatever I could get my hands on.
#
One interesting book which left a lasting impression on me was Ayn Rand, Atlas Shrugged.
#
So my brother had gone to college.
#
He had got the book home to read.
#
I was in ninth standard and I read that book and I was completely enchanted.
#
Looking back, I don't know how much I understood.
#
But it seemed to me that there was a whole world, there was a struggle between meritocracy
#
and equality and socialism and where in that fight the society would land.
#
And it was very fascinating.
#
I could see some of that around me in the social construct we were all living in.
#
But I felt quite impressed by the book.
#
I remember reading Animal Farm, again, some books which just happened to come my way and
#
other books which I have forgotten, but they were interesting.
#
So anything I could get my hands on.
#
In fact, one of the stores my father bought was a bookstore, which he converted into a
#
But as a result, we got a whole lot of books which were to be thrown away and I got to
#
So there was a horror novel called Oman 2.
#
Yeah, so this was the fun way of reading.
#
A bookshop becoming a pharmacy is it a metaphor for your life?
#
It seems from this that like three books a day is pretty awesome.
#
And it seems from this that as someone who used to read a lot myself as a kid, I realized
#
in hindsight, looking back, that in a sense, it set me apart from everyone else in the
#
sense that my interior world was very different from theirs.
#
And you could argue it is richer, you could argue it is more cluttered, you could argue
#
whatever, but it's different from theirs and I'm spending a lot of time in that interior
#
world and the way I look at everything is shaped by that.
#
And there is perhaps a danger there that that can also isolate you from others, that
#
it can, you know, you can withdraw into loneliness in your case, that's clearly not the case
#
because you also sort of did sports and you said, so you would read three books a day
#
and play four hours of basketball a day, which is good days, in a sense.
#
So tell me about what that process was like, like that shaping of yourself, like, what
#
was the story about yourself that you told yourself?
#
You know, what you said was very real to me, this isolation and loneliness.
#
So it was very interesting for me to read books and I immersed myself more and more
#
into it because I started to disconnect from the conversations around me.
#
If it was clothes or boys or she said, he said, it was, it didn't seem to be important
#
But thankfully, and I was a bit of a lost child because I was in my head with the books.
#
I have to really thank my friends that they did not abandon me.
#
They thought I was this crazy, interesting, funny person and they would just keep me around
#
and they were just nice to me.
#
So I loved playing with them and I had a great circle, which prevented me from being isolated.
#
But in a way, I never also fitted in fully because I feel my mind also did not work in
#
some conventional ways, for example, during exams, if someone would call me and ask me
#
about what to study, I just could not answer anyone, anything, because my mind was just
#
not processing information the same way.
#
If someone was having a conversation about clothes or boys, I just was not able to participate.
#
So I felt a bit lonely and not understood.
#
But you know, in those days, I do not think there was a deep desire to be understood.
#
I was happy to be friendly and distracted from my troubles at home or not wanting to
#
And I was just happy to have a very friendly, happy environment.
#
So I feel like sports helped me to be mentally strong when I needed to be.
#
And my friends were really, really amazing and fun, but I did not get to connect on the
#
thought level with anyone at home or at school, which I found much later in my life outside.
#
So I'm only grateful for the good I got, but I do feel I was lonely and I really got to
#
have conversations only in college and afterwards.
#
Yeah, you know, what you said about you didn't want to talk about loads of boys reminds me
#
of the quote, small minds discuss people, average minds discuss events, great minds
#
discuss ideas, stop quote.
#
And I guess people who sort of read a lot are also more drawn towards ideas.
#
But tell me about then the rest of your journey from there, like what happens after school
#
How are you thinking of what the future holds for you?
#
What are your inclinations like and where do you go from there?
#
I would say I was a lost child.
#
I knew I did not want to do a conventional IIT because that's what was needed.
#
I did very well in school, but I was told to drop a year and attempt IIT and I was not
#
Maybe I just wanted to play and read books.
#
Stevens happened by chance.
#
Someone I knew, her sister had gone to Stevens and I was a bit naive.
#
I just applied to one or two colleges and I happened to I was lucky to get through.
#
Looking back, I was very naive.
#
I should have been more systematic about it.
#
I feel like I was not I did not know anyone who had been to Stevens.
#
I had not spoken to anyone before and it was the first time living outside by myself.
#
But it was actually very liberating and very, very nice for me in a way.
#
It broadened my horizons.
#
So there were sciences, there was arts, economics, English, history, Sanskrit, chemistry, every
#
field and I was in the residence in the hostel and I got to speak with everybody.
#
There was a lot of time spent under the Dahabatri as a lot of people from Stevens do, drinking
#
Iwo Pani and eating samosa and just chatting about the world.
#
So I felt much more comfortable in that environment in a way, discussing ideas, learning about
#
the world, seeing the whole tapestry.
#
I feel like I wasn't very focused even then.
#
I was just happy to explore.
#
It was a very relaxed environment, which later on I think I've really missed.
#
After that life became very hectic and busy, but Stevens was very, very relaxed and peaceful.
#
So I do value my years there and KP Krishnan in the episode he did with you speaks about
#
Stevens as a place where he got to connect with a lot of people, like-minded people.
#
I feel like my experience was slightly different.
#
I feel like I was still a very much of an introverted child in my books and my music,
#
but I got to explore ideas with other disciplines and I feel like that's what I really treasured
#
You know, you mentioned about how it was relaxed there and afterwards things got hectic and
#
Do you think that we undervalue that kind of relaxed atmosphere?
#
Like one of the problems with a lot of education, but also a lot of the approach that a lot
#
of people have towards life itself, whether for themselves or whether for their kids is
#
a very goal-directed one, that if you want to do IIT, then go, study, one year off-law,
#
Or, you know, you're doing this because you want to get that, you want to be a vice president
#
in Citibank, you want a nice house and whatever and everything becomes goal-directed and everything
#
then becomes extremely hectic.
#
And there is a value to the relaxation in two different ways and one way I think which
#
applies especially when you're a child is that what you do in that leisure time, whether
#
you're reading fiction or playing a sport or you're just chilling, you know, it helps
#
you think in different ways, it helps you get a richer interior life than just doing
#
something that is goal-directed.
#
And I think even as an adult, you know, being in that relaxed atmosphere gives you a chance
#
to, in a sense, arrive at yourself, arrive at who you are without the pressure of, you
#
know, doing stuff or expectations vice-reported upon you.
#
So what is your sense of time?
#
I think the coming many, many years would teach me when you're acting and in that hustle-bustle
#
of the life, you do not have time to reflect or to declutter your mind or just to be happy.
#
You don't even know how to appreciate happiness.
#
And so I feel like it was a very unique moment and that relaxation also helped give space
#
for exploration and observation.
#
So there were great personalities who would come to the college and just because of what
#
St. Stephen's College was, and it was amazing to talk to the chief election commissioner
#
or to talk to other great thinkers or Nandita Das or whoever came to the college to absorb
#
and to explore things which were not related to your fields.
#
So I feel like that exploration comes along with relaxation and so I fully agree with
#
I feel like I am Ahmedabad was a shock for me.
#
In a way, again, I was not very goal-directed, you know, I just did not, I knew by the end
#
of St. Stephen's College that I did not want to do a PhD in physics anymore.
#
I did not want to sit in a lab and not talk to the world.
#
I had done some elective courses on economics and I found it fascinating.
#
And I wondered if I had more exposure early on, would I have not gone into that space?
#
But I just went along to IIM Ahmedabad just because my brother had been there before and
#
I always looked up to him and I was maybe perhaps trying to catch up with him in my
#
But I feel like arriving at IIM A made the contrast between the two places to me really
#
Extremely goal-directed, extremely ambitious, extremely cutthroat competitive and a bit
#
of a stressful environment where everybody is trying to move ahead.
#
And in many ways, a struggle for many people because everybody had been top of their colleges
#
before and they had all ended up in this place and there can be only one topper among other
#
Also the placement process is a bit dehumanizing, I felt.
#
So all of this would create a stressful activity-driven environment, which is a deep contrast from
#
my past few years at St. Stephen's College.
#
So I felt the contrast very, very keenly and I felt those years I reduced my exploration
#
And do you think in a sense that it's a blessing that you didn't take a formal route into economics,
#
for example, by actually studying it and all of that?
#
Because I certainly feel that way about myself because it was taught so badly when I was
#
in college that if I'd actually gotten degrees in econ and all, it would have probably closed
#
my mind to different other frameworks and so on.
#
I would just have become ossified in the conventional thinking and it would kind of have been a
#
danger whereas in whatever you've done, whether it's using economics in your work or public
#
policy or healthcare or whatever, you've actually taken a really unconventional path there,
#
which I think is great because it A, allows you to be multidisciplinary and B, or not,
#
then the conventional wisdom isn't the default, you're still questioning stuff.
#
I feel I have only had an advantage because I have come from different disciplines.
#
I spent a lot of my years in science and physics, which is all about rational thinking and evidence-based
#
cold-hearted critical hypothesis testing.
#
I feel like my business years in management and consulting really opened up the worlds
#
As in my consciousness, the market-oriented thinking is something which I grew up with
#
a little bit, but that's the world I was sort of given.
#
So my default is not that government needs to start with things.
#
My default is things are happening by itself.
#
So I feel a circuitous path into economics has definitely helped me to not conform as
#
you were earlier alluding to.
#
I do not know in what ways it has specifically helped, but I have also taken time to come
#
to be comfortable with myself because health is a field which is very, very specialized
#
and they're very specialist who have only done health economics or health for a long
#
So when you come from outside, you feel you have to earn your stripes or you have to
#
understand the language or you have to understand the history.
#
So I feel like it has taken me some time to be comfortable with myself in this space.
#
And tell me about how you kind of built your frameworks to look at the world.
#
For example, when looking at markets, I guess some of it would have been just by osmosis,
#
by growing up in a Marwari family and Jamshedpur is a little more multicultural, I guess.
#
So there's more interactions happening.
#
Some of it is diving into more nitty gritties when you're at IIM.
#
But the default thinking of all Indians of our generations was a very statist one, that
#
the state is a maibab and the state will do everything.
#
And that becomes a default thinking that top-down engineering mindset kind of is very hard to
#
And that also happens to be conventional thinking in most areas.
#
So what was your intellectual evolution like?
#
Is it that you start from a particular point and then gradually you have your mug by reality
#
in different ways and you adapt and you adjust?
#
Or is it that you were always sort of the Atlas Shrugged person saying that, no, you
#
I do not think I came from it, came to any of my later years from the point of freedom
#
I came from, again, what is the meaning?
#
What are we driving towards?
#
What is the evidence-based approach towards it?
#
Therefore, what makes sense?
#
What you said is very fascinating that we start in our generation with the statist
#
I feel I did not have that growing up.
#
In fact, my path to health systems started when I was in consulting and jumping ahead
#
to my years at Bain & Company and I was there for close to a decade.
#
And I used to only work with private firms.
#
Private firms were solving the world.
#
And it was one report, there was an HLEG report early on in 2011, you know, Dr. Srinath Reddy,
#
Nachiket Mohr, Nachiket I worked with later and a great mentor.
#
That report plus additional analysis around that really opened up to my mind about state
#
failure and market failure.
#
So I was very happy in that construct, maybe in contrast to every other thought process
#
in the country, that markets could solve everything by default.
#
And then coming into the space that, and there was this specific analysis, I remember starkly
#
in my head, that 80% of the mortality in India is NCDs and non-communicable diseases.
#
But 80% of the spending is communicable diseases and maternal and child health care.
#
That contrast really, really shook me up that something was not right in the system, including
#
So till that moment, I had not thought about market failure or state failure.
#
I was just a regular MBA person going about working with firms.
#
And that sort of, at that moment, I went back to my childhood and realized that, okay, there's
#
something really not right with the system.
#
And that's what pushed me into saying, okay, let me go figure out what is happening with
#
And again, because of my journey, which happened, which was not from humanitarian fronts or
#
which was not from state capacity fronts or state failure fronts, I feel like I could
#
go into it very evidence-based.
#
So I knew that I did not want to work in an NGO, because that would not solve the problem
#
statement I had been posed with.
#
Sorry, nobody was posing that problem statement to me, I was posing the problem statement
#
And I knew that I had to take a bigger picture of the US to understand what was happening.
#
So it evolved step by step on its own.
#
I don't think there was a preconceived notion I had on state failure or market failure.
#
Tell me about the years in consulting, like when you were doing an MBA, how did you envisage
#
yourself at that time when you were in IMA, that what are you going to be?
#
Did you think of yourself as having sort of a typical corporate track and you're eventually
#
CEO somewhere or did you think someday I'll be an entrepreneur?
#
Were you someone who thought in terms of, you know, problems to solve?
#
So what was that journey like doing your MBA, trying to figure out what you're going to
#
And, you know, take me through your sort of trajectory after that.
#
I was always a bit of a lost child.
#
I remember in the IAM M.Dabat interview being asked, why do you want to apply for IAM M.Dabat?
#
And I remember saying, I do not know and all credit to them, they still took me.
#
So I continued to feel a bit lost because I did not understand then, but I was searching
#
for meaning and I was not able to find it in the day zero college or packages and to
#
be honest, in some ways, I was lucky because it was less hard for me than for others.
#
And I got shortlisted and I got placed relatively easier.
#
But did I have a specific view as to what kind of company I wanted to work on?
#
Did I have a view about what I wanted to achieve?
#
I do not think at that point of time I had one.
#
I was just going ahead with life because one needed to do something, but I also was sure
#
in my head that I was not doing this for money or I was not doing it for status.
#
I think I was still exploring.
#
I interestingly did my internship with Lehman Brothers in New York in 2007.
#
Oh, do you know Mukul Chaddha?
#
Oh, I don't think I was an intern on some desk.
#
He was around, I think, maybe a year before that.
#
He's an actor in Mumbai.
#
So you're the second Lehman Brothers person on my show.
#
So, actually, there's another world event where I have been close to the time of the
#
I was in Wuhan in 2019 July.
#
So in a way, looking back, quite interesting.
#
We've got to track your movements.
#
Yes, and then the next world disaster.
#
But my New York stint in Lehman Brothers, this is when the credit desk was starting
#
to turn bad, made me understand that I did not want to just do the topmost job out of
#
IM because I didn't understand why we were doing things.
#
It was a lot of the what and the how, but not the why.
#
And I feel that moving towards consulting, I did not know what I was getting into, but
#
it was really good for me because it was a lot more of the why and then the what, the
#
So I feel like it just happened because it's one of the more prestigious jobs coming out
#
But I felt that compared to investment banking, it just fit me much, much better because it
#
gave me room to delve deeper, to understand, to interact with the systems around me, to
#
change things around me.
#
So I feel like I was blessed.
#
I did not know what I was doing, but I was blessed to have made it to consulting.
#
Tell me more about your consulting journey.
#
And I'm also curious about, you know, when you speak about the asking of why, and this
#
is, I guess, a continuing search for meaning just going on.
#
But a lot of the whys I would imagine in consulting would be proximate whys, answering perhaps
#
smaller questions, like maybe there's a new technology, how does my firm adjust to it,
#
or how do I break into this other market and etc, etc.
#
And they're all interesting whys and it provides you a place to start and etc, etc.
#
But they're not the kind of larger whys that give you meaning in your life.
#
So, and I'm guessing that later comes obviously from healthcare.
#
But take me through that journey of consulting, like what were the kind of problems you worked
#
What did you enjoy about it?
#
Was the kind of thinking that was required something that came naturally to you and therefore
#
And what was the kind of or was it something that also shaped you in a sense?
#
I think what really was good about consulting, which fitted me, was even if it's proximate
#
questions and more smaller questions, and which is the case in many, many assignments,
#
it still was very open to first principles thinking.
#
There were not so much jargon and technical aspects of just finance where you had to just
#
There was room to think about the first principles and pressure test and innovate.
#
And I feel like that freedom to think was important.
#
I remember in the first year at Bain, I had a German transfer boss and I remember fighting
#
with him at 10pm in the night because he had asked me to not think and just do.
#
And I was this child coming out of college and I shouted at him, how can you tell me
#
Obviously, I got a bad rating, so none the less.
#
So I feel like there was space to think and that's what really fitted.
#
Why it was really good for me is it shaped me.
#
What consulting firms are good at doing, especially the top tier ones, is really because the human
#
resources is their core goods.
#
They want to hone the human resource into a change agent.
#
So if you're an introvert, how do you learn to deal with the world?
#
If you're not very systematic, how do you learn to be systematic?
#
If you're not a great communicator, how do you learn to be comfortable or find your own
#
space for communication?
#
If you do not know how to work with different styles of people, how do you learn to adapt?
#
And at every stage, consulting firms, the good ones, would scale you up.
#
So it's in the incentive of the people above you to get more leverage from you.
#
And how will that happen if they push you to grow?
#
So it teaches you to be a very growth-oriented person.
#
And in a span of a few years, I could see a lot of changes in myself for the good.
#
I would not speak to anyone the first two months being the introvert sitting in one
#
corner to being able to converse with a lot of people, being able to have the confidence
#
to push clients, to push projects.
#
So I feel like it was very much shaping me to become a person who will be more useful
#
But at the same time, as you said, there were many challenges at least, which I faced.
#
I feel like it's a great career for a lot of people, but I constantly felt three things
#
One is that the lifestyle is not great.
#
The second one was that the world view is very narrow.
#
I felt I constantly had this feeling that I was missing out on the bigger picture.
#
So I also felt I didn't have any other experience and only done consulting.
#
What did I truly know about being in a firm?
#
What did I really know about any of these things I was talking about?
#
Third was I was working on other people's proximate problems and what does it all mean?
#
So again, that search for meaning was there and I felt that I needed to push myself out.
#
So I feel like it was an important growth phase.
#
And then I had to go out and explore and figure out for myself.
#
You know, just thinking of the act of consulting, it is at one level very daunting because,
#
you know, yeah, you're kind of once you sort of figure out how to get to the first principles
#
and answer right wise, that kind of helps.
#
But everywhere you're essentially a generalist and you're trying in a very short span of
#
time to crock what a client's problem is and then you have to sort of consult them and
#
give them advice and etc.
#
And what was that sort of process like?
#
Even before you answer that, like one question I sometimes get, like Ajay and I on our show
#
have sometimes spoken about, you know, working from first principles and all that.
#
And there's this question that's been posed at various comments or whatever that what
#
is first principle syncing?
#
And we haven't taken that question on yet, but I will conveniently throw it to you now
#
that I'll ask you this, like what is first principle syncing?
#
Can you illustrate it with an example and you know, how asking the right why and getting
#
to the core of the matter kind of makes things much easier from there?
#
Okay, that's an interesting question to be posed.
#
And I'm going to take 10 seconds to think about what example if I have, if any.
#
So you know, I feel like my whole exploration on health has been first principles thinking,
#
but in consulting, I was not sure about if I wanted to stay in consulting.
#
And I thought this through from a first principles basis, I questioned, okay, what will be the
#
end future of consulting itself?
#
Is there any value consulting has for the world?
#
And I think AI had just arrived on the scene and data analytics was beginning to be all
#
So I had to, you know, when I was trying to pose a larger question long term, one, what
#
was the future of consulting?
#
Two, what did it mean for me?
#
Three, is this the kind of life I would want to lead?
#
I feel like there was, I could have had conversations with people, but I chose to just sit with
#
it myself and create scenarios and break this down into evidence I have for which scenario
#
was likely to be to win out because, you know, there's a probability of every scenario.
#
And if that scenario were to happen, then what would be the impact of it on what it
#
mean for me and therefore what choices I had?
#
So, for example, on AI and data analytics, I had a worldview that consulting was an important
#
service, but was it absolutely necessary in the sense there were firms existing without
#
So what is a value add which consulting was truly doing?
#
Was it bringing innovative ideas to the table?
#
Was it spreading the known ideas to other firms?
#
Was it augmenting capability and capacity?
#
Was it just being a therapist to the CEO and who's a lonely figure?
#
And where will or was it the analytical horsepower of the young bright mind from IITs and IIMs?
#
What was the true value add of the space?
#
And therefore in an AI driven environment, what would it really mean?
#
And I quickly understood that no, it was not the innovative thinking because that's not
#
a great business model.
#
Because how do you create a repeatable business model will not come from the newest ideas.
#
You cannot create cookie cutter service delivery models and replicate it because the cost of
#
innovation is too high and you cannot make enough scalable money on it.
#
And some of those proof points came from conversation and pressure testing with senior leaders in
#
How were they thinking about each of these scenarios?
#
And then on AI, yes, there are things around the first principle for the analytics, which
#
could get supplanted by analytics, but there are additional value adds which a consulting
#
firm provides, which is additional capability, et cetera, et cetera.
#
And therefore, is this the kind of work which I want to do?
#
So if there's no innovation and analytics will take away a lot of the cool thinking,
#
And I felt that that was not interesting enough for me and there was larger interesting things
#
So I don't know if this answers your question.
#
Yeah, no, I mean, the three basic questions, where is consulting going?
#
What is a value add and do I want to live my life like this is kind of a great example
#
of getting to the core issues, almost sort of, you know, finding out the expected value
#
of your future happiness.
#
So a perfect way of sort of doing that.
#
So how many years were you in consulting and what was that journey like and through what,
#
you know, what was the arc of that journey like?
#
At what point did you begin to feel that there has to be something more for me?
#
And what were the areas you were kind of looking at?
#
I think, you know, I'm very, very grateful to consulting because it really shaped me
#
So to all my mentors in consulting, Ashish, Sri, Karan, Parijat, a lot of people who have
#
seen me almost grow from a baby, which I was in my first few years to a much more capable
#
I'm just only grateful.
#
I felt like my own journey was baby steps growing up in each of those skill sets which
#
are required to do that role of consulting.
#
But along the journey, every few years, I had a personal crisis of faith and search
#
So I would be that spoiled consultant who would go every two years and ask to leave
#
because I was just feeling burnt out.
#
And looking back, it was not the number of hours of the travel.
#
I felt I was incongruent with what I was doing.
#
So I was really spoiled and I would do this every two years.
#
But I was there for eight plus years.
#
And I would just have kindness and gratitude for people who had patience with my childishness
#
and who helped me grow.
#
But having done this twice, and I was what was then called associate partner, and I feel
#
like the nomenprinciple, the nomenclatures have changed over the years, I just decided
#
that I will not ask for another leave of absence.
#
I would push myself out of consulting because I knew how seductive it was to just go back
#
So it was growth interspersed by a few years of crisis every few years and me just taking
#
a cut off saying that I need to now force myself to rethink my life and then leaving.
#
So what was the balance between the push factors and the pull factors, as it were, of eventually
#
Like you mentioned, the lifestyle was an issue and the fact that there were proximate problems
#
of clients and not something that could give you meaning, I'm guessing all of those could
#
Was there also something attracting you?
#
What was then, if you asked yourself the question that I don't want to live my life doing this,
#
then what was your answer to the question that I want to live my life doing this?
#
So this is what I want my life to be?
#
I did not have a pull factor.
#
Growth was something which was interesting to me and the problem statement I just posed,
#
which is I saw a misallocation of resources towards the mortality rates and that was in
#
the back of my mind, but I felt the challenge was I do not know who would work on this.
#
I did not know that space at all.
#
So I feel like there was in my mind something about now what I call policy impact, but I
#
did not know what it was called then and it was in my mind that I need to work on something
#
I just did not know anyone who had done it or what the organizations were.
#
And the few organizations in the development space I spoke to were not doing system thinking.
#
They were working on proximate problems or humanitarian efforts, which was not tying
#
up with my problem statement.
#
So I feel like I had a vague notion.
#
I did not have a clear pull factor.
#
Again, I feel like I have been open to exploration, so I decided I would give myself space for
#
Let's double click on a couple of the phrases you mentioned and one is system thinking.
#
So just as I asked you about first principles, I will ask you about system thinking.
#
What is system thinking?
#
What were its applications when you first discovered it and how do you think of it as
#
a framework for looking at the world?
#
I was introduced to systems thinking by Nachiket Moore and I'm ever grateful to him for introducing
#
me to the world of systems thinking.
#
My interpretation of it was in the health context or in the broader context was not
#
to look at the first level order of first principles thinking, but to go to the next
#
Okay, why is that happening at the next level and why is that happening at the next level?
#
So it's first principles thinking drilled down to many, many, many, many levels to come
#
to the core essence and especially looking at interconnected factors, which are not so
#
obvious at the first level of first principles thinking.
#
So in a way, it was comfortable and instinctive to me because it was extending of what I already
#
was attuned to doing, but at the same level, I felt it was more deeper because it forced
#
you to think about the second order effects and the third order effects and the fourth
#
And I also discovered that there were ways of looking at the same problem statement when
#
you start looking at it from a systems thinking perspective, which are so intuitive in the
#
sense they're intuitive once you start thinking about that way.
#
And which makes the problem statement so solvable.
#
But arriving to that is really, really difficult and convincing everybody else to arrive to
#
So I discovered this space, you know, in my Gates Foundation years and with a lot of good
#
mentors globally and in India.
#
But it seemed like something I was very, it's like a duck getting into water.
#
It felt very attuned to me, but at the same time, it felt better than what I was used
#
An example of systems thinking maybe I can again use help, but that's the whole discussion.
#
So as we come back to it later, you can double click on it.
#
Tell me about the evolution of your problem statement.
#
Because the way you describe it, it seems that the first thing that you're looking
#
at is a misallocation of resources when it comes to solving mortality, right?
#
80% this 80% that and but that is an effect of something that is kind of more underlying.
#
So I'm curious about how through the years as you would have gotten deeper and deeper
#
into it, how would that problem statement evolve?
#
Like what is that problem statement now?
#
What is the problem you're trying to solve?
#
So I think great time to get into what is health and so health, my current definition
#
of what is health is health is largely a private good.
#
Using the economics jargon, it's excludable and rival and health care, especially is private
#
This is a big debate in the health community because in health community, public health,
#
public goods are government provided.
#
In effect, the government provided private goods.
#
So the nomenclature is a bit confusing.
#
So just clearing, taking a step back and clearing it a bit more.
#
So there are private goods.
#
So what we normally think of as drugs, tests, primary care, secondary care, tertiary care,
#
all of this is what I would call private goods.
#
And this podcast has spoken about private goods many times before, so I will not get
#
There are many aspects to health, which are public goods, which is again has been discussed
#
before, which is say clean air, clean water, parks, public spaces, many more things.
#
And those are often also called social determinants of health.
#
There are elements of health, which are externalities, which are both negative and positive externalities,
#
infectious diseases, often vaccines, etc.
#
And then there, so public goods is the first priority, which comes to health, which is
#
this is the highest return on investment, which anyone can have.
#
We should try and have for everybody, if everybody has clean water, nobody will fall ill and
#
have diarrhea and therefore the whole disease burden will go down and costs will go down.
#
And externalities, if during COVID people were wearing masks or taking vaccines, the
#
chances of transmission would go down and therefore it would make sense to take care
#
And private goods market failure, we know the standard market failure, which is, and
#
I will go into deeper into market failure of service delivery of health care a bit later
#
subsequently and look at what does it mean in terms of solution, addressing that market
#
failure in private goods, I think is the three things.
#
And the fourth pillar for me is part of global public goods, which is things like knowledge
#
and research and innovation.
#
So these are things which are global public goods, humanity learns how to vaccinate and
#
therefore we have a big order jump in our overall productivity.
#
And that's, it's such a big impact across centuries that I almost want to call it out
#
as a fourth pillar in itself.
#
To me, this is what health is, these four things, there is the individual.
#
So all these are the health systems, then there's the individual, what you and I, each
#
person does for our own self.
#
And as you said about healthy aging, we can do a lot ourselves.
#
So that's the fifth pillar.
#
I also want to call out in the health community, you hear the word UHC, universal health coverage.
#
I do not think that is health system.
#
What is universal health coverage?
#
Universal health coverage just means that cover as many people as possible for as many
#
diseases possible for as much cost as possible, but it doesn't provide a framing as to what
#
are you covering in private goods, public goods, externalities, global public goods,
#
what are you really doing?
#
So I feel like that's not a very healthy framing for health, but this is how I would characterize
#
And what is the end outcome towards health is to deliver value for money, biggest bang
#
for the buck, best health outcomes at the most cost effective prices.
#
So let me break that down and tell me if I've sort of understood it correctly.
#
Ajay once illustrated the difference between public health and health care by saying that
#
look, health care is if you get malaria, you go and you get drugs to cure your malaria,
#
And public health would be the spraying that you do to make sure that there aren't that
#
And there is no incentive for private parties to do that spraying per se.
#
So that is a public good and that is something therefore that the government should do.
#
But on the other hand, there is a lot of incentive for people to provide malaria drugs and to
#
provide anything that you would use to kind of treat yourself.
#
You sent me this great piece by Jeff Hammer about the conventional thinking, which I'll
#
link in the show notes.
#
And he quotes Keynes there on what government should do.
#
And Keynes said, the important thing for government is not to do things which individuals are
#
doing already and to do them a little better or a little worse, but to do those things
#
which at present are not done at all.
#
I remember paraphrasing this as saying, you know, do public goods before private goods
#
because no one else is doing public goods, so you do it.
#
And private goods, again, is something that time and time the lessons of history have
#
shown us that a well-functioning market will deliver it much better than a government will.
#
There's simply no point for a government to be out there.
#
And if there isn't a well-functioning market out there, then the question to ask is what
#
are the structural issues for that and how do we solve them rather than say that, oh,
#
these guys can't do it.
#
Let's put more restrictions on them and let's, you know, go and try to sort of do it ourselves.
#
So this is sort of a fundamental disambiguation that is important between health care, which
#
you want to enable the market to do well, and public health, which is a public goods,
#
which is what the state can actually focus on.
#
So is this a good summation just to lay the distinction out there?
#
As you said, and I fully agree with Jeff Hammer, public goods is the highest priority.
#
It's the biggest bang for the buck and the distinction I would make slightly differently
#
from what you articulated is this is an area where government needs to intervene or finance
#
or regulate, need not be the actor to do it.
#
So for example, I grew up in Jamshedpur where I took public goods for granted and it was
#
fully delivered by a private municipality with clean air, clean water, trees, public
#
spaces to walk, safety, you know, safe roads.
#
They would come back and expand roads as the traffic evolved so that people would be safe.
#
So the level of public goods I saw getting delivered by a private entity was quite apparent
#
However, having said that, that was a very unique case of a company town with aligned
#
So the delivery of this can be by private actors or by the government actors.
#
But often the regulations or the standards or sometimes the financing of it because it
#
may not be something everybody will pay for for a common park, often is something which
#
the government needs to intervene on.
#
So I just wanted to distinguish the delivery of it from the financing and the intervention
#
I absolutely agree that those are the priority items and everything else which we typically
#
think of what we think of as Ministry of Health and Family Welfare, what we think of in terms
#
of hospitals and primary care and drugs and testing, it's all private goods.
#
Now what tends to happen is we are very emotional about health and we tend to think those private
#
goods should be public or it should be available to all irrespective of pricing.
#
Now I understand the sentiment, but what it distorts is the market's incentives to be
#
efficient and to adapt.
#
So I feel like there are two separate questions about equity and access and respecting humanity
#
versus understanding that the private goods are most efficiently and effectively delivered
#
through the market mechanism.
#
And yes, there will be market failures, which will impose a very high cost, again, because
#
human lives are very sensitive, we are happy to think about market failure and be okay
#
within the context of a shirt or toothpaste, but with respect to human lives, we feel very,
#
But those are things where the government should intervene.
#
So keeping that equity should be solved through transfers of funds, equity should be solved
#
through other mechanisms and not try to distort the market mechanism, which is the best place
#
to deliver the private goods.
#
And when I'm saying market mechanism, it could be including by the government actors.
#
It may not be only by the private actors.
#
So I feel like that is where the conversation on private goods gets distorted.
#
Yeah, that's a great sort of clarification.
#
And I'm wondering if this default mindset that we have that the state should do everything
#
at one level, it is, of course, a statism that is embedded in India, per se, because
#
just of the way the state is designed and sort of culture is taken at you from the institution.
#
So we automatically say that, hey, if something is desirable, the state should do it.
#
But is it also the case that if one looks at the evolution of health care, you know,
#
you go back to earlier centuries, for example, a lot of the things that were responsible
#
for poor health were actually public goods.
#
And once the state started solving them, like issues of water and sanitation and pest control
#
and, you know, immunization and et cetera, et cetera.
#
So a lot of the low hanging fruit of doing something about the health of the people at
#
was from fixing these public goods that you fix, you know, you give clean air, you have
#
safe transport, you have et cetera, et cetera, you take care of all of that stuff.
#
And today we are in a scene where in the developed world, for example, those things are more
#
or less sorted, they more or less work efficiently.
#
And yet the state involvement is just assumed to be necessary and assumed to kind of be
#
So it's really a mindset question about why that mindset persists.
#
I mean, and of course, you know, a third way of thinking about the mindset simply is that
#
a lot of, you know, the fashions of economics are, you know, you have statism coming in
#
and out of fashion and in the academy, it's given far more respect than it should be given.
#
I don't know, I agree with you and maybe I think, yes, the historical empirical answer
#
seems to be that public goods have been delivered by govins in higher income countries.
#
But I feel like I'm an empiricist at heart, like I feel like we do not know the context
#
and the capability of the low income settings and what will work in our context.
#
I also feel, I believe in service of the republic had taught me a very important lesson, which
#
is to understand that state capacity is a scarce resource and especially in developing
#
And we should conserve it and focus our energies on things which nobody really else can do
#
to the point you were saying earlier.
#
So if there are aspects of public goods which only the government should do, which is around
#
laws, about funding, about doing some parts of the delivery, like I feel we should focus
#
But if you try and do too much with the state capacity, it may just not go the right way.
#
And the answer could be different for every different state of India and every different
#
It need not be one answer.
#
I just feel like I tend to approach it without priors.
#
But I agree with you on that the private goods, private delivery of public goods may not always
#
be a solution because at the heart of a non-company town, which is bulk of India, there has to
#
be a social contract with the local level government and the preferably an elected local
#
government and the local population and both that two parties, two sides have to move towards
#
a consciousness on public goods, public health, which is public goods.
#
And that is the heart of, that I do not think a public private actor could solve.
#
But we do need that to be solved by government intervention on governance, which is, so that
#
is the heart of the problem.
#
So we need to solve for that.
#
For example, I had visited Colombia in 2019, just before the pandemic, we were visiting
#
different countries to understand how the health systems operated.
#
We met Ministry of Health people, we met the financing element of Ministry of Health who
#
used to buy facilities from providers, the insurer, the regulator, but the most fascinating
#
conversation for me was the mayor of Bogota.
#
And he was not in the health department and he was worried about public spaces, he was
#
worried about greenery and he was worried about crowding in culture and bringing people
#
for sustainable transport and exercise.
#
And I felt that was really something which at the local level needs to be done and I
#
do not know how a private actor can form that social contract.
#
So I think that has to be done something at the government level for sure.
#
So give me a sense of what was like after you quit consulting, then what was the journey
#
you made towards actively getting involved in this field and what was the existing ecosystem
#
I just sat at home for six months contemplating the world.
#
What were the options you were contemplating?
#
I was just chilling out.
#
And I think just I was really, really lucky that one of my Indian office heads from Bain
#
sort of knew about my interest because he had been at the receiving end of many of my
#
time terms in the past.
#
And he understood that I was yearning for some more meaningful things in health.
#
And he knew the India office of Gates Foundation, Nachiket Mohr used to head India office then
#
and he connected me to them, Alkesh Vadhani who was a key person in the India office interviewed
#
me and I just it was lucky that I chanced into this.
#
And I was lucky that I chanced into it in a moment where health systems work was taking
#
off because I feel like that was what I was looking for without knowing what I was looking
#
And I do not think I would have really fit into anything else.
#
So it was luck and my good fortune that I got this opportunity.
#
So again, for people who try and who are trying to look for something, they are not such clear
#
pathways and you're smiling.
#
And so I feel like one of the things we can all try and do is create more knowledge around
#
What are the options and what are the pathways?
#
And if there are people who are who can fund these kind of things for places for people
#
who are looking to create impact and meaning to create spaces for them.
#
Gates Foundation India office at that point of time had just embarked on the work on health
#
It is not an area which it had worked on globally or in India before.
#
So it was a blank slate and then I got to work on that.
#
I got to build that out.
#
So that's how my transition into this happened.
#
So a friend of mine who I've invited on the show, I don't know, I mean, I'll record with
#
him later, but I don't know whether that episode will be out before, but he gave me this lovely
#
metaphor for life where he said that, you know, some people, they are like boats and
#
you put a motor and you set it into a direction and the, you know, the motor will take them
#
very far, very quickly.
#
And he said that my life is like a sailboat, which motor water, I was just going with the
#
wind sailing this way and that way.
#
And I did all the various things that I have done.
#
And I think we often like, you know, underplay the role of that kind of serendipity in our
#
lives that things happen at the right time at the right place.
#
And apart from, you know, the timing in terms of your joining the Gates Foundation and coming
#
to health, actually work on health care, there is, it's also an interesting time because
#
over those years, what is happening is that philanthropy is also a kind of getting serious,
#
getting organized and so on and so forth.
#
So since you've kind of been inside that world, you know, take me inside that world, like
#
there was a time where you would have a sort of rich people with extra money and they'll
#
find some pet cause and they'll put the money there, et cetera, et cetera.
#
And it's very ad hoc and very whatever.
#
But over the last couple of decades, perhaps there's been much more systematic thinking
#
about, you know, how do we spend the money, where should we spend it, what, what our approach
#
should be, et cetera, et cetera.
#
So give me a sense of that landscape as well.
#
Yeah, my years in this space was quite an eye opener.
#
People who work in the more private sector space, they think of this as one big monolith,
#
but it is not really one big monolith.
#
There are various actors, various shapes and sizes and various objectives and risk appetite.
#
I feel like there are three levels at the very, very basic, you know, cross segmentation.
#
One is what we've discussed is more humanitarian effort, which is there is someone in distress
#
We know it will not be sustainable, but right now there is a real benefit which someone
#
So I feel like it is important.
#
So the second level being, okay, let's create selective areas of lasting impact.
#
So I would call it selective impact.
#
I'm using the word impact instead of effort, where it is lasting for a sustained amount
#
of time and is sustainable, but it's in the selective areas.
#
And often one tends to, you know, why that happens, we can speak about.
#
The third area is what I call system level impact, which is the system itself resets
#
in a way, it creates a positive flywheel where it then starts moving towards the promised
#
Yes, it's a very, very long journey, but that slowly and steadily shifting the system towards
#
public goods away from market failure, externalities, that direction is I would call system level
#
Now, historically, globally and in India, my experience or my exploration showed that
#
a lot of effort, especially on philanthropy, was on the humanitarian effort and it was
#
genuine and, you know, everybody gets to choose and especially philanthropists are spending
#
their hard-earned money and they have full birthright to choose what they want to spend
#
So again, it's a lower risk, but a very tangible impact, which people are looking for.
#
Graduating to selective impact, I feel like there are very great examples of this.
#
It's a bit higher risk.
#
It's medium term, five years, 10 years, 15 years.
#
Great examples, you know, what Bill Gates did with vaccines, it's, you know, the world
#
has to thank him for creating capacity in developing countries to do vaccines manufacturing
#
and R&D, it has saved many, many lives.
#
I feel like it's very, very powerful, higher ROI, return on investment impact, which has
#
But again, it's in selective areas for in that larger space.
#
And then comes, so also what tends to happen is people are happier to work in a medium
#
risk environment, you know, individuals, employees, ecosystem.
#
Everybody wants to work towards 30 years, 50 years when one knows the outcome and they
#
cannot even pursue the metrics in the short term.
#
So it becomes very unwieldy for governance purposes.
#
So I can understand why that tends to happen.
#
But the highest risk and the highest impact is in the system level impact.
#
So I was naive when I started with the Gates Foundation, that I would fix the health system
#
of India in five years.
#
I was naive consultants.
#
And I have understood since then that that's not how it works.
#
The reason why many philanthropists do not work on the space is because it's truly 30
#
And the path to that high risk, but high outcome is not clear.
#
There is no tried and tested method from other countries which you can supplant.
#
It has to be figured out by walking the steps.
#
It also cannot be left to others to figure out.
#
One has to bring everybody, you know, one has to be involved to figure that out.
#
But when I look at what is the highest, you know, philanthropy is the lowest cost, most
#
flexible capital in which it can be spent on the most risky things.
#
So if I am the well-wisher for philanthropy, and I think philanthropy has a big role to
#
play for development overall in countries, I think it should be towards system level
#
Now that is easier said than done.
#
And there are many aspects of what it looks like.
#
I feel a couple of them by no means exhaustive list would be one is just having the clarity
#
of thought as to what a system level impact again, there are no consistent frameworks
#
by which everybody thinks everybody in health and in other spaces comes from their own
#
There is no baseline framing on public goods, market failure, externalities, etc, etc.
#
And I feel like if one doesn't have the ground grounding of that, you will lose your you
#
will not get to system level impact.
#
I feel like the many other elements of this which needs to be taken into account into
#
thinking what capabilities need to be built in your organization and in the ecosystem
#
There are a lot of debates whether you should build institutions, fund individual researchers,
#
whether you should evangelize and communicate these broader set of thinking what you should
#
I feel like I'm more agnostic towards the tools.
#
One can figure out in what ways you can drive towards the actions as long as your overarching
#
risk appetite is clear and your core principles, first principles and systems thinking is clear.
#
I think everything is up for experimentation and grabs and it's very hard because there
#
is no status, there is no metrics, there are no things in the short term which you can
#
Optimizing allocation of spend also is difficult because you do not know what is driving success.
#
So I feel like it is the toughest things for philanthropy to work on this and hats off
#
to every philanthropy which is working on this.
#
So that's really my thought process on philanthropy, whether it means funding individuals, institutions,
#
whatever the tool and form is.
#
I'm reminded of that old sort of cliche about give a man a fish, feed him for a day, teach
#
him how to fish, feed him for a lifetime and I guess that's a choice a philanthropist
#
faces and like you said that the first of the three categories you mentioned the immediate
#
humanitarian aid must be incredibly tempting because then what you are doing is both visible
#
and attributable and attributable to yourself.
#
So you can if a fair amount of philanthropy is sort of driven by self-aggrandizement where
#
you want to see yourself as doing good, then it becomes really easy that oh I fed someone
#
or oh I can kind of see the effect of this and like you said for longer term there are
#
no metrics like I'm just thinking aloud that supposing you want to do some good in a slum,
#
one immediate way of doing good in a slum would just be to go and feed everyone or distribute
#
free stuff and that's an immediate sort of intervention that you've made but it's very
#
short term and it's just happened then.
#
Another could be to send all the kids to school to fund their schooling because then you know
#
that okay that's going to play out over the long term and these kids will get a better
#
education and there'll be some social mobility possible there.
#
But a third way is just to say that let me not even think about the slum, let me think
#
what can I do at the level of a system, at the level of the state so that there is prosperity
#
in the economy and that prosperity comes here as well and 30 years later there is no slum
#
So all of these questions don't arise, you don't have to feed anyone and all the kids
#
are going to good schools anyway.
#
I would imagine the third of those is the hardest because it is perhaps the highest
#
EV, you know it's low probability but incredibly high impact but like you said you can't measure
#
it, you can't set metrics for it, people within your organization if you have an organization
#
will argue about what are even the metrics, what can we attribute to ourselves, how do
#
we justify our existence, how do we ask for more funds etc etc.
#
So what is your sense of then, like as a philanthropist I guess sitting here rationally,
#
if I had money to give I would obviously want to do the third kind for the longer term whatever
#
but I wouldn't know how to begin there whereas it's very easy just to go out and do some
#
instant kind of response so I'm guessing that there's an evolution of philanthropy where
#
you move from the first type to the third type gradually over time.
#
So what have you seen of that evolution, like what is the current state of the art in philanthropic
#
I can't claim to be an expert on philanthropic thinking, I do not have tons of money to give
#
But the little that you've seen from inside the system?
#
I feel like a lot more global organizations have been doing the second kind of thinking,
#
at least the ones which are operating in India at scale or in other developing countries
#
at scale because they may have had many many years of trying one and not seeing it sustain
#
once the funding stopped.
#
So the second kind is selective impact, you pick an area.
#
So for example, maternal child health care or polio or you know so you pick your bets
#
where you can like small back box eradication you can just put the flag on and declare victory.
#
I feel like that has at least been a model I've seen being practiced quite a bit.
#
I've also seen many some global organizations maybe not many which have looked at number
#
And you know, one of my good friends and ex World Bank person has also always advocated
#
to me the importance of World Bank and I feel like there are some good thinkers in these
#
institutions which have also looked at system level thinking.
#
So these experts have gone out to the world, they have also influenced some thinking and
#
there have been aspects of the system level thinking like strategic purchasing or local
#
level public goods which has happened.
#
But perhaps this is not mainstream, it's not truly entrenched the also system level
#
thinking is hard in the sense the same model cannot work in every country.
#
So you have to have to build local context understanding and customize it and figure
#
And since very few people work on number three, it's really not one accepted to enough focus
#
and bandwidth is going into it.
#
So I do not see Indian philanthropy so much focus on number two, I think it's growing
#
I think Indian philanthropy is graduating from number one to number two stage.
#
Very few selective ones are now beginning to talk about number three.
#
So it is perhaps we're a bit behind global philanthropy.
#
I do not really know how to do number three well, unless there's such a principal agent
#
problem because you just do not know which if your theories are correct, if your actions
#
are correct, there are no markers, there's principal agent problems.
#
Also if everything is so vague, how do you build salience in the system?
#
How does the ecosystem around you know how to value you?
#
Because you're doing something far away in future, why should the government or the other
#
actors in the space or the private sector care about you?
#
Just you're meaninglessly doing something in the long term.
#
So perhaps a mix of, I'm just freewheeling right now, a mix of second selective impact
#
grounding in because it teaches you something about the system when you go and act on it.
#
And then but also having a portfolio allocation towards three and but it requires a lot of
#
right people, right mindset, involvement, challenging yourself, bringing external voices,
#
not creating echo chambers.
#
So I don't think three is a tried and tested fully done model, but it's not a completely
#
And if we talk about three, would the state be the elephant in the room?
#
Like I guess a state would either be a big obstacle to systemic change or it could be
#
a big potential enabler of systemic change.
#
But is there no getting away from it or is it possible to work on three outside of what
#
I feel like the state is one of the critical actors which will have to get involved at
#
But I feel like there is things to be done before that and there's things to be done
#
For example, public goods, public health, I've had a conversation on this with long
#
term health experts and everybody will tell you, oh, we should do public goods, we should
#
But what should we do about it?
#
What are the laws which need to change?
#
Who are the people who need to act?
#
How should the governance change?
#
What are the steps to it?
#
I don't think we have any work on that front.
#
So we talk about 1991 reform or big milestones or what have happened in the country.
#
Whatever I understand is it's many years of prep.
#
It just doesn't happen one day you wake up and you decide that this is how it will be
#
and people talk about Thailand as a great model for health system.
#
It did not happen one day.
#
There was a lot of research, there was a lot of understanding, the nuts and bolts and
#
therefore they went into their Thai model.
#
So I feel like we're not at that level of maturity on many of the fields and health
#
is one field I know better.
#
But this maturity needs to come in our research, in our thinking and it's a bit of a challenge
#
which I experienced myself.
#
I was young and naive in this field when I started.
#
This requires multiple skill sets, which no one tells you, right?
#
I need to learn how to read the law.
#
I need to learn governance.
#
I need to learn markets.
#
So it depends on which space you come from.
#
This requires too many aspects which you need to grow into.
#
So there is lots to do on the what and the how beyond, yes, we should do it.
#
So I feel like that doesn't need to depend on the government.
#
The government in fact gets confused because we do not have a path.
#
So we can go and say do public goods, they will say how and we will have no answer.
#
So I feel there's also things which private sector can do.
#
I'm not absolving the government of action, please do not think I'm doing that.
#
There's also things private actors can do.
#
If we believe there's market failure which creates trust deficit in citizens and customers,
#
can you think of branding yourself?
#
Can you think of creating that as a value proposition?
#
Can you create a club of conscious providers which are trying to be partners to the citizens
#
and the customers in longer time and not have episodic delivery of care as and when you
#
need, then I will charge you the highest amount of money or not guarantee you protocols.
#
So is there no way for our private sector to innovate further?
#
I feel like there's room which it's easy to blame the government, government is not
#
But I feel like the private sector is also powerful if it really wants to do and sees
#
So I feel like the customers also need to demand better.
#
Each of us, there are things which we can all do, but in our healthy aging, and we do
#
And as customers, we can be more conscious customers.
#
We can have louder voices, we can have more red minds, and we can do better.
#
So I think there's lots to do apart from the government, and philanthropy could do to support
#
And but yes, government is a elephant in the room, which also needs to be looked at.
#
Before we go on for the break, a couple of questions before we really dive deep into
#
And one of them is again, you know, it isn't necessarily the case that if you want to do
#
number two in a particular field and have a selective impact, that it is immediately
#
obvious that we need to do ABC, nor is it immediately obvious that if you want to do
#
number three and make systemic change, that it is even obvious what should be the direction
#
Like a lot of actors in the education space will actually go in the wrong direction and
#
say that government needs to put more money into it, you know, as if outputs will necessarily
#
lead to better outcomes.
#
And just that philosophical thinking behind that is wrong.
#
And I guess in any healthy organization, there is either you're driven by a sense of purpose,
#
or there is a healthy contestation of values driven around what works.
#
So what was it like at the Gates Foundation and what should it be like in an ideal way
#
that should you have a clear vision or can a clear vision actually be a problem because
#
the real world is deeply complex and should you instead be driven by efficiency and what
#
works on the ground, which can also get incredibly muddy and deviate you from a coherent path.
#
Yeah, so I think there are a couple of different aspects to it.
#
Efficiency has two levels to it, which is one is practical on the ground, what is workable
#
and efficiency is what is the most system level efficiency and therefore it may be practical,
#
but it's not really efficient in the long term and therefore why do we even do it?
#
Then one is, you know, we have a clear goal and we will ram through it.
#
And then no, actually we have a goal and we have a path, but we do not know if it's true.
#
So we will try to challenge ourselves, we will also try to bring other viewpoints and
#
we may lose our way and we may not know which way we are going, but that's a more sustainable
#
way to sort of consensus driven way to go.
#
It is not easy to figure out which way, how to spread oneself.
#
I have been at fault personally.
#
Sorry, let me just talk about this health space more broadly and not going to Gates
#
The health space, at least my experience rather than a sort of deliberate research has been
#
that the health space tends to have views and have consensus and then at the crossroads
#
of more short term practicalism and lofty ideas or bold statements without clear pathways.
#
So that's the three corners in which the larger health space.
#
So let's do practical, let's make incremental improvement, let's try to get to consensus
#
primary care is good, we need to have improvements in how the market feeling private sector needs
#
to be addressed, et cetera, et cetera.
#
And then let's try to have an aspiration, which is stated.
#
Now I feel like there's less room sometimes for debate.
#
And where the point you were saying, we need to have more debate about how do we get the
#
lofty aspirations because the practical everyday will not get us to that.
#
And the challenge I feel is in the consensus because you can act as a lonely philanthropist
#
or lonely actor, but you cannot do it alone.
#
But trying to convince everybody onto this system level thinking is also extremely, extremely
#
So that is where the challenge lies.
#
Like I feel you cannot, the efficient is the system level thinking and system level action,
#
but to get everybody's attention on it and act on it is difficult.
#
And also you mentioned the 91 reforms and how it took a long time in the making.
#
I have had many episodes on this, I'll link them from the show notes that, you know, right
#
from the 70s, some would say right from the 60s where Manmohan does his PhD thesis and
#
then he invites, then he meets Montaic and then later in the 70s he asked Montaic to
#
And you have this whole community of reformers silently working through the late 70s and
#
the 1980s and they're doing all the work, writing all the papers, just doing out there.
#
They are against the prevailing climate of the time.
#
They are against the consensus and the conventional thinking even within the state.
#
And certainly they are very far from the popular imagination.
#
And it so happens that in a sense we get lucky that there is a crisis which then acts as
#
a spur and we manage to get some of it through.
#
And luckily we have 20 years of continuity between 91 and 2011 and, you know, across
#
politicians and bureaucrats somehow we are extremely lucky and I think of them as outliers
#
rather than representative of either a general climate of opinion or what you would expect
#
the incentives in the system to produce.
#
But we managed to have those reforms going on for some time.
#
Now if I use a metaphor of that process and come back to thinking about health care, how
#
Like where we were on thinking about the overall economy in the 1970s, for example, is that
#
where we are in terms of health care?
#
Is the conventional thinking all wrong?
#
How sort of difficult it is, you know, I was about to ask, are you the Montaik of health
#
But give me a sense of how far we are from, you know, where we need to be.
#
And obviously we can look back and that narrative is completely clear now with hindsight because
#
But what is your feeling of where we are?
#
Like, you know, medicine in the 19th century was incredibly primitive compared to today.
#
Some theory of disease hadn't sunk in, bloodletting was common, et cetera, et cetera.
#
And when we look back now, then it looks incredibly primitive.
#
But now we think we are the cat's whiskers and obviously will continue evolving.
#
Similarly, in terms of policy, are we still in terms of policy, health care policy at
#
the in the 19th century bloodletting era?
#
Because I look at, it's not just India, I look at the health care systems of America
#
or England or whatever.
#
And I'm like, you know, this stuff is really going to evolve a lot.
#
I don't think it's an India only problem.
#
I think India is a bit worse off than others, though.
#
It is a universal problem.
#
Health is one of those vexing challenges.
#
I think health overall needs a revamp, right?
#
With the lifespans extending potentially and with lifestyles changing completely and
#
demographics also changing completely, I feel, and technology changing.
#
I think technology is changing rapidly.
#
We don't think that even 15 years ago, we had as good an understanding of input, output
#
and outcomes from a biology perspective.
#
How our genetics and our metabolism and how our genes and our muscles and how our environment
#
So what happened 10 million years ago, 1000 years ago, our parents during our birth, first
#
few years, last year, what has happened, last minute, what has happened?
#
How does it all translate into what is happening to you right now?
#
I feel like the science is still evolving on that front.
#
And therefore, what is our ability to deal with that from a health perspective is also
#
So we are in like, perhaps we'll have a glorious age of health renaissance going forward.
#
So I do not know how far it'll go.
#
But my question wasn't so much about health care, but about policy that in terms of policy.
#
So in light of that, the policy is not adapted to that.
#
The policy in most developing countries, especially is still on maternal child health care.
#
And we are talking about infectious diseases and that's absolutely important.
#
But the disease burden has shifted.
#
The problem statements have shifted, the technology has shifted.
#
And the structures aren't going to keep up with these new requirements.
#
Most urban Indians feel disconnected with the government system because the government
#
system is not set up to do more broader level.
#
It's set up to do maternal child health care and vaccinations in rural India.
#
Now, I'm just being crass, which is not true.
#
But I could say a lot of resources are getting going there and urban PHCs or urban administration
#
is just left to chance.
#
So I feel like we're not set up to deal with the new requirements or new technology.
#
So I feel also we do not have a pathway to solving for it.
#
So we are stuck in system one and humanitarian effort and two and we are not, we don't have
#
a pathway to solving three.
#
And are the pathways known?
#
So we don't have a consensus on this in India and we don't have the actionable how to do
#
So is it the case that if you keep trying to make the type one interventions where you're
#
doing something immediate humanitarian, that there is always going to be a lag between
#
what is required in the present moment and what you're actually delivering, which is
#
why we're still doing maternity and child care and all that.
#
But there is a lag in understanding and that lag just remains, especially as the world
#
changes faster and faster.
#
That lag is not something you can do anything about.
#
But if you manage to actually reform the systems, then it doesn't really matter so much because
#
a good robust system will continue evolving on its own anyway and it will take care of
#
No, but that is not the answer.
#
We have to talk about what that system is and how we get there from here and what the
#
system is like now, which we will all do after a commercial break.
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Welcome back to the Scene in the Unseen.
#
I'm still with Amrita and we are now going to get into sort of the meaty and consequential
#
part of this conversation where we talk about healthcare itself.
#
So you know, when you get into Gates Foundation and you're working on healthcare, give me
#
a sense of what you learn about the system.
#
Like one, what are you actually trying to do in terms of like, are you first trying
#
to gather information, get a sense of the lay of the land and whatever, and give me
#
a sense of what the lay of the land actually is then.
#
So in a sense, take me through your journey of discovery of, you know, what the problems
#
are and how they can be tackled.
#
It is a new space for me on development and Gates Foundation specifically and the broader
#
I think I spent almost a year just understanding what is happening.
#
I would say I start feeling comfortable at the mark of one year.
#
The beginning is obviously internal folks at the Gates Foundation and a lot of my earlier
#
work was with Nachiket, Jack Langenbrenner, who was a health system specialist who had
#
worked in multiple countries and I was privileged to, you know, have his mentorship and early
#
guidance and with other colleagues at the Gates Foundation, Sandhya and many others.
#
But I also spent time beyond the health system to understand what the foundation was doing
#
It was in the areas of, you know, selective impact on the areas of infectious diseases
#
and maternal child health care and I think it's important to understand any organization's
#
perspective of what they are trying to achieve.
#
I think bulk of my time was however spent understanding the broader ecosystem.
#
And I largely worked with national government entities, but also with various multilateral
#
actors or bilateral actors, international ones.
#
I also got to meet other not-for-profits, but also for-profit entities and industry
#
bodies, and also international researchers, you know, MIT, Harvard, just a plethora of
#
That really helped me to understand where individual entities was coming from and I
#
think the lasting impression was left in my mind is that everybody is coming from their
#
narrow perspective, or not narrow, their perspective.
#
So I did not see so much of a system thinking, I saw what was the problem statement to be
#
solved at that point of time, which was dominant.
#
I think my first initial understanding of health system was really from Nachiket and
#
Jack and slowly I got to tap into other experts as well.
#
And that was the lens which I was initially given and then I further built on was to say
#
that there's market failure in private goods.
#
So the kind of health system slice I was looking at when I was at the foundation was
#
not about public goods.
#
So I think I came to public goods much later in my life.
#
The problem statement was in the private goods space, there is market failure, how do we
#
The areas of externalities, especially the negative externalities on infectious diseases
#
was something the foundation was anyway focused on.
#
So there was a separate group which is working on that.
#
I got to see their work.
#
But my primary focus was on market failure in private goods.
#
Can we sort of double click on each of these things?
#
Maybe starting with the primary focus on private goods and the market failures that can come
#
I mean, firstly, how can market in terms of negative externalities and stuff?
#
So tell me in specific ways, for example, what and what other and when you say that
#
people bring their own perspective, different stakeholders will have their different specific
#
perspectives where you stand depends on where you sit.
#
Can you illustrate all of that with maybe an example of a particular problem and the
#
different perspectives that come from different directions and what you felt would be a better
#
So maybe I'll first talk about private goods and the market failure and in that context
#
I will talk about what different perspectives were there.
#
So just recapping what is private goods is primary care, secondary care, tertiary care,
#
hospitals, diagnostics, pharmaceuticals, what each of us individually can buy, use,
#
And I'm not talking about clean air, clean water for right now.
#
So the primary market failure in this construct, and again, I'm not talking about pure externalities
#
of infectious diseases.
#
The primary market failure, one important market is information asymmetry.
#
So Amit, I do not know how much you know about your genetic history, how much you know about
#
what your parents' lives impact was on your health, how your mother's health was during
#
her pregnancy in her last trimester, your early years, I don't know if you have great
#
memory and in the first five years of childhood you remember everything which happened to
#
you and how the environment is really affecting you today.
#
All of these consequences, how does it impact you today, you do not know and you may have
#
a subjective experience of this, but you yourself do not know what is truly what is happening
#
with you and you may not even remember because, you know, my memory is always not as precise
#
as we would like it to be.
#
So that is the one point of contention.
#
The second point of contention is we do not keep great histories of our families, right?
#
This is what happened to them.
#
We just do not know what is really the causality of what is happening to us.
#
Then it comes with, we may not want to tell the doctors everything when we go and meet
#
We do not want to tell them that actually we eat a lot of chocolate at home or we are
#
actually not doing so much exercise as we pretend to do or we are not adhering to our
#
medicines like they have told us to do.
#
It's not like the patients and citizens are purveyors of truth.
#
Everybody will lie and that's the one starting point which causes failure.
#
The other side of the story is the provider.
#
The provider actually may also not know what is a good healthcare to give because the technology
#
They may have studied under a regime which is 30 years ago.
#
They may not be up to date with it.
#
They may have forgotten.
#
Second is, they may not have the incentive to do as per the protocol.
#
They want to refer you to a big hospital where they will get an incentive.
#
They have families to live for and yes, there is intrinsic motivation and historically the
#
view has been that doctors have intrinsic motivation and the code of conduct and the
#
Hippocratic oath, absolutely yes, but there is also a human element to this and given
#
their capabilities and given their incentives, there's that information asymmetry.
#
They know things which the patients do not know and patients know things which the doctors
#
do not know and therein lies the challenge and in the crisis of a health emergency, the
#
price elasticity is insane.
#
So you and I will pay a whole lot of money when our health is not good.
#
So therein creates a bigger problem as well and often people see health as a moral issue,
#
but even this dynamic creates enough problems for good quality of health to be judged and
#
The other problem is most interactions at least in India and sometimes outside are all
#
So here we are, it's the same classic transaction failure, you are meeting each other once,
#
you may not meet each other again.
#
So the incentives to have good behavior with each other, to form trusted relationships
#
is limited and health also is not an episodic event, it builds over time and because it
#
is episodic in India, that doesn't lead to solutions being built to overcome the market
#
failure of episodic information asymmetry to become overcome through multiple interactions.
#
The last challenge which has happened in health care, I feel, is that it has become more specialized.
#
So we had this earlier conception that the primary care doctor could be the guardian
#
or could be the gatekeeper who would sort of have enough knowledge to judge whether
#
you needed hospitalization or not.
#
Yes, that is still true, but the truth is, your heart doctor will not tell you anything
#
about your kidneys and your kidney doctor will not tell you something about your brain
#
and the knowledge of science has become very, very specialized.
#
So there is a role of referral pathways.
#
So it's not only interaction with one doctor, these are multi-organ challenges we face many
#
times and in the same course of the same event, you may have to work with the whole host or
#
group of people rather than one person.
#
So imagine the failure with interacting with one provider for one thing, but when it comes
#
to multiple providers, the complexity just increases.
#
So this is the, at the very layman's term, this is the problem statement which is there.
#
Now, historically, what has been the thought process is that, oh, obviously, private sector
#
would make money off this, right?
#
There's no incentive for the private sector doctor to provide good quality of care.
#
So, you know, we should have government doctors and government doctors will have intrinsic
#
They're also not paid per patient, they're paid a flat fee and therefore they will be
#
able to drive better outcomes or only we need to drive accountability and productivity.
#
So we need to sort of do better governance and better performance management, better
#
training and that will help us get to the picture and which is a classic, you know,
#
of the government delivery system problem.
#
Now, the challenge is that the same problem statements and market failures actually apply
#
to the government doctors as well.
#
The government doctors also, they also have needs of money, they also have gaps in knowledge
#
They also do not know enough about the actual pathways.
#
So it is not necessarily just because there is also potentially better intrinsic modification
#
and a flat fee instead of per interaction fee that you will not get market failure.
#
So I think that I will solve it through supply, which is more ethical, which is more accountable.
#
Yes, it works maybe with many individuals.
#
As a system level, can it work?
#
There's a question mark on it, at least globally.
#
Now where much of the other countries have transitioned to empirically, when we study
#
There's a whole bunch of developed countries which have thought, okay, can you regulate
#
Can you dictate to the doctors that, you know, this is the regulation by which you will not
#
miss sell or misbehave or patients, you will also have your own code of conduct and you
#
will tell the truth and information technology that we will record your past history and
#
That has actually not been the solution for most countries.
#
So it's not been regulation.
#
What has been an approach which is practically used by Japan, UK, Germany, France is to track
#
So I need to have observability about you are the doctor, Amit and I'm the patient.
#
You and I will have many interactions.
#
I could have interactions with other doctors as well.
#
But every transaction, every engagement will be observed, will be interpretable.
#
So, you know, you will be able to have clinical protocols written in a way which someone can
#
third party can interpret.
#
It will be also in a way standards on costing and standard on coding will be there so that
#
I can judge whether this was a value for money interaction.
#
So instead of taking an intrinsic motivational approach, or instead of taking a market failure
#
can be regulated away with standards sort of approach and I can have inspectors sort
#
It's gone away from that thing to say the quality is the market failures overcome in
#
Now the other part of the problem is how do you create incentives around it?
#
So it's not a market failure in every interaction, but it's over the lifetime or longer period
#
and across the referral pathway because you will have to meet not only one doctor, but
#
also the multiple other specialists or other levels of care along the way.
#
So that is the path which most countries have gone towards.
#
Now this is the empirical of what I discovered by going to many different countries and by
#
understanding and talking to various players.
#
In the Indian context, what would happen is that a lot of the people were working on improving
#
the government delivery system.
#
So private sector is seen as a competition because we stand in the government delivery
#
system and which is important because it's about equity and access to the poor.
#
So we would confuse government delivery system with equity.
#
So then a lot of focus would only be in the government delivery system would not be in
#
Now private sector was 80% of the outpatient, 70%, 60% of the inpatient.
#
So a lot of market failure there would be ignored.
#
Market failure in government would also be ignored because we would believe intrinsic
#
more motivation was good enough, plus some better governance and would sort of take care
#
of the other things and training would take care of other things.
#
That was one thought process which was there in a lot of actors supporting standing of
#
the government delivery system.
#
The other thought process was primary care.
#
So the problem is not really about market failure.
#
Another thought process, WHO's famous 70s, 80s pushed towards primary care to say the
#
solution is not really about market failure.
#
The problem statement is not the market failure.
#
Problem is a gatekeeper.
#
If you had a powerful enough primary care gatekeeper with the right incentives and the
#
primary care is going to be the intrinsically motivated gatekeeper who will act on your
#
behalf, then they will help you navigate the system in a manner which is good for you.
#
This almost presupposes that there is no market failure at the primary care level.
#
The market failure is at the hospital level and patients having too much ready access
#
to specialists in the hospitals.
#
Again it completely bypasses the market failure problem statement.
#
So there's a whole school of thought, WHO, other places which will talk about primary
#
I'm not against primary care, but I'm saying it doesn't really address the core issue
#
Then there's a whole other set of actors who will focus on what is doable, which is infectious
#
diseases, which is maternal child health care, family planning, but it will be in a manner
#
which can lead to outcomes in the short term or medium term, five years, 10 years.
#
When you try to attack things in a vertical manner, you do not build horizontal capabilities.
#
There's not only one or five infectious diseases, there's like hundreds of infectious diseases.
#
So you do not have the wherewithal because that other horizontal capacity building is
#
very very difficult and a long delay.
#
So that is the other thing.
#
And this observability which I spoke about, how other countries have solved it by looking
#
at the transaction observability and looking at the incentive alignment once you understand
#
that interpretability of that interaction.
#
That has not been at the heart of the discussion in India.
#
So this is what is called strategic purchasing outside.
#
It's financing, health financing is the broader area.
#
You have to look at the payment mechanisms of how providers are getting paid, how patients
#
And you have to lead this capability of observability, interpretability and incentives in that system
#
and therefore align and overcome the market failure to an extent.
#
Now it can't 100% be overcome and that's the problem with each of the systems outside.
#
They will be suboptimal in their ways, but at least it makes the system less prone to
#
This is an area which was a blank space when I started working on.
#
Now as a first order thing, it's not so obvious that we should work on this, but when you
#
start looking at the solutions for the underlying market failure, this is very obvious that
#
this is an area which requires a lot of work.
#
But again, this was an area which didn't have capability in India and was not seeing much
#
effort also in that space.
#
So that was one of the gaps which I saw.
#
And lastly, there were not great mechanisms to interact with the private system.
#
So there was almost two systems, it's like two states, the movie and with occasional
#
skirmishes but existing as two parallel states.
#
So there was no overarching system view, there was no policy view, there was no system view.
#
So how would all of this come together to produce outcomes?
#
Because we are trying to do things in a narrow, narrow field, but the system is actually very
#
So even within the private goods space, which I described I was working on and I was at
#
that time not working in public goods, there were several challenges which I discovered.
#
So just at the level of framework, let me try to get some clarity for myself on a few
#
And one of them is that, you know, the conventional view and certainly in India, there is a sense
#
that oh, healthcare, the state has to do everything.
#
There are two ways in which the state can look at it.
#
One way is that let us do, we have to do all the delivery ourselves.
#
And if private people are doing delivery, that's fine, we'll compete with them, screw
#
it, it's a separate thing.
#
But for the sake of the poor, we have to deliver the healthcare ourselves.
#
The next evolution of that would be to say that no, no, equity doesn't require delivery.
#
Let the delivery happen through market mechanisms and let's get the incentives right there.
#
But let's do the funding of it.
#
So let's pay for it and let's fund it.
#
And that'll be equitable.
#
So if you're not poor, we'll figure out a way to, you know, fund your healthcare.
#
But we don't have to provide the healthcare ourselves, because within the government system,
#
the incentives can get messed up.
#
Let the private sector do that.
#
Let's enable that and let's build in mechanisms which kind of take care of market failures
#
An even more evolved way of thinking about it would be that if you are in a prosperous
#
society, which of course we are not, but in a prosperous society, healthcare per se, all
#
the private goods that it involves, and the government state doesn't need to be involved
#
either in the delivery or the funding.
#
And where the state can come in is only as far as the public goods are concerned, that
#
you make sure you have clean air, water, sanitation, etc., etc.
#
And one would imagine that this is a journey and that basically no one has made the journey
#
And it, you know, so is that one correct frame of looking at the evolution of the role of
#
And I would add one interim step in between.
#
One is, yes, government needs to deliver it.
#
And there have been many countries which have successfully, so far successfully done it,
#
you know, the future will say whether that is a more successful model, for example, Thailand
#
These largely work in a government delivery model.
#
The government finances, the government delivers, and, you know, the outcomes are not so bad.
#
In the case of Thailand, for example, the government finances and the government delivers,
#
but the government pays for delivery based on outcomes and output on observability.
#
Ah, so the incentives are great that way.
#
So it doesn't suppose, so there are two parts to the government.
#
So the payer and the deliverer, both are government.
#
But they're separate entities.
#
But they're separate entities.
#
So we're just still talking about private goods, but it takes into account that there's
#
Intrinsic motivation is not good enough.
#
And it has, in delivery, they have hospitals and they have primary care providers in cohorts
#
or they have different experimental models of what combinations of this will be.
#
And they pay based on observed data.
#
And they're trying to sort of then pay on longitudinal outcome data as well.
#
So basically, you're trying to align the system.
#
So it does work in Thailand.
#
Thailand is one of the supposed examples of good cases.
#
Then there are other countries where the government may finance, for example, NHS.
#
The government finances, the hospitals are government, the primary care doctors are private.
#
So there it's moving towards models like in France or Germany, where the deliverer can
#
be anyone, private sector or government.
#
The government is financing.
#
Actually, in Germany, the government is not even financing their sickness funds.
#
So not-for-profit sickness funds, they're called sickness funds.
#
There are many, many not-for-profit financiers which are getting mandated premiums from individuals.
#
And these not-for-profit sickness funds, there are many of them, they follow the same protocols
#
for observability, for interpretability.
#
They all compete on service.
#
I will get you the claims faster, etc., all of them.
#
And then they interact with the providers for that alignment of incentives and outcomes.
#
The government is probably regulating how these sickness funds are operating.
#
And they also do it in a collaborative manner with providers.
#
So they have commission groups now forgotten exactly what these groups are, which sort
#
of also gives input into how this entire operation will exist.
#
And there are models in which this is not only happening at the central level, but there's
#
So there are many, many, many variations of these models.
#
But so if I talk about the evolution of this, there's the out-of-pocket model, which is
#
pure private sector, free markets, you have high income.
#
In many ways, the US is like that.
#
Yes, there's a lot of government spending as well, Medicare, Medicaid.
#
But for a large percentage of the population, they're paying their own insurance, which
#
But a lot of it could also be private payability.
#
That has market failure in the transaction without observability, without alignment of
#
So I do not know that necessarily is an end outcome, which will be perfect.
#
Then there is the government delivery model.
#
If you have very high state capacity, like Thailand, sure, why not go for it?
#
Now it does presuppose that you have a lot of fiscal space, that you do not need to spend
#
You do not need to spend on XYZ, other priorities of the country, that you have enough fiscal
#
budget to spend on this, or you have the state capacity to control that spending and make
#
the value for money very effective.
#
It requires very high level of state capacity.
#
Now if you do not have the state capacity on delivery, then you have built state capacity
#
If you do not have state capacity in financing, let not for profit sickness funds do it.
#
But I do think there's a role on regulation of financing.
#
Because if they're in India, for example, just coming back to our context.
#
So we have actually multiple fragmented financier.
#
So we'll just discuss what is the problem with it.
#
So we have Ayushman Bharat, we have state government sponsored other insurance schemes.
#
We have ESIS, Employee State Insurance Scheme for the blue collar workers.
#
We have CGHS for government employees, we have army scheme, we have multiple private
#
There'll be many, many other schemes as well.
#
Now imagine that I'm a hospital.
#
I get 50% of my income from actually individual patients walking in where there is no observability.
#
Then I get one set of payments from Ayushman Bharat, which is 5% of my income with a different
#
set of standards on what they want me to report observability and interpretability on standards,
#
And then I get another completely different set of requirements from some other payer.
#
And so on and so forth with every payer.
#
And then the pricing for each payer is different.
#
So I will get to pick and choose which payer I want to work with.
#
So I have no incentive to align myself and who do I align myself to and to why I have
#
enough money from not doing any of these things.
#
Why do I make the effort to even try to figure out how to improve quality of the system?
#
There's no incentive for me.
#
So this observability, interpretability and alignment of incentive works when it's meaningful.
#
It's material to the provider ecosystem.
#
If it's not material, it will be confusing and not worthwhile.
#
Now why is the Indian financing space in this fragmented space?
#
And there are multiple problems with it, where I feel that government needs to play a role.
#
So you know, you mentioned like horizontal capability structures building that.
#
Can you illustrate that?
#
Like, what do you mean by that?
#
What is horizontal capability in that sense?
#
So one horizontal capability is, okay, you are getting treatment for cancer care or you're
#
getting treatment for heart disease or you're getting treatment for some bad bug which has
#
put you in the hospital.
#
Okay, one horizontal capability is that I can, I have pre-contracted packages with the
#
providers, which is negotiated already.
#
I can change those packages as per the dynamics of the local market and local disease patterns
#
and some supply demand dynamics.
#
So I can basically incentivize providers to put up more for that disease area versus some
#
I can have the data coding required for being able to understand what that, what each of
#
these disease areas really mean in terms of clinical protocols, in terms of how much money
#
is being spent on what type of clinical protocol.
#
And I can do that all in 30 minutes.
#
So I can play the claims out and settle the bill with both the insurer and get the service
#
to the patient flat in 30 minutes.
#
So that's a horizontal capability.
#
I can do this for every disease area.
#
Now if I tried to think of it in not in a horizontal fashion, then I will create a department
#
of cancer care in Ministry of Health.
#
And there are many, many departments like that, right, for deafness prevention, for
#
blindness, for tuberculosis.
#
So I have departments for every single thing.
#
And then I will start to think about each of them in terms of, you know, which providers
#
will provide it, should I have government to provide it, I will train them, I will spread
#
awareness about them, I will finance them.
#
So again, and I will procure medicines for them, then I will do this for every single
#
And again, the procurement capabilities could be horizontal, actually procurement capabilities
#
are not even required because the government can sanction a service and under that package
#
there could be allocation of some medicines which they can get from the nearest pharmacy
#
So it's just that thinking, which is, you know, do you want to do it vertical wise and
#
replicate each of those steps which are required for treatment of the private good, or do you
#
want to build a horizontal layer which can address the market failures in that space?
#
So what a good metaphor be this, that if I'm making a building, right, one approach is
#
that I build in horizontal capabilities like plumbing and electricity and those hold for
#
So you'll have plumbing in every flat, electricity in every flat, waste disposal systems in every
#
And it's a one time thing and then it functions smoothly, or I just build the flats and I
#
let each apartment figure out how to do the plumbing and the electricity and then it just
#
Is that a good metaphor?
#
Yeah, so everybody will come and redo the plumbing and the entire building will collapse
#
because none of the plumbing which is interacting with each other is now working.
#
Yeah, so someone can then say, okay, and if anyone wants to change things, we will take
#
you know, what is the best engineering protocol and then we will have to change.
#
But that amount of changes requires state capacity.
#
Someone needs to be and it doesn't need to be state capacity in the same sense, state
#
needs to run it, but someone needs to convene it, right actors need to be involved.
#
So that the re-engineering of that, so, you know, you touched upon a very, we've chanced
#
upon a very important part of the matter.
#
Why is it so difficult?
#
It comes back to money.
#
You know, we could become NHS or Thailand and pay a lot of money for it.
#
But you know, we are a poor country, we do not have so much money for health.
#
As the evil Ministry of Finance people tell us, you people in health just want free money.
#
Now when you have limited resources, there is the, you want to, you start with the premise
#
that you want to give as many services as possible.
#
So for example, Ayushman-Bhar is 1350 packages or now it may be even more and I stopped working
#
on this a few years ago, you want to give maximum number of services to the maximum
#
So 700, 800 million people are covered and for indefinite period of time.
#
Actually we do not have that money, right?
#
We just do not have it.
#
So we do not know then how to get that capability to get that engineering and plumbing right
#
to deliver it correctly because there's so many things to be delivered.
#
We don't, we've started with the impossible list.
#
What if we had said that we have only money for 50 packages, 50 diseases, which are the
#
most important ones for the country.
#
We will not try to do plumbing and electricity and 10 other things with the building, but
#
we will try to do three things which are essential for that building to function well.
#
And then we would learn the engineering for it.
#
We would learn the payment for it.
#
We will learn for the information tracking for it, metering for it, everything.
#
And we would learn how to build the capacity to then change what is the, these three things
#
you work on because the needs of the house will evolve in winter versus summers and was
#
this extreme climate crisis has hit therefore we need to evolve.
#
So first what we will do instead of covering everybody for everything, we will learn how
#
to do a few things, but do them well.
#
Once we know how to do well, now we build a technology which can change itself.
#
Then you see the disease pattern of this location is different from that location.
#
Why do you need to have the same three things for every building?
#
Every building is different.
#
You decide which three things need to be done.
#
And therefore for that, the capability will need to be tweaked for different, different
#
Over time, disease is changing, technology is changing.
#
We will take out these one things and we'll add these two things.
#
So through this mechanism, what you've created is a change flywheel.
#
So where it's a horizontal capacity building, which is constantly happening.
#
Now what this, what this building manager engineering house will do, or this financial
#
purchaser will do, will say, I will dictate the protocols as I know best today.
#
I will pay you for these protocols, but I will know through observability of longitudinal
#
data that actually this is not working.
#
It's not leading to good outcomes.
#
Then I will start paying you for different protocol or new evidence has come into picture.
#
Because I'm paying you for collecting data longitudinally, I actually will know what
#
And this is the power of NHS.
#
NHS is one payer, all the providers following the same standards of protocols and costing.
#
They have the best data on what input output led to what outcomes.
#
And during COVID times.
#
So this heart of this purchaser is very important.
#
Now, unfortunately, if you have so many things you ask the purchaser to do, they have, they
#
can't build capabilities on all of them, nor do they have the money.
#
They just become a pass through.
#
So they just are sending the money downward.
#
They cannot build capabilities on so many areas.
#
And also the exchequer actually doesn't have money for so many areas because they're not
#
properly, you know, if you have money for all of them, then the budget will shoot up.
#
So you start doing on a cash basis when you have money, you start trying to manage those
#
problems and the whole contract with the provider then breaks.
#
So this is something which we should avoid.
#
Chile is a fantastic example where they walked back from this problem.
#
So there was a lot of packages promised.
#
You cannot then build capability to manage all of them with the providers aligning incentives.
#
Then they decided to say, okay, all that exists, we made those promises, we can't backtrack
#
What we will do is we'll create a first among equals, we'll create an exclusive first mandated
#
So among the many diseases, we'll cover these 50 holistically, all the money will go to
#
Everything else, whatever is remaining money will go to everybody else.
#
So they're not saying no to anyone, but they created a first among equals.
#
And then they focused on building capabilities for those 50 areas, not 1500 areas, but 50
#
And they built capabilities, how to contract better, how to understand quality better,
#
how to understand outcomes better.
#
So a fantastic example of how do you get out of the political mess.
#
Now, this is one payer in India, we have many, many payers and each of them subscale.
#
But because each is not functioning to its optimal, there is no incentive to put in more
#
And they're all at different, different standards and different, different price points.
#
So we have to bring it to some level of signaling information, capturing traceability.
#
For example, ESI is employee state insurance scheme.
#
It has 100 million, 150 million odd people enrolled into it for comprehensive set of
#
packages for all private goods, primary care, secondary care, grocery care, pharmacy, testing,
#
It spends 50% of what it collects.
#
So it's not about money.
#
They have lots of reserves for years on end sitting in their reserves.
#
It is about the capability to work on this output based track, improve, change the package,
#
They have their own hospitals, they have their own clinics, which they pay on an input basis.
#
There's no observability of the protocols, there's no interpretability of what is happening.
#
There's no focus on outcomes.
#
So it's not a matter of intention, I think.
#
It's not that people were intending for it to be bad.
#
I think these are just capabilities which not many low income countries have developed.
#
So one part of the development field globally feels that this is too complicated for developing
#
But you know, India is also developing best of class things for the world.
#
So I do not think there is a way out of there's a third method I am not yet able to conclude.
#
Is there some other methods to work on market failure?
#
This and some variations of this has been the methods which many, many variations of
#
this which most countries which are have been able to manage market failure have really
#
One, you know, Jack Clendenburner, who I spoke about once, quizzingly teased me, Amrita,
#
do you know how many countries pay for service really through line item budget?
#
You know, government pays with many, many line item budgets.
#
And he was talking about high income countries, developed countries, I said I do not know,
#
Let me take a step back and let me take a common man's perspective, maybe RK Laxman's
#
common man perspective or my own layman perspective and sort of first talk about what this standard
#
perspective of the Indian healthcare system is from a perspective of the user and the
#
citizen and then I'll ask you on A, whether the description is broadly correct and then
#
B, the why question that why is it like this?
#
Like then if we look at the system design, where have we gone wrong?
#
Now from my like one clear perspective is that for the poor, healthcare is a big problem.
#
You know, a single serious disease can just cause a welfare shock which could send billions
#
of families into this country in poverty.
#
They're basically one disease away from sliding back into poverty from which they might just
#
have come out of and it is, you know, quality care is just inaccessible and when it is accessible,
#
Statement two is even for somebody like me, one, of course, I don't have a, like you correctly
#
said, I don't have a holistic view of my own sort of health map as it were, all the things
#
that might be going wrong.
#
But even apart from that, when I do fall ill and I go to a private provider, firstly, I
#
have to go to a private provider because the government providers are just too bad and
#
unreliable and whatever, so I'll end up going to a private provider and when I do, I'm being
#
charged out of my nose.
#
The incentives seem to be out of whack.
#
If a doc is working in a particular hospital, he's incentivized to make me take 20 tests
#
He's incentivized to over-medicate, et cetera, et cetera.
#
I had an episode with Lancelot Pinto on the practice of medicine and how this also works.
#
So that is the other problem that even for a privileged person like me, health care can
#
be ruinously expensive and most of it can be a waste.
#
I've heard of really five-star hospitals recommending, chalo kidney nikalna parega when actually
#
you take a third opinion and find that it's not really necessary, but they're incentivized
#
to take that damn kidney out.
#
So that is a problem here and looking at that on the surface and anybody could say that,
#
hey, but the private sector is, everything you say about them is true, evil capitalists,
#
look at what's going on.
#
And the other thing that I see around is that there simply aren't enough doctors and part
#
of it is, of course, things like the Medical Council of India, as it used to be earlier,
#
the medical council of India actually constraining supply and there being an artificial scarcity
#
But regardless of that, again, the reasons, I'll leave it up to you.
#
But the truth is there aren't enough doctors out there to the extent that most people outside
#
the cities when they fall ill are getting substandard treatment and often are going
#
to quacks and there's all this alternative medicine going out there.
#
And the fourth angle is that the pharma companies can't be trusted.
#
Now, this is also a popular view.
#
I had an episode with Dinesh Thakur on the whole Ryan Baxy scam and all of that.
#
And the argument there would be that there is, that the regulation really isn't good
#
It doesn't cover enough.
#
You know, and while somebody like me would look at the FDA in the US and say that, oh
#
my God, that is mad over regulation they're getting in the way of innovation and science
#
When I look at India, I'm like that there is possibly under regulation in this space
#
from everything that I hear about from Dinesh and Dinesh and Prashant where they wrote an
#
excellent recent book on the subject as well.
#
So these are the four things that I see that healthcare is very hard for the poor.
#
Even for number two, even for someone like me, the incentives in the private sector seem
#
out of whack and it's almost like a lottery.
#
Number three, you know, the supply of doctors is not kind of keeping up with demand and
#
generally the market should take care of supply and demand in practically everything it does
#
when it comes to toothpaste or whatever.
#
The market takes care of that.
#
So what's the problem here?
#
Why isn't it happening here?
#
What are the core reasons?
#
And fourth, finally, you know, the pharma industry, many people feel it simply cannot
#
We've had so many scandals in the past.
#
So these are, I'm summing up, you know, what the popular perception of the problem would
#
be, most of which I have sympathy with.
#
I think as description, it is fine.
#
But the naughtier issue, which I'll ask you to weigh in on is the why, like first of all,
#
is this more or less an accurate picture?
#
And beyond that, I want to get to why are things the way they are in each of these dimensions?
#
And then what is the system redesigned that you would need to fix that?
#
What framework are we not using that we should use to look at these problems?
#
And how difficult is it to make these changes happen?
#
And so your next seven hours are going to be taken up answering this question.
#
I do not know if I have all the answers.
#
We have many, many decades to go to answer everything.
#
Let me attempt a few of the areas.
#
On the poverty question, I feel I agree with you have a lot of sympathy on this front.
#
It is hard enough as a middle-income, high-income person, but for the lower-income population
#
anyway, it's a very small set of resources, a lot of uncertainty in life and very little
#
safety net if something happens, low amounts of information and connections for a second
#
of opinions and overcoming all the information asymmetry or figuring out even the referral
#
If some sophisticated doctor is telling them something, how do you even challenge that
#
by ability to read papers from NIH, etc.
#
It is very much compounded and, you know, the informal doctor looks like the formal
#
We've heard stories where people are operating on cancer, not being a formal doctor and it's
#
quite ghastly what happens.
#
Now the reality is a lot of this is not market failure.
#
So now what is the solution for it?
#
Is the solution for it is transferring income to them, but which is tight, which is what
#
Ayushman Bharat and some of the common sponsored schemes are in perhaps an even more targeted
#
manner where you get access to care because potentially if you transfer money directly
#
to them, they could still want to buy food or housing and shelter and not buy healthcare.
#
Now there is ethical debate whether you should just transfer money and let them choose or
#
should you even tie these to specific healthcare services which they are entitled to or not.
#
Like healthcare vouchers for example.
#
Yeah, and government sponsored health insurance schemes are like healthcare vouchers, right?
#
You are entitled to these services in these hospitals.
#
So they're exactly like healthcare vouchers with a little bit more information tagging
#
So now you have PHCs and CHCs, which is the more affordable places.
#
Now in any of these situations, how do you drive quality of care will again follow the
#
same market failure problem.
#
PHCs, CHCs will exist, referral pathways will be hospitals will exist, referral pathways
#
will be very difficult to handle and along the way they will be taken away to the private
#
sector, which is more responsive, which drives better immediate customer satisfaction and
#
relief through many other things and they may not even, you know, the footfall from
#
the rural areas is very low in government settings as well.
#
So it's not necessary just because you have the infrastructure, people will come.
#
People value a lot more than just the presence of a doctor and infrastructure.
#
Many cases you may not even have the presence of a doctor or nurse.
#
The alternative is a voucher system you spoke about where they can walk into whatever they
#
want and they have accessibility to them.
#
The challenge there is if you do not price it correct or you have too many unnecessary
#
packages again, they will be taken, the system is ruthless.
#
There will be a machinery to go find patients who do not need his hysterectomy and then
#
they will be given hysterectomy.
#
Both government and private hospitals will do unnecessary c-sections and which is the
#
facts when you look at some of the data points.
#
So it's not necessary that the gaming of the system will not happen.
#
It's like a fight against the system.
#
It has to be constant battle.
#
Where there's unnecessary procedures happening, you cut down the prices, you make it unprofitable
#
for people to do it, but not to the level that necessary procedures are getting challenged.
#
You innovate on the payment mechanism.
#
Instead of paying per event, can you pay them per patient outcome per year, whatever.
#
So there are many countries innovating on how do you incentivize better so that the
#
ability to make money off it is lower.
#
So for the poor, for the low income, I would say targeting better through some sort of
#
voucher system, which is like government sponsored health insurance scheme or employee state
#
insurance scheme, which is blue collar workers, mandated insurance is a more freedom driven
#
because they have a choice to go to any provider plus there's efforts to, you can build capability
#
to overcome the information asymmetry.
#
So that's for the poor.
#
The bigger picture, I would say, when it comes to poverty, we have to become richer.
#
Economic growth cannot be substituted away.
#
We'll have to allocate a lot of health expenditure to the appropriate spending, which is required
#
to meet the needs of low income population in India.
#
We have to become richer so that we can finance this before we become older.
#
So the cost curve in health is medium level when we are very young, zero to five years
#
of age, decreases, stays low and past 45, 50 very rapidly increases.
#
So as our society, as India becomes older, our health costs are going to balloon.
#
So you know, and which is going to happen post 2040.
#
So there is there is actually a deadline to solving this problem.
#
There's a deadline to solve for this.
#
And we know that by doing proper healthy aging, we can lower the cost curve, right, as we
#
So all of that concentrations also need to take into picture.
#
So if we have bad health caretaking for ourselves, if the system treats us badly and mistreats
#
as wrong treatment and selling, then it will all impact the cost curve as we become older.
#
So there's a time frame and poverty and age is a death trap.
#
And you know, there's large implications for savings and pensions.
#
So we have to do this before we become older.
#
So that's on the poverty question.
#
I'm going to pause if you have any questions on this, otherwise I'll go to the other ones.
#
No, let's let's continue because at one level, it's not even a health care question.
#
It is this larger question of, you know, how do we get ahead?
#
And handouts are clearly perhaps in certain situations, a short term anesthetic requirement
#
because what do you do?
#
But ultimately, growth is the only answer as I keep stressing through across many episodes
#
as I've kept stressing and there is no way out.
#
We can't we can't redistribute our way out of this.
#
So I would say economic growth has, you know, after many years of doing health system, I
#
did come come away with this same insight as what you're saying, you know, I should
#
have just spoken to you earlier that economic growth is critical.
#
It's not a nice to have.
#
We have to become rich before we become old.
#
No, and I just want to say that I just want to add here that people don't get that this
#
is a one thing that goes across all dimensions and all disciplines because like Nitin Pai,
#
for example, often says that a rising GDP is the best foreign policy.
#
You look at any area, you look at foreign policy, you look at health care, you look
#
at gender rights, you look at absolutely any area that you are concerned about, social
#
concern, economic concern, whatever, and economic growth is the way out of it.
#
And, you know, we kind of have to face that head on.
#
Last, two things I would say on low income population.
#
One is going back to what Jeff Hammer said and you said, public goods.
#
It's the most cost effective way to help everyone.
#
So I think self-reported health paper, which, you know, La Patna, Krone Kasane, Ajay Shah
#
and others have done shows wide variation, richer having worse health than poor in some
#
districts and HRs of India.
#
Public health has disproportionate effect on everyone, including for the poor.
#
So we should try to invest in public health and public goods.
#
It is a non-negotiable.
#
Again, if we want to become rich before we become old, that is one pathway.
#
The other pathway is we figure out how to do local public goods and public goods in
#
And the other bit is innovation.
#
Yes, US does innovation, European countries do innovation, but there are disease burdens
#
which are specific to our region, neglected tropical diseases, or how our genetic makeup
#
interacts with the environment and what is happening around us.
#
The expression of genes is very different.
#
And more importantly for the low income population, innovation for low cost.
#
As in there's so much innovation for low cost which needs to happen, right?
#
Why do we still need to do so many things in the hospital settings?
#
Can we just make everything DIY, ambulatory settings?
#
Can we just make everything low cost?
#
And everybody will be healthy forever.
#
So I think I'm not despondent.
#
I feel there is pathways, it just we do not have infinite time to work on these and perhaps
#
we need more energy on them.
#
So that's on the poverty issue.
#
I think the next two questions, the next two issues are actually linked.
#
Like when I think of private providers or distrust of them that they tend to be incredibly
#
expensive even for people like me and their incentives are skewed all over the place,
#
has our test curve, et cetera, et cetera.
#
And I think that typically in any other area, I would say that the solution to that is simply
#
That if you have more and more hospitals and healthcare providers and et cetera, et cetera,
#
competing for you, that there is an adequate supply of doctors and medical professionals
#
everywhere, then they will compete against each other for customers and they will find
#
a way to serve us better.
#
But we are very, very, very far from that now, as far as the doctors are concerned.
#
Some of the reasons are because of artificial scarcities, which are the fault of the state.
#
I don't know what I'm sure there are other reasons that apply.
#
But you know, what are the constraints there?
#
Like why isn't there more competition inside?
#
Like if I want to buy a shampoo, there's so much competition.
#
I want to buy potato chips.
#
There is so much competition, 40 varieties of the local supermarket.
#
You know, there is so much competition.
#
There is so much customization and there is so much affordability in every other area
#
of all these trivial things which have no import on our lives.
#
But something as fundamental as healthcare, we don't see that.
#
So past that for me, like, do you agree with that firstly?
#
And then what are the causes?
#
The why here is critical for me.
#
So you know, I started the podcast by saying I just come from the market's perspective
#
first and think about the failures.
#
I do have misgivings on the private sector as well.
#
It's not it's not as straightforward and free of complexity.
#
I think it's also become much more difficult in the in the era of, say, private equity.
#
Now, you know, I have friends in that space.
#
But when you have VC investments or private equity investments and there are two different
#
capital pools, you have you drive towards very fast growth.
#
And, you know, health is a health care is a private goods and health care is a field
#
where supply creates demand.
#
So it's not a it's not a fixed demand.
#
Supply is creating demand.
#
Explain that to me, because I think most people have the default attitude
#
that I'm not going to go to a doctor unless it is serious enough to justify that.
#
And I'm certainly not going to go to a hospital unless it's serious enough.
#
You didn't want to go third day.
#
You have a pain. You ended up going.
#
Then they said, you have a scan.
#
You need a scan. You have this because you did.
#
We have more sophisticated tools now.
#
We have you will discover something.
#
Then you're told it's very, very serious.
#
If you do not do this, how do you know what is happening,
#
which referral pathway you're sent?
#
Oh, no, I'm not the specialist.
#
So I'm not saying this is what is happening every day long.
#
I think there are good, trusted doctors.
#
And I'm lucky to have we've been in good health care hands
#
all, you know, in many times in my life.
#
And so has my family been.
#
But supply in health care can create demand.
#
So it will not when you're sitting in the confines of your home.
#
Like once you go there, it's likely to get exacerbated.
#
But my contention there is that if there was simply competition,
#
There clearly isn't enough competition because and in that case,
#
therefore, the key question is, how is health care different from shampoos?
#
Yeah. So in a way, actually, there is a lot of competition.
#
When you see MBBS doctors in India, there's a lot of MBBS doctors.
#
In fact, many of them do not have patients.
#
Oh, OK. So there is a huge tearing in in doctors.
#
So the top key opinion leaders will get maximum because there is a trust deficit.
#
So everybody wants to go to the best doctor.
#
So everybody will try to access the top one percent or top five percent.
#
And there will be over demand and shortage of supply.
#
Then people will go to the next 20 percent.
#
Then people will go to the next 20 percent.
#
And how the tearing gets defined is perhaps by word of mouth, by perceptions,
#
by awards, by the ministry, et cetera, which people have gotten or by hospital branding.
#
It may not necessarily be on what gets signaled.
#
It's really on what is signaled.
#
We don't know the intrinsic quality, but the bottom 30, 40, 50 percent
#
or the ones who do not know how to do referral marketing very well,
#
who are not good at connecting like I know some specialist cases of specialist
#
doctors have trained in very high expertise areas,
#
but they do not know the referral pathways and they're not happy.
#
They're not willing to pay to the junior doctors sitting in a smaller town.
#
And they may not get patients.
#
So it is it is it's the market is is is skewed.
#
So it's not like there's not a lot of competition.
#
There is a lot of generalists where there's a shortage of specialists.
#
The number of oncologists in India, the number of cardiologists in India,
#
the number of nephrologists in India and where there's a shortage
#
is in care coordination between them, which is holistic,
#
which we all experience.
#
So that is where the shortages are.
#
And perhaps there is not enough competition.
#
Also, once you believe that you want the top one person,
#
you're willing to pay whatever.
#
You know, you know, the top 15 percent would want to go to the top one percent.
#
The next 15 percent would want to go to the top next five percent.
#
So this will be how do you get to the competition?
#
Even if you add the double the number of doctors,
#
that funnel will still remain skewed.
#
Now, what will help is the protocols are more standardized.
#
A lot of the quality of the doctor may be experience driven or branding driven.
#
If we have more equality on clinical protocols being followed
#
and clinical protocols being updated and it being known
#
and more either certifications or branding,
#
which sort of gives more assurance to people that even in tier two towns,
#
this hospital has good quality cardiologist.
#
They will not need to run to Chennai or Bombay or Bangalore or Delhi to get a bypass.
#
We should have enough, you know, we should one have enough specialists
#
and enough signaling mechanisms for trust.
#
I would say that it's not only a matter of doubling supply.
#
It's about, you know, in all small towns, I know people always run to the top
#
more cities because they did not trust the local cardiologist.
#
the next level of the population would.
#
So the other issue is in terms of private equity, I would say, or or VC firms.
#
That's a bit, you know, given my market orientation, I still a bit worry about.
#
So the incentives are I put in this money and in three years, five years time,
#
I have to get very high growth and high margins, say in a hospital.
#
So what is my incentive on that hospital?
#
I have to get more patients.
#
I have to get more tests out of them.
#
I have to get more procedures out of them.
#
So health care doesn't work in a nonlinear growth fashion.
#
Health care works in a linear fashion.
#
So then what are your incentives you're building into the in the service delivery
#
is a bit not clear to me, or then you will do consolidation of supply
#
and try to reduce supply so that it can price as a premium.
#
So reverse of what you were saying is a competition.
#
So in many other countries, service deliveries,
#
much of service delivery is actually not for profit.
#
So there's not for profit, for profit and government.
#
So perhaps the incentives are different and not for profit
#
because you don't need to go for supernormal growth and supernormal profit growth.
#
So I'm a bit, to be honest, not not clear in my mind
#
between my market orientedness and just the vagaries of how health works.
#
How that how one that sort of takes into account some of these aspects.
#
But like in one sentence, what is a why here?
#
Like, why is the system like this?
#
As in, why is the system not able to market, not able to sort of manage itself?
#
Or why are the incentives?
#
What are the incentives that are leading to this bad outcome that, you know,
#
that any private person like me will firstly be incredibly wary of going to a hospital.
#
And when we go, we are pretty much we know we are going to get fleeced
#
and we don't really have options.
#
We don't know what's going on.
#
The information asymmetry is huge, of course.
#
So, you know, what's the way out of this?
#
And what's the way out of this?
#
So, you know, the provider, you know, even if the provider is working in good faith,
#
we may not really trust because now we are on opposite sides of the coin
#
and the information asymmetry is too high.
#
And some of the procedures may actually be very expensive
#
because, you know, if you look at the prices of pharmaceuticals in India
#
and some of the procedures in India versus, say, the US or China,
#
they are much, much, much more cheaper in India.
#
So, you know, you'd be surprised that the US, you know,
#
you've all heard of stories of people going to the US and they paid through their nose
#
if they had to do it out of pocket or even in insurance coverage.
#
Even in China, the prices are much higher for the same drugs.
#
So, it's not necessarily that only the Indian system is fleecing everybody.
#
It is, it sometimes can be expensive and that's its own market failure.
#
Why aren't we doing innovation enough to disrupt those two?
#
Why is it so much more expensive in America and China than?
#
I mean, America, I have a sense. China, I have no sense at all.
#
So, China, historically, has been a very brand conscious economy, even on health care.
#
They have trusted branded drugs from the US
#
because they don't trust their own internal quality.
#
So, they would go not for the branded generics or generics-generics,
#
which are lower cost, you know, sort of off-patent things,
#
but they would go for the more premium version of this
#
because there is a trust deficit in quality.
#
So, at least in the pharma side, I know I used to work with some multinationals.
#
I've lost my train of thought, but where I was coming from on the solution.
#
So, there is a there is likely to be trust deficit,
#
even if the provider is working in all good faith.
#
And the insurer may also not be 100% on the behalf of the patient, right?
#
Because the insurer is also trying to balance their budget, trying to also not.
#
They can also be taken for a ride by the individual, all of that.
#
The concept of a patient care coordinator,
#
which is a person who knows much more than you,
#
knows his or her information, knowledge, and it could not be one person.
#
It could be a group of people who are your agents.
#
So, they're not the provider's agent, they're not the insurer's agent.
#
But you're paying them either a subscription or something
#
to act on your behalf to help navigate the referral system
#
or help organize the second opinion.
#
So, patient care coordinators
#
is potentially a way because there's no other way to sort of
#
for a layperson like you and me to figure out what is,
#
we're not going to sit and read the latest protocol development from NICE.
#
So, that's maybe a gap in the market.
#
Yeah. So, it is happening in other countries.
#
Now, how do you do this in a low cost manner in India,
#
where we don't want to pay for even our own health care, to pay for such services?
#
You know, we tend to trust our recommendations with our friends and family.
#
We also have to see longitudinal benefit in this.
#
So, if we have more medium term focus on our healthy aging,
#
perhaps we will invest in something like that.
#
Perhaps there will be a market for this.
#
And can technology ameliorate some of this?
#
Like during COVID, for a very brief while,
#
I was chatting with a friend about, should we do a health care startup?
#
And I thought that, look at the information asymmetries that I have,
#
for example, no record of all the treatments and all the diseases
#
I've had through my life.
#
It would be nice to have all of that on one app.
#
So, I know it's tracking everything about me,
#
which, whenever I want it and give consent, is available for viewing
#
to whichever health care provider or doctor I'm with or whatever.
#
And I also get a holistic sense of their treatment record
#
and how they are rated by people.
#
So, you kind of solve the different asymmetries.
#
And then what also happens is that at a broader level,
#
then you kind of get a picture of what's happening in a particular region.
#
Like if there's a certain outbreak of X disease in a particular region,
#
instead of being isolated individual cases,
#
you are maybe able to find the data can find patterns,
#
AI can find patterns, which otherwise, you know, humans would completely miss.
#
And, you know, so if eventually you move to a solutions to information
#
asymmetry like that, you know, does that help a lot
#
where all the data is getting gathered?
#
All of it is getting passed.
#
There are protocols for everything.
#
Perhaps AI assistance can help doctors come at, you know,
#
We know what human failures are.
#
You have so little information in front of you about the patient.
#
You have your own biases.
#
You know, you might have got out of the wrong side of the bed
#
and not had breakfast that morning, and that can affect your judgment.
#
So, you know, just that and this is obviously orthogonal
#
to the whole question of policy or state or markets or whatever.
#
But do you feel that in the long run, you know, technology can play a part,
#
whether it is data or AI or just, you know, better coordination?
#
There's an entire field of digital health,
#
which is just trying to do exactly what you said.
#
So there are electronic health records.
#
In fact, there are startups in India which are trying to do this.
#
You send them all your paper and they will digitize it
#
and codify it and provide easy access.
#
I mean, I, the consumer, have not heard of any of them.
#
So I have no idea what you're talking about.
#
No, but I should have heard of them.
#
You know, so what's going wrong?
#
Are they are they not marketing well?
#
I will tell my friends, please market better.
#
So there are electronic health records or digitization entities.
#
What you also discussed about health information exchange,
#
that it should be available to any other provider.
#
The providers could access it based on consents from people.
#
So health information exchange is a thing in other countries.
#
And yes, artificial intelligence could help doctors suggest better.
#
They could be more accurate.
#
So, but on the first two aspects, I feel there's also a need for
#
observability and validation.
#
What is the incentive for providers?
#
You know, many providers in India still do the paperwork, right?
#
And and may not fully codify what all the proper input testing output.
#
That's not the what I was saying about standards, which is interpretability,
#
which is the protocols, the codification, the
#
observe the costing, how do you analyze that entire thing?
#
There's a science to it.
#
And there are many, many versions of it in other parts of the country.
#
Now, for providers to adopt that.
#
So this information exchange would work seamlessly.
#
What is that incentive?
#
So there's a lot of players who are doing health information exchange,
#
EHR systems, electronic medical records.
#
Most hospitals would still use digital health for billing.
#
They're not trying to use digital health.
#
And maybe some of them are, but it's very nascent.
#
You know, how much effort is going to use digital health for telling
#
their star doctors to sort of share information in a manner, which is
#
observable, interpretable, validatable as per the standards.
#
And it is a lot of work for the providers.
#
And we don't have those coders in other countries.
#
Coders do it, digital coders do it.
#
So we don't have the incentives, nor the infrastructure, nor the standards.
#
It's a cottage industry today.
#
And therefore, it's not useful.
#
And the reason why someone would do it is a classic example.
#
You know, Argentina has taught the health community, which is, they
#
have a program called Plan Nese.
#
I don't know if you've heard about this, you know, again, some of my
#
global health experts, this is a World Bank program many, many years ago.
#
And I met Martin who used to drive this program.
#
So what they did was they said, okay, we want to come overcome information
#
asymmetry for maternal, child health care, and one or two other services
#
in Argentina, because the local level, we do not know what quality of care
#
is finally being delivered, what they said, but we do not want to pay for
#
that entire services, we just want to overcome the information asymmetry.
#
So they said to what 5% of whatever that costing for that services was,
#
we will pay you as flexible funds to the last mile, to the last mile.
#
To the last mile provider, VHC or whatever.
#
If you send us data, but the data is third-party audited, that's it.
#
So you need to have, and people were so used to having tied funds, they
#
were happy to have 5% or 2% untied funds.
#
And this is one of the success programs.
#
So perhaps we should try something like that on digital health.
#
On not enough doctors, in other countries, also in developed countries,
#
which have more income than us, doctors going to rural areas, lower
#
population, less lifestyle-driven entities, not safe places is always a challenge.
#
So it is not like we have a lot of MBBS doctors, some of them, as I described
#
to you, it's cute, some of the lower stratified ones may not actually have
#
as many patients, but they still may not choose to go to rural areas.
#
They may choose to work with insurance companies.
#
They may choose to switch to other sectors.
#
So I do not know if the solution is to increase the number of doctors where
#
we do need more doctors is specialists, which there's a huge, insane skew for.
#
Now for training as specialists, you need specialists.
#
So it's a recursive loop and more specialists on the private sector.
#
And most private sector doctors make a lot of money just treating
#
patients because there's a demand supply gap.
#
What incentive they have for teaching.
#
And you know, the rules around regulations around private medical
#
colleges and teaching are onerous.
#
Why would the top specialists spend time doing that?
#
You know, apart from intrinsic motivation, which is good.
#
One potential way for this is to give them grants for research.
#
If they teach, it's a win-win.
#
You build capability, you build knowledge, you build research, you
#
build a community, you build branding for that hospital network or college
#
as you know, you'll become next loan catering or college.
#
So many spillover effects, which is not the amount of money.
#
And there's so non-monetary incentives and non-monetary benefits or small
#
amounts of money, how can we use that as an inflection point to, you know, this
#
idea that we will fill, we will make specialists go to rural area and teach
#
people how to be on colleges or open medical colleges in every district in
#
India, it will never happen because the patients will not go there.
#
Doctors will not go there.
#
So I think we have to understand incentives and everybody's a human
#
being and try to work within that constraint.
#
So that's my view on doctors.
#
I don't know if that sort of echoes or makes sense.
#
And on pharma companies, to be honest, I haven't looked at regulations enough.
#
I think global regulations, how much do they put?
#
But we know that manufacturing practices are different for the same pharma company.
#
The same manufacturing facility can be different when serving
#
different, different markets.
#
So pharma benefits package is a concept which exists in other countries, right?
#
Similar to purchasing services, you purchase pharmaceuticals.
#
Now quality management accreditation, that's a complete space.
#
So I'll not get into that for now.
#
So, you know, kind of get back to, you know, your journey with Gates Foundation
#
and your journey looking at Indian health care and trying to fix it in five years.
#
You know, you failed us.
#
So when you were sort of diagnosing the patient, as it were, the patient being
#
the Indian health care system, what was the diagnosis, like what is wrong and
#
what is wrong, I ask it at two levels.
#
Like what is wrong at a, you know, systemic design level, number one.
#
And what is wrong in terms of the mindset that existing stakeholders have.
#
And obviously I understand there are no easy answers because across the world
#
you have a hodgepodge of different systems, which all seem to fail equally.
#
So what was your sense of like, what did you discover?
#
What were your TIL moments as you got deeper and deeper into Indian health care?
#
You know, one was that all that we have discussed today is not the
#
consensus in the health system.
#
As I said, different, different parts.
#
This is my interpretation of the health system and my experience exploring it.
#
But when you talk to every actor, there are many, many fragmented actors, right?
#
There's IRDA, there's ESIS, there's World Bank, WHO, Ministry of Health, State
#
Departments, BH, there's so many actors in this space.
#
What are some of their views?
#
Like, how do they commit it differently?
#
I don't think I've had this conversation coming to me from someone else.
#
And I feel that is the gap, like individual pieces of it.
#
And the predominant view is, you know this, that, you know, it's government
#
versus private sector, that is one predominant view which happens.
#
And there is acknowledgement that we've been very focused on maternal child
#
health infection diseases and NCDs are increasing, but we need to add another
#
department and a scheme and a mission for NCDs.
#
So that's another view.
#
There has been health, national health mission for strengthening how the
#
government delivery systems operate, so productivity improvement in the
#
government delivery system, but still very input-based, not based on output,
#
observability, debatability, outcomes, all of that.
#
So that has been the narratives and within that there has been
#
marginal tinkering, right?
#
There's the government-sponsored insurance scheme, paying on output
#
are separate entities, not linked to the rest of the government delivery system.
#
Private system is completely fragmented and separated.
#
There's no actors who think holistically or have incentives to form policies or
#
thinking at that holistic mixed system level across financing and service
#
delivery and digital health and public goods and across public and private
#
sector, that space does not exist.
#
So when you look at the departments also, there's no department for health
#
policy, as in the health policy department, mostly look at the government
#
health delivery or some government health financing, it will not look at
#
the mandate of, you know, Neeti did this wonderful exercise, I was involved
#
with this to look at health system as a whole, we did bring in a lot of global
#
experts to understand from various countries, but, you know, that was
#
before COVID and there was no action and post-COVID, perhaps that agenda
#
What, what, what did you find?
#
It's the kind of things which I've been talking to you about.
#
A lot of my experiences also went as part of understanding that journey as well.
#
So exactly what we spoke about.
#
What were the fixes you recommended?
#
So the critical things is one, we should have a holistic common systems view,
#
which everybody should know that this is the important one, right?
#
Public goods, the, what we spoke about, we should have a more integrated
#
version of externalities on infectious disease, which are not one infectious
#
disease at a time, and maybe local, more regional capacity building on execution,
#
tracking, surveillance, all of that, on market failures being addressed through
#
output based, outcome based, tracking of visibility, weight based, voucher
#
based payments, and building that capability for a narrow set of things,
#
not for an infinite set of things and slowly evolving that capability.
#
And it doesn't need to be all national level.
#
It could be transferred to the decentralized level, which is partly
#
happening today, but focus on rather than expanding the package on building
#
the capability, so, and then also engaging with the private sector on
#
incentives for innovation, for research, like the one which I was talking to you
#
about specialists and how we can encourage innovation at the same time as
#
boosting the supply of specialists and then on research, which is we need to
#
get the government grant system to be simpler, engaging with the private sector,
#
also being open for universities and colleges to, medical colleges to work
#
with commercialization of that with the private sector as well.
#
So that whole seamlessness needs to be worked on as well.
#
Also, there needs to be governance rethinking, at least in my view, I have
#
not seen that there's no one responsible who holds this vision, maybe all
#
researchers hold this vision in their heads and they will organically come
#
together and this will be the path we will work towards, but there is no
#
separate health policy department in government, it becomes an entrenched
#
actor with the doer or the financier.
#
So there needs to be a system thinking unit, which also anchors and brings
#
knowledge because some of these things are known from other countries, so we
#
can adapt, we can choose, we can experiment, but that also needs to be done.
#
So this not competition to the private sector, but this let's experiment with
#
all of these incentives needs to happen.
#
Is there something specific about India that our journey has been so hard,
#
apart from poverty, by your point about economic growth and et cetera, but
#
Like other countries solved this like a hundred years ago, to whatever
#
extent they did and people, you know, there have been different ways in
#
which people have, in which states and governments have evolved and so you
#
have many different competing visions and you would imagine that when you
#
have many different visions and many different designs implemented across
#
the world, that can give us a lot of clarity on what will work for us and
#
So a two part question, part one is that why haven't we figured this out?
#
Like what are the structural barriers to our figuring it out?
#
Like is part of it a mindset issue?
#
Is all of it simply due to our poverty?
#
Does the design of the state have to do something with it?
#
And yeah, so, I mean, after this, why I'll come to the sort of the next
#
question of what can we learn from the rest of the world and what design
#
would fit us best in your view?
#
You know, we do have unique features.
#
One is clearly the income challenge.
#
We have to grow our income.
#
I feel like on public goods, this local accountability, which, you know,
#
you've also spoken about decentralization, it's just not been there for us.
#
And it may have been there for other developing countries and perhaps that's
#
why they have sometimes better health indicators than us, so it may not be a
#
matter of income, it just, we haven't figured out the local accountability
#
issue and there are many more experts who can delve into why that has not happened.
#
It was intended to be devolved, but it didn't ever happen in practice
#
or it's happened variably in some parts.
#
So I think that has been, I don't know if it can be solved in the next 5, 10, 15 years.
#
I do think it's extremely important that it's the highest ROI which we need to
#
get that accountability and to move the tension.
#
So it's not, people know how to do clean roads, people know how to do clean water
#
and parks, it's just many of your other guests would have spoken about it on
#
reclaiming land and building public spaces.
#
So I think that has been how India has evolved, but I feel like we are stuck.
#
Other actors will not give up that space, how to rejig the entire governance.
#
I think it's a bit of you build a jigsaw puzzle or you build a Jenga block.
#
And that's how we were involved on the health delivery side with our policy
#
interventions, we've tried to in all good intentions, build one patch, right?
#
Like, you know, smallpox and then polio and then maternal child health care
#
and now mental health and then NCDs, we've just kept adding to a block.
#
And there has been perhaps a lack of understanding on both sides.
#
About and maybe it is then health, maybe there's in other sectors as well.
#
This appreciation of markets and and government and how to cooperate
#
and how to leverage and but how to also regulate or how to understand
#
the follies and incentives.
#
And that that perhaps is a is a cross sector gap.
#
And in India, because a lot got privatized very quickly post 1990s,
#
in terms of health care, and we didn't build that capacity to cooperate
#
or manage or regulate or not even regulate form policies.
#
We just did not bridge that gap.
#
This is not unique to India.
#
A lot of low income countries have not graduated.
#
So like Brazil, some parts of the system is like us,
#
which is government delivery system, which is 40, 50 percent of them.
#
And rest of the system is insurance driven and some part of the insurer
#
is out of pocket, so a bit similar to us.
#
So a lot of low middle income countries have not
#
graduated to the mixed model of output based payment.
#
It does require capacity building.
#
And that larger framework of how mixed systems need to be,
#
you know, managed with strategic purchasing and the policy framework around that,
#
that you have to bring the system together.
#
So I feel like that has also been a.
#
Nobody explored that space.
#
So those two, three things, I feel, have have led to more.
#
And I feel like perhaps we we don't move our
#
our, you know, it's entrenched.
#
You know, how can we give up on one past investment?
#
We have a limited amount of money.
#
We do not have discussions on allocative efficiency.
#
So one is technical efficiency, which is how to make that money,
#
you know, that operations go better, faster, more productive.
#
But where do we want to put our money?
#
We don't really have debates on that, right?
#
It's a it's a difficult conversation to have.
#
In fact, UK has nice health technology assessment where they have a debate
#
whether they should move money on cosmetic surgery or,
#
you know, heart surgery.
#
So do we have debates on where should the money go?
#
And what is the we want to give as much to everybody where we cannot afford it?
#
So that instinct is also there, which is coming from
#
humanitarian side of things and not not the practical reality side of things.
#
Yeah, and I want to double click on the decentralization point.
#
I'll link to an episode of Everything is Everything Ajay and I did on it.
#
But it's a key point because that really brings in competition among states
#
to figure it out and to find best practices.
#
And different states can try different things.
#
And that has simply not happened.
#
One of the things I've learned across multiple episodes of this is how
#
centralization becomes such a problem, especially in something like health.
#
For example, you know, you'll have a centrally government sponsored scheme
#
for nutrition, for example.
#
And in Bihar, you have a malnutrition problem.
#
And in Kerala, you have an obesity and diabetes problem.
#
But from the center, because Bihar is closer to Delhi,
#
the scheme will be tackling malnutrition, which absolutely doesn't make sense
#
if you think about Kerala.
#
So ideally, you want to decentralize as much as possible.
#
You know, China, in that sense, even though it looks like so top heavy
#
and whatever, at the level of local governance, it's superbly decentralized,
#
17 times more than India, I think.
#
And that really works for them.
#
The other thing you pointed out, you know, about we don't think of second
#
order effects, third order effects.
#
I was at a mall the other day and it was it was a Sunday evening
#
and I was just sitting in the food court and there were just people all around,
#
almost like a railway station.
#
And this was, of course, a mall in Malatso, also, you know, Gujarat Central,
#
in a sense, so that could have biased the sample size.
#
But I was looking around and everybody that I saw around me,
#
everybody, man or woman above the age of 10 was just visibly unhealthy.
#
You know, you had ponches, you had slouching, you had it was just
#
dark circles under the eyes.
#
Everybody was visibly unhealthy.
#
And part of this is really the fault of the state and not culture in the sense
#
that in the 60s, for example, MSPs were instituted on cereals
#
to encourage farmers to grow cereals.
#
And therefore, farmers moved away from pulses and towards cereals.
#
So basically towards a carb heavy diet and away from proteins.
#
And if you're a vegetarian, pulses are like your main source of proteins, practically.
#
And for me, that is like one hidden factor in India's diabetes.
#
Epidemic, it is not that all Gujaratis eat a lot of veg carbs.
#
No, that is a very facile thing that, yes, of course, some people eat more carbs
#
And before we end this episode, I'll ask you to do a disease map of India for me
#
as well, if you have any sense of that, because I'm really fascinated.
#
My guest yesterday was telling me about how Bengalis just have a lot of ease up gold.
#
And, you know, that is their key problem.
#
But leaving that aside completely.
#
So I just wanted to sort of double score on that point.
#
And I also sort of want to move on to my question about, you know,
#
and a lot of these like the MSP on cereals or like the centrally sponsored
#
government schemes almost seems to be something the Indian government is really good at.
#
They're good at being on mission mode.
#
You tackle one thing and you figure that out.
#
But you never have that kind of holistic view.
#
So before I get to my next question, as far as that holistic view is concerned,
#
you know, is there a knowledge community in India now?
#
Is there an ecosystem that is thinking about these things and building a body of knowledge?
#
Because otherwise, the danger is that different governments succeed each other
#
and they just add in an ad hoc manner every time.
#
Of course, you have a deep state that continues as it were.
#
But even that deep state may not have institutional memory.
#
And you're reinventing the wheel all the time and you're reinventing it badly.
#
So do you get the sense among you and your, you know, your fellows in the space
#
that there is a knowledge community building up that, you know,
#
that there is layer upon layer of knowledge being added so that the
#
learnings of the past are not wasted.
#
What's what does that ecosystem look like?
#
You know, it is happening in parts and smaller aspects.
#
But on this framing, which you had, I think is so important, right?
#
On this negative externalities, as you said, this every ministry is doing things
#
which is harming health and the way roads are being constructed,
#
the way the PDS system works, some other ministry is doing things.
#
And I don't, you know, I used to earlier think that maybe the Ministry of Health
#
does not really have a voice, but is it is that the role it is expected to do?
#
So are they, you know, able to tell that PDS, why are you doing this?
#
Is that what it's expected to do?
#
Give me some examples, PDS, roads, how do they harm health?
#
For example, if you badly construct a road and there are a lot of accidents,
#
this marginal increase in disease burden of accident injuries and injuries and
#
mortality, and for example, exactly what you said, PDS makes the relative costs
#
of carbs, you know, lower than proteins and people find proteins to be expensive
#
or we ban on certain proteins and therefore the consumption is not...
#
Actually, every ministry is a ministry of health.
#
Exactly. So for example, urban development ministry is not
#
adequately, you know, thinking about walking spaces and everybody lives in
#
condominiums and we have great, you know, spaces for us to swim and exercise,
#
but actually public, which just do not exist.
#
So people are not walking and therefore they're not like in Bombay, where is
#
So every ministry is a ministry of health and sometimes at the national level that
#
No, but I must point out here with my Bombay hat on that in Bombay, we may have
#
little space to walk, but unlike Delhi people, when we do go out to walk, we
#
don't fall dead in the heat and 50 degrees.
#
So, sorry, I couldn't, I couldn't resist that.
#
You are a former Delhi person, aren't you?
#
And so in Delhi, we'll follow different policies, which are also bad for the
#
Absolutely, but I agree on this decentralization with air pollution as a risk
#
factor is much higher in North India, a lot more diarrhea is there in the east of
#
India and southern India.
#
There's a lot more, you know, behavioral and metabolic health issues.
#
So it's not like the same is existing in every part of it.
#
Even the public goods you need to focus on are different in each locality.
#
And the context of every city, right?
#
Pune is different from, say Chandigarh is different from Jamshedpur is.
#
So the way the local look, what aspects are more problematic in that region is
#
different. For example, in Bogota, I realized a lot of what the numbers are
#
mayor was doing because the historical violence in that city, he was trying to
#
create public spaces for people to interact.
#
And, you know, if you go to Bogota, they have houses, very high fences.
#
And I was a bit puzzled. I've never seen, you know, houses with such high fences
#
and barbed wires. But then you could see it's contextual to what that context is
#
and what mental health is a thing, social community connect is a thing, which
#
helps, you know, everything is a public health in that context.
#
So it has to be contextualized to what is there.
#
But it also needs citizens which want that.
#
You know, maybe we are in the Maslow's hierarchy of roti kapra maga and maybe
#
we have not graduated to understanding how these things are interlinked to each
#
other. And maybe as, you know, what each of us as individuals can really think
#
about is, yes, as you said, the mall people are on, it is so easy in today's
#
world, being bombarded with so much access and knowledge, which perhaps we
#
didn't get growing up, you know, it was not so attuned to us growing up and we
#
lived in a different physical world that we just need to take charge of our
#
nutrition. But we don't even know the provenance of the food which is coming to
#
us. Maybe that it's a local government thing on kaha se food aa raha hai, how it
#
is stored. We know some sort of where how and when where it is stored could
#
cause certain kinds of cancer. So the provenance of the food, where it is
#
coming from, the storage, many of those things need to be looked at. Public
#
spaces. If we can't find public spaces, can we seek out communities which will
#
help us one, you know, stay honest with ourselves or ways for us to exercise
#
vaccine ourselves, adult vaccines are not a thing. We think vaccines are for
#
children. We know health seeking referral pathways is problematic. Both
#
what we tend to do for ourselves. So how do we become more disciplined or use,
#
you know, players like grief case and other people who map out our histories to
#
help ourselves and also look for these other referral pathways for us to get
#
there. I think mental health and stress, especially as economic growth is an
#
imperative. And there's a lot of uncertainty, especially in the middle
#
income India, when you look at the volatility of lives which people lead is
#
very high. And as we try to go towards more growth, and there's volatility, it
#
comes with more stress. So I feel like there is there may be perhaps economic
#
growth. And the volatility of growth may not always be in tandem with health. But
#
we have to learn how to manage it, we have to invest in mental resilience to
#
ourselves, we have to invest in relationships, we have to do even things
#
like basic finance management, you know, we all need to learn how to do personal
#
finance. Or, you know, it sounds very, you know, not so hard headed, but we
#
need to come to love and humanity. Because everything will trigger us,
#
everything is stressful, everything in the environment is, is sort of too much
#
is happening, there's too much is changing. So how do we, in the increasing
#
complexity of the world, how do we drive self growth so that we can adapt to it
#
in a manner which doesn't harm our own body. I think there's lots for us to
#
think about. And none of it is easy. I struggle with it every single day. And so
#
does everyone. But being conscious that it's worth that effort as we do healthy
#
aging. I'm optimistic about technology. Maybe in five years, 10 years, 15 years,
#
there'll be dramatic breakthroughs. And, you know, researchers and scientists in
#
the West are only are already talking about it, right? From all the seven
#
biomarkers of aging to all the gene editing, which could make us the next
#
future race. I'm not saying it'll come in five years. Who knows in 15, 20 years, it
#
will be there. Now, if we don't have the best versions of ourselves, one, the
#
health costs anyway, going to get us because, you know, we'll become older
#
before and, and costlier than before we become richer. But also we will not be
#
able to benefit from all that innovation which will likely come. So I feel like
#
it's worth investing in all of this. And more importantly, to stay happy.
#
Yeah, so let's immediately fix a date. In June 2074, 50 years from today, we will
#
again meet and do another episode to kind of catch up and see where we've
#
reached. I will still be alive, you will still be sentient, we will somehow
#
manage. But you know, I recorded this episode recently with Rajeshwari
#
Sengupta and she gave me a lovely spin on the term K-shaped recovery. So
#
economists have this term K-shaped recovery about how one part of the
#
economy is doing really well, like the formal sector in India, and the other
#
part which is informal sector is just going downhill. So it's K-shaped. And
#
she twisted this and presented me the phrase K-shaped economy. And I was
#
thinking of that in terms of health care, that in terms of health care,
#
also, there is a K-shaped economy that the elites like you and me can actually
#
exist outside of the system. And can, you know, even if these private people
#
are facing us or whatever, I mean, we could even go abroad for treatment,
#
though I can't, maybe you can, but, you know, but elites can do that. And
#
that's the upper end of the K and the lower end of the K is you can't
#
reckon afford anything, some random thing happens, which requires
#
hospitalization, you're back into poverty, and everyone is screwed. And,
#
you know, I did an episode with Abbie Phillips, a liver doctor, and he
#
tells me about the trade offs of some of his poor patients, that there is
#
someone who is an alcoholic and needs a liver transplant, otherwise he will
#
die. But even the liver transplant has a certain risk of failure. And more
#
importantly, it is so expensive that it will definitely send the family into
#
destitution, at which point often he will counsel the family. And the
#
choice they will make is that let him die sooner than he would have, but we
#
cannot afford the destitution. Right? And you have those kinds of tragic trade
#
offs happening at the lower end of the ladder. But one would imagine even at
#
the higher end, certain things you cannot escape. You cannot, if you live
#
in Delhi, no matter how beautiful your condominium is, you cannot escape the
#
hot, the 50 degrees temperature, you cannot escape the smog of Delhi, all
#
of which also have tremendous health consequences. So one would have hoped
#
that there would be sort of some pressure from there. But so here's my
#
question, that, you know, when I was briefly trying to look at healthcare
#
systems around the world, one, I see a lot of dysfunction everywhere, even in
#
places like the UK with their NHS, or even in places like the US, which you
#
which are advanced economies, which have figured most other things out. I mean, I
#
do see a few places which I kind of like, like Singapore, Switzerland, Hong
#
Kong, where the, you know, the state has a clearly defined and narrow role where
#
the incentives are in place, and they're all also different from each other and
#
all that. So from your studies of healthcare systems worldwide, like, what
#
is your sense of what definitely works, what definitely doesn't work? And then
#
there's a lot of gray area in between, how do we figure out what is applicable
#
to India? And how do we figure out what mistakes to avoid? And I'm trying to
#
come at a picture in my head of what an ideal system would look like, say, 20
#
years from now, if we get absolutely everything together, what would an ideal
#
system be like? Like, if you get a call from the PMO, and you're made the health
#
minister, right? Let us indulge me in that thought experiment. What would you
#
tell me five things you would do, not in terms of immediate policy, but just in
#
terms of anything that would foster a change in systemic thinking? You know,
#
how do you look at that big picture? Where do you start making the changes at
#
You know, economic growth is important. I would-
#
If the PMO called you, you would say, health nahi chahiye, mujhe Ministry of
#
I have really, I've really, you know, I spent so much time on health, but I do
#
feel on the poverty point, you were saying, that the poor have it tough. I
#
think economic growth has to happen for everyone. So that economic growth
#
question is important, and innovation at low cost. And not only for India, for
#
all developing countries is critical. Now, if there's a country I can paint the
#
picture for, and as to what good looks like. So I unfortunately do not have a
#
specific country I can point to and say, this is how I should, how we should look.
#
It is problematic because of our constraints. Like I know what we will end
#
up with. We'll end up like the America, the US, without the income.
#
Right now, the way we are structured. Okay, and like, that's how we are set up.
#
We end, we will end up, if we continue this path with the best effort basis,
#
which we're doing, we will be a fragmented system. We will not have enough
#
public goods at the local level, and they have better public goods than us in
#
some places, and in some ways worse than us, but not enough public goods. We will
#
have a lot of private goods. It will be fragmented and market failure will be
#
rampant because there is not, there's fragmented payers and financiers. So
#
again, different incentives, not enough observability or transparency and
#
sharing of data. There's no incentive for HIS to be shared seamlessly across
#
systems. Health information system, information cannot, asymmetry is very
#
hard to overcome. And the innovation is all high cost innovation because it is
#
VC private equity driven and chasing for the rich to spend more money and
#
therefore solving that problem statement. So, and there is a small, we
#
will be slightly different. We'll have a government delivery system. Perhaps
#
today, it is a third or less than a third, maybe it'll become a 20% of the
#
share. So in the US, it's like 10-15% is government system. So this is where I
#
feel I fear we are moving towards. Now, I hope and you know, with as we age as
#
the economy, there will be pressures to have larger allocations of fund for the
#
higher age income. So, you know, we recently announced the expansion of
#
allocation, you know, packages for the 70 plus year old population of India and
#
the recently, you know, with the new last week, I think we there was
#
announcement. So it will go towards managing that care rather than
#
preventing, you know, that cost to happen because we're aging in a healthy
#
manner, we have good public goods, we have we are addressing the market
#
failure. So this is how we are. I'm not trying to paint a do mistake scenario,
#
but this is how we are stated to be. So a not so well funded US.
#
So the kids of 2074 are fucked because they are paying for the pensions and
#
healthcare benefits of like eight generations of Indians who never got, you
#
know, the preventive care they should have.
#
Yeah, yeah, or public goods or the right kind of care or we did not take care of
#
ourselves. Yeah, including our own mistakes. And so all of that will pile
#
on and plus we'll have innovation at a very high cost available to the rich and
#
not the poor. So all of that problems will lie in an unequal society.
#
Now, but all innovation percolates round like has there ever in any field been
#
innovation for the rich which hasn't percolated down? Like whether it was, you
#
know, so even with AI, I'll sometimes hear the criticism that, oh, it will
#
create a new kind of inequality. And I'm like, No, are you crazy? This is the
#
greatest leveler of the playing field possible. Like you look at how cheap
#
telephones are today compared to like, 30 years ago, and all technology
#
eventually percolates down and kind of goes everywhere.
#
I feel in healthcare, it takes a long time. For example, whatever like
#
was MPEG in the US right now to come to India in an affordable manner will take
#
six, seven years. And then that is the rich Indian will use it.
#
So then there are structural issues for why that?
#
Yeah, because, you know, the company, which is manufacturing was MPEG, they
#
will not make money in India. India is one to three percent of the global
#
farmer economy. It's not the first in line. And within India, the top 10% is
#
of the wealth or income or, you know, maybe worse. So just a hierarchy, which
#
is, you know, when you have supply, which can charge high premiums through a
#
section of the society, then it just trickles down slowly. And the
#
economics may not be restructurable in the way, because new innovations will
#
come on that was MPEG 2.0, which then
#
it'll get evergreen, you're saying in terms of patents.
#
Yeah, or some new innovation will come. So the trickle down takes a lot of
#
time. And then it's not only the trickle down of the products and the
#
technologies and the testing, it's also the knowledge. So the doctor in the
#
tier three, tier four city has to have been trained and knowledgeable of the
#
new innovation, which is happening and to correctly administer that.
#
It is, it's, you know, innovation, you know, this used to happen. I came
#
across a few companies who were doing innovation in India, and their issue
#
was they did not know how to reach the last mile, it's too costly. Because
#
there's entrenched systems and incentives or knowledge in the current
#
service delivery or doctors to use what they already know. Why to adapt to
#
something new, they're making, you know, it's working. To learn something new,
#
and then to start using it to explain to the patients, to explain to the
#
ecosystem, and to work it down, it's the cost of going in a fragmented
#
system. Like in other countries, there's either national purchaser, or
#
few sickness funds in Germany, which will say, Okay, now include it in my
#
benefits package. So a new innovation has happened, very cost effective,
#
will save everybody, they will negotiate in bulk for a large population, and
#
they will bring it to the benefits package. Then they will update the
#
clinical protocols and start paying for it. Suddenly, a whole bunch of
#
providers will have access to it at one shot. So the entrepreneur will go to
#
every doctor, knock and train and sell the new innovation goes away. So it
#
percolation takes time. It's not that easy.
#
Yeah, I just I'm just trying to wrap my head around this, because I feel that
#
then there are obviously some deep structural flaws within the system that
#
don't allow this market to function efficiently, because in no other field
#
would this happen in any other field, the lag is very little. And you know,
#
it percolates down super fast. Over here, like, typically, I would imagine that
#
there will be intense competition, and there'll be other rival drugs, just like
#
Ozambique, and cheaper and cheaper takes time deeply complex. Yeah.
#
So which country we should be like, or which, you know, what should we be like?
#
And before that, I had asked you, and you didn't answer, and I completely
#
forgot, but I will push on it after you talk about, you know, the learnings from
#
other countries, piecemeal learnings, we can't take, obviously, anything entirely
#
from anywhere, but the piecemeal learnings of, you know, what are good
#
practices we could emulate. But after that, I will go back to what I asked you
#
before, that if you are in Ministry of Health, and you don't give me that
#
answer, ki nahi Ministry of Finance chahiye, growth hoga, sab theek ho jayega,
#
nahi hoga, Amerika mein growth hua, England mein growth hua, theek hua, kuch nahi hua.
#
Yeah. So on which countries would I want to look at? I feel, Sri Lanka for the
#
public goods, local accountability, elections, how do they do the magic, we
#
should understand. That would be my ideal state, looking at Israel or
#
Netherlands, for how do they do managed care, you know, and, you know, this is
#
what I've heard, I have not studied it myself from some of the experts, that in
#
Netherlands, the Dutch authority regulates both the financiers and the
#
providers. So they see the systemic risk of financing and service delivery as a
#
whole. So they are trying to, it is trying to look at the private goods and
#
manage the whole market failure and risk allocation across the two financiers and
#
service providers. Now that's a very high level of capability. And even in
#
Israel, there's four managed care systems, which finance and provide service
#
delivery in an integrated manner. And people have a choice to switch, even
#
Netherlands have a choice to switch, so you can switch every year or at certain
#
intervals. So that creates competition. But that also creates standards that, you
#
know, hey, everybody is not going off on a tangent, every delivery system and
#
a financier is not going off on a tangent. It's very efficient, but also has
#
market like dynamics. That takes a lot of capability. And I'm told that that is
#
utopian. But how do we build capabilities towards that? IRDA is very,
#
okay, now I'll come to what I would do. And then I would want to do NIH like at
#
low cost in India, maybe South Korea has been doing some of that. How do we do
#
innovation in a low cost setting? And I would like to learn from that. So as a
#
Minister of Health, I would say, let me go talk to and convince the Prime
#
Minister that we should do decentralization and do public goods at the
#
local level. And I should have a say to say to tell each ministry not to do one
#
thing. So, you know, trying to do positive externalities takes money and
#
effort and time. First, I'll start with every ministry is Ministry of Health, and
#
I will just tell each of them one thing not to do. Next year, I'll get to have
#
one more vote. I will come with one more thing not to do. So I will demand-
#
So what are some examples of things you would ask ministries not to do?
#
Exactly, like don't do PDS for-
#
Serials, I will just say don't distort the system. So I would, I don't, you
#
know, eat up the parks when you're giving approvals for buildings, etc. So I will
#
just start every year, not all at once, one thing a year and tell that for the
#
next five years, we'll make, you know, it's a visibility for next five years.
#
This is the kind of things which will come. So be mentally prepared. Now that
#
will also have an impact on the economy, right? Because every trade off will have
#
an impact on the cost on the society. But net-net, it will have a positive
#
impact on the country. And I would argue that because I'm freeing up the health
#
cost, overall, it adds to your GDP because that, you know, freed up
#
resources and ROI and people's time goes to improving the GDP overall, then I
#
would say, okay, let me be leader for, let me have an oversight or a convening
#
power for all the payers of the country. So IRDA, which is a regulator for private
#
insurance, ESIS, PMJY, CGHS, can I convene them? I don't need to dictate to
#
them. Let's work towards a common sort of standards and frameworks and data
#
dictionary and accounting standards and clinical protocols. And let's also
#
include the private sector. Let's include the global experts. Let's try to sort of
#
bring capability building to this madness which we have. First, we will
#
build capability to do a few things well. Let everybody do what they're doing. We'll
#
first come to common consensus and working on 10 things or two things. And
#
we'll all jointly learn. We have enough money each of you. I'm not asking for
#
more money. I'm asking for rights to convene this, create this ecosystem and
#
work towards building capacity. We'll add, go to 10 things, 15 things, 20
#
things. You can exist as independent things. Once it starts working
#
efficiently, we build the system, then we can ask for more risk pooling, more
#
money. So we don't need to do it day one. So I'm not asking for it. Then the
#
Ministry of Health gets a lot of money as inputs for infrastructure, etc.
#
Slowly, I want to shift it to output. So it's great for Ministry of Finance
#
because they don't need to double pay because they have the same pricing for
#
the package and they're also paying for the infrastructure. So can I
#
incremental disbursals will be lesser on the fixed side, but more on the
#
output side? Can I start making slower shifts towards that? Can I support a
#
community of researchers at the Ministry of Health? So this is a lot of
#
change and information and how to do and what to do. We do not have the
#
capability building for that. I will drive data transparency. I will put out
#
a whole bunch of data, which is there with these payers and providers and
#
maybe these electronic systems and we will create a community which will
#
think more boldly how to extract value from the system every day in and day
#
out. I need a little bit of budget to do grant research quickly and
#
efficiently to the top most specialist researchers. Maybe I will create
#
collaborations with NIH. I'll create collaborations with South Korea. I will
#
learn how Israel does create linkage of research universities and
#
commercialization. And I will use that. I'll get that flywheel going in a
#
more integrative manner. And yes, infectious diseases that continues to
#
be the mainstay. We still need to support that. But perhaps the states
#
can play a more role and we will do capacity building. And we will try to
#
steer towards a more horizontal approach. So that's what I would create
#
my own department of policy to work on these many, many things away from the
#
everyday action which each department is already doing. So let me not
#
disturb any of the existing actors.
#
No, wise words. And I especially like that in the first part, you said you
#
will go to each ministry and tell them not to do one thing a year and then
#
not to do. You know, I think there's a revelation there as well, that
#
sometimes there are certain things we are doing which are making things
#
worse. Not doing them, getting out of the way is, you know, the first step
#
and should be pretty low hanging fruit. Though I suspect for this, you
#
don't need to be Minister of Health, you need to be Prime Minister. But I
#
will change the thought experiment. It's my thought experiment. Who can
#
stop me? So you are Prime Minister. So you know, you proposed a number of
#
questions, which is actually a framework Ajay likes. We've done it in
#
some of the Everything is Everything episodes, which is what should X do?
#
Right? And the first of those was what should governments do, which I think
#
you kind of answered right now, right? And the second is what should private
#
firms do? And I want to ask this in the context of something that you
#
mentioned at lunch from your experiences in the private sector, that we think
#
of governments not thinking about the world properly. But it is also the
#
case that many private firms, even if their incentives are aligned well, are
#
too often in a kind of crisis mode, they may not take the bigger picture,
#
they may not see the bigger picture, you know, they may get stuck in the
#
rut of doing whatever they're doing and not think out of the box, etc, etc. So
#
can you share some of your insights on that? And while you're tackling the
#
question of when it comes to health care, how should private firms think
#
I don't know. I think the private firm, especially from a service delivery
#
angle, which is, you know, hospitals, primary care, testing labs, and so on
#
and so forth. There is a information asymmetry and there's a distrust. Is
#
there not a is there not a model towards value proposition of trust? It does
#
happen in other industries, right? Where the value proposition is trust, and
#
then there's efforts to operationalize trust and to signal trust. So can the
#
industry take a and that's a differentiation, especially in large
#
cities like Bombay and Delhi and Bangalore, there are a lot of providers,
#
can we build a differentiated model of trust and create a club, create
#
clinical protocols, for example, there is the cancer grid, which says that we
#
want to we want to be known for trusted cancer care. So we will share protocols
#
with each other, we will advertise who's part of this network, we will discuss
#
cases with each other to get the best of experiences, there's learning sessions
#
that network building can that become a brand calling? And can more of that
#
happen? Also, we perhaps learn how to do managed care, right? Not episodic care.
#
And there are many, many versions of managed care around the world. I think
#
Naran Hidadali got permission from IRDA to do managed care. And if I could be
#
wrong, this is what I've heard. But if that is true, I think it's a wonderful
#
opportunity, because we do not know today, hospitals do not know how to
#
take care of the the citizen or the patient through the lifecycle, or
#
through a longer period of time across all their needs, we do not know how to
#
estimate the disease burden in a population set, we do not know how to
#
treat it over lifecycle, we do not know how to cost for it, we do not know how
#
to report it, how to track it, how to know that you're moving forward. It's a
#
lot of learning to do. So if there are opportunities like that, and why? Why do
#
this? Because you know, today people are making money. So why is it necessary to
#
do this? I feel there's a lot of opportunity outside of India. And that
#
has much higher standards of quality of care, that also has a lot of need. We
#
are aging slowly than the rest of the world and rest of the world has a lot of
#
money, but they also have higher quality standards. We can build these
#
capabilities for the world. So like has happened in IT services or other
#
spaces in India, or in, for example, Actual Sciences, some of the top
#
expertise in Actual Sciences resides in India serving the world, not necessarily
#
for the Indian market, but that expertise then can be turned towards Indian
#
markets. So can we not tap into the global opportunities by building these
#
trustworthy skills to serve the global markets, which are more discerning of
#
quality and able to differentiate that it will need support from policy
#
industry bodies for us to be able to serve other countries more strategically,
#
but there's a lot of opportunity. So one, it should not be seen a low level of
#
aspiration and a local market opportunity. I think there's a very big
#
play on health care globally. And where we have a lot of lower cost talent and a
#
decent quality talent at some places which can be converted into that
#
services for the world.
#
And I like the way, I like the drift of think of providing for the world,
#
because, you know, that helps you find a competitive advantage and there's a
#
market out there. And then when you are competing in a global marketplace and
#
you've gained expertise in something, then that, you know, follows over to the
#
domestic marketplace and it helps us as well, which is great. Next question in
#
this format, what should the thinkers do? And here, I mean, it ties in with a
#
question that I asked earlier about, is there a knowledge community? And you
#
said, no, I'm the only one.
#
I will claim you said that. And therefore you didn't say that at all.
#
But you did point out the loneliness of the journey and how conventional
#
thinking is entrenched in old ways of thinking and doing things. So tell me a
#
little bit about this sort of knowledge community, because I'm sure many
#
listeners of this are either just interested in health care or they are
#
people on the fringes of the policy world or the economics world and perhaps
#
the health care people themselves directly in that world. But for all of
#
them, you know, there is a chance to, I think, get excited at this because, you
#
know, to tie back into what you said earlier about finding meaning, that if
#
you are a naturally problem solving kind of person and if you, if you want to
#
solve a problem really worth solving, what problem is more worth solving than
#
this? I mean, obviously solve poverty because then you've solved everything.
#
But apart from that, you know, health care is a huge problem, you know,
#
instead of building a better on time delivery app for whatever narrow segment
#
you want to hear, all of which is making our lives better. And I respect that.
#
And that's also great. I'm not dissing any of those guys. But you know, this is
#
a huge problem. But no, but to go back to that, what should the what should the
#
It's not that there's no thinkers out there who are thinking along these
#
lines. There are, you know, people have been at it for many years. There's a
#
lot of lone soldiers, there's communities and institutions. I do not know if
#
there are too many spaces for this problem statement framing. And perhaps
#
this problem statement framing is wrong. But perhaps we also need more spaces to
#
What is the problem statement? Remind me again.
#
Market failure, public goods, externalities, innovation.
#
How do we solve this? Is this framing or the framing is private sector versus
#
public sector? Is the framing that we need to add in series? What is the
#
framing of the health problem? Is it UHC? So in the health community, in the
#
researchers and thinkers, there are many, many framings of what is the problem.
#
So the problem statement is that there are many problem statements.
#
Correct. So what is the problem statement to solve is the problem. And
#
you know, this is my version of the problem statement, but there are a lot
#
of versions of the problem statement. And that is one issue. And as a
#
community, then we should debate it out. I obviously should say I should
#
win this war because I have, you know, I have a source of truth, which has
#
told me this is the divine.
#
You'd rather have a debate than lose and not have a debate because if there's
#
no debate, you don't even have a chance of winning.
#
Right. I'd rather have a debate and win. And the challenge is, it comes with
#
a lot of blinkers on what has been the past experience, what is doable. This
#
almost seems like, you know, saying the wishlist I just mentioned seems
#
impossible. I have to become the prime minister of India. Plus, I may have to
#
change so many things. It sounds almost daunting. So why invest policy,
#
research, thinking capacity had operationalization of all of this. So
#
just audacious problem statement is just debating between the community and
#
then what version of the truth each for, you know, what version of the problem
#
statement each word, each community feels like solving. Even if you take
#
parts of the problem statement, I've articulated and try to solve it. I think
#
it's good. And there's just a lot to do. And each of this is like, decade, two
#
decades worth. And this is not getting going to get solved anytime soon. So I
#
feel like that fragmented views is, you know, a problem, you know, a lot of
#
people are working towards UHC, a lot of people are towards primary care, a lot
#
of people are working towards common delivery, improvement, a lot of people
#
are working towards getting more money from Ministry of Finance, a lot of
#
people are working towards holding the private sector accountable. So what is
#
that problem statement? We as community should, you know, and I've been out of
#
the community for three years, it's easy for me to say we, but we need to solve
#
for because the picture I painted today is impossible to arrive at from a
#
first level thought process. This is, it's not intuitive to say what I just
#
articulated as what I would do as Minister of Health or Prime Minister. So
#
I think that is then brings focus into where we put our energies and perhaps
#
we need to collaborate with other sectors. As you said, every ministry is
#
every sector is ministry of public health. And we need to think and health
#
financing insurance, I feel is something which is alien to health community.
#
In India, so I feel like again, we need to bring economics people and
#
insurance people to that for and I have found those people who have done this
#
work in other countries, imagine sitting in India, who have done benefits package
#
costing, who know how to do the standards, who know how to do the pricing,
#
they've done it for Africa, they've done it for Middle East, they're sitting in
#
India, but we do not leverage them. So it's not like we do not have the
#
capabilities. It just it's we don't have agreement on the problem statement.
#
And then we are not leveraging the expertise and resources we have to work
#
Yeah, I mean, I feel that, you know, if any of the listeners are kind of
#
confused about what exactly the self care sector is like, what exactly are
#
the problems like the way I think about it is that imagine a thought experiment
#
in which there is an elephant with 1.4 billion body parts and people are
#
feeling different parts of the elephant and drawing a picture of the thing and
#
it is really as complicated like my understanding of like the problem
#
statement I would derive from your problem statement is really a two part
#
thing and part one is how do we make markets deliver private goods
#
efficiently? And the second part is how do we make the state deliver public
#
goods efficiently? And as you said, both of those are a decades long problem.
#
I have hoped that, you know, the answer to the first is essentially growth.
#
And I hope that happens, but it's a decades long problem.
#
And the answer to the second is there is no answer.
#
Yeah, on the first answer, it's not growth because at the same income price
#
point, different levels of health outcomes exist.
#
As I said, we are likely to become US without the money.
#
So it is not only the money, it is also how it is organized about, you know, to
#
overcome the market failure.
#
So, yes, unless we do something, we will not be in a good place to use more
#
polite phrases. And on the second one, also, there is no easy path.
#
So if I were to make a statement like to achieve the kind of health care
#
outcomes we want as a nation, economic growth is both necessary and
#
sufficient. Would you agree with that?
#
It's necessary. It's not sufficient.
#
Right. Because other nations have gotten there and not reached those
#
health care outcomes at all.
#
Some are marginally better than the others, but it's more than just the
#
Yeah, so necessary, but not sufficient.
#
Yeah, this is nuts because health care is just so different from everything
#
So my next question, again, you've tackled a part of it before, but again,
#
in the format that you sent me, what can X do?
#
What can philanthropy do?
#
I think just support the ecosystem.
#
First, I would say in the framing of humanitarian efforts, selective impact
#
and system impact, the framing I mentioned earlier, and I do believe in
#
freedom, it is totally the philanthropist choice what they spend on.
#
So it's their money, their birthright, they can do whatever they want.
#
But I do believe this is the flexible high-risk capital which is there, which
#
can have disproportionate impact for the world to spend on system impact, which
#
is one of the things we spoke about, which is getting what can we convene
#
and get an alignment of the problem statement?
#
Can we work on public goods?
#
Can we work on overcoming the market failure of private goods?
#
All of the things which I said we should do as Minister of Health or Prime
#
Minister requires a lot of understanding of so many different pieces of governance
#
and operations and laws and financing flows and regional disparities.
#
It is not easy and that capability, knowledge building is something
#
which will not happen by itself.
#
It needs to be supported over many years.
#
So I would say this is an area where philanthropy can really
#
have a disproportionate impact.
#
So another grand thought experiment I will throw at you, right, which is
#
this, that Elon Musk gives you a billion dollars and says,
#
so you can do whatever the hell you want, no conditions attached with a billion
#
dollars. I wanted to actually break it down for me.
#
Give me some concrete things.
#
You know, what will you do with what will you do with it?
#
How much of it goes into building this course and research and whatever, how
#
much goes into interfacing with the state, being a pressure group, how much
#
goes into research labs, etc.
#
I mean, I don't even know the possibilities, but you do.
#
I do not want to jump to an answer.
#
I know a lot of things which have tried and failed.
#
For example, a classic answer is build an institution.
#
And I have said, I have thought building institutions is very hard because we
#
believe institutions can last for a long time, but building good institutions is
#
very tough. So I do not know, you know, you think you can build individuals, but
#
individuals will change interests and things evolve and you can start engaging
#
with the state, the state governments change, and then you're back to square
#
Everything is probabilistic.
#
There are probabilities to everything.
#
Like, how do you estimate expected value?
#
Come on, I want to see you thinking aloud.
#
This is like a great lesson for me and my listeners.
#
How does one do these things?
#
So one, yes, I would break it into, I would break it into the selective impact
#
and the system impact, because through the selective impact, you do learn.
#
And I would take selective impact bets on picking one geography or two
#
geography, two city states, and just work at them for building use cases,
#
building use cases for how public goods can be done in two very disparate
#
That is a narrow place to start.
#
It will take many years to get it right.
#
I feel like that's worth the investment.
#
I would support strengthening the insurance agencies and payers of the country.
#
I think there's a lot of global knowledge.
#
For example, South Korea has a lot of good practices.
#
They have a dedicated agency called Hira, which manages all the information
#
coming out of this entire payer provider system.
#
There's a lot of information being shown.
#
They understand all of that exactly to the point you were saying.
#
And they bring out insights, which helps overcome the information asymmetry.
#
Can we not partner with them?
#
They've tried to partner with India many times.
#
Can we not partner with them systematically to support some South
#
Korean Hira researchers to sit in India and work with all payers and
#
convene Indian researchers, not only at the national level, but state level
#
to build expertise so that we do not have to depend on South Korea and
#
Taiwan and Netherlands and Israel to learn from how this is.
#
We learn how to build provider systems, which knows actually how to manage
#
health over multiple interactions and over a period of time.
#
If none of the other many other providers in different, different
#
configurations, if we can support it, we should to again get proof points.
#
So all of these will be more experimental in the hope that we know, learn
#
not only the what, but the how to do it.
#
And if there is appetite in the government, some state governments to
#
build the governance and the state capacity to work on all of these areas.
#
So research community is a must to sustain all of this.
#
As a philanthropist, I cannot do all of this on my own.
#
So it will have to be some combination of Indian researchers, but Indian
#
researchers may not always have all the practitioner skill sets to deliver it.
#
But leveraging some private sector expertise, it could be individuals, it
#
could be some firms, it could be specialists, actual firms or otherwise.
#
And also leveraging global expertise, because a lot of work has been done on
#
this globally, so I would try to create a community which can sustain over time.
#
And some communities like this exist globally, for example, joint learning
#
network, which is a community which across 50, 20 plus countries works
#
on how to make payers better.
#
So how can we plug into the global communities which exist, but create
#
local knowledge and expertise on it.
#
So it is not a very considered answer.
#
It is a fragmented potshots that taking a bet on different, different things.
#
Work with two states, all of that.
#
But I have become more interested in innovation because I feel like public
#
goods is such a bet on politics and economy, local governance.
#
So it's too conditional upon things you can't control.
#
I think financing and market failure, all of these things are known.
#
We need to have the right conditions under which it can be built in few
#
places and perhaps can be replicated.
#
I feel like there, I feel a lot can go wrong in the sense we could spend
#
money in wrong things, we could have incentives not to build capacity.
#
We can blow up the fiscal space because in the US, 17% of GDP's health
#
of which nine is government.
#
We think government doesn't spend in the US, but half of it is government.
#
So you can really, it can become very expensive.
#
So there, I worry about having the right sort of economists and health
#
technology assessment people to sort of keep guardrails on that they should
#
not destroy the economy just because we want to support health.
#
That is a bit of worry.
#
But on innovation, I feel more optimistic if we can drive low cost
#
innovation, if we can serve the world as well and just being optimistic
#
because health things keep changing.
#
I feel like perhaps there is, because overcoming market failure will
#
improve productivity on the margin, 30%, 40%.
#
It will not change the productivity curve when a step jump.
#
So I feel like perhaps we have to rethink completely how health is
#
delivered and how do we think about health in the future.
#
So even though you're the expert, I have inside information on a meeting
#
that happened at the Ministry of Finance when a team from Hira from Korea came
#
out there and they gave a presentation and there were 44 slides and at the end
#
of the presentation, a gentleman in the team of the politician who was present
#
said, wo sab toh theek hai, lekin Hira kahan hai.
#
I'm sorry, I had to do that.
#
And this next question encompasses a lot of things, encompasses a personal,
#
so I'll actually turn it back to you as well, which is essentially what can
#
individuals do to achieve better health.
#
And here I'll also ask you that how do you think about health?
#
How do you think about something like health span, you know, at an abstract
#
level, it is true that we will be an aging country in a short while, but at
#
a concrete level, it is true that you are aging and I am aging and we are living
#
in an interesting time where we are on the cusp of lifespan and hopefully
#
health span, which is how long for which are healthy, you know, going up perhaps
#
dramatically, how does one think about this?
#
How do you think about this across two dimensions?
#
One dimension is the planning of your health and the way that you live your
#
life, knowing that the arc could be longer.
#
And the other dimension is that how does it change your mindset about living
#
per se, like there's a very interesting framework that Ajay had shared with me
#
during one of our episodes where he said that, you know, your typical life design
#
is that you're going to get educated till a certain age, you specialize in
#
something or the other, you have a career, you follow that career path,
#
then you retire, then you grow senile, then you die, right?
#
Whereas now you can break your life up into 20 year chunks and you can learn
#
new things every 20 years.
#
And, and of course, my sense has always been that the key skill in modern times
#
is learning how to learn, right?
#
That is what I want to master.
#
And you're a first principle sinker.
#
So obviously you can do that as well.
#
You know, you shifted from physics to management to, you know, picking up
#
economics along the way to healthcare.
#
And, you know, so how do you think about all of this, both in terms of planning
#
your own health, and there will be lessons in that from, for all of us,
#
obviously, but, and also in terms of mindset and thinking about your life.
#
So on the first part, which is how do I think about health span, it is an area
#
of interest as it should be for all of us.
#
I think technology is still, you know, some time out.
#
It's not that in next three years we'll have a magic pill and we'll all live
#
to 400 years, which is, you know, what some species live to in the world.
#
Agenbic, just have Agenbic every day and we'll be fine.
#
So I feel like it'll be some time out, but there's a lot of innovation
#
which is happening in the West.
#
And I do keenly track that is one of my free time interests that I sit
#
and listen to all the scientists and I read the papers and I'm like,
#
OK, this is the next innovation.
#
So what do you do differently?
#
What do you do differently?
#
I just read I'm a theoretician on this front.
#
But what I want to do is track all the innovation which is happening
#
and wait for five years, 10 years to go.
#
Before we when we know all the side effects and we have seen it play out.
#
So I'm happy if the Western countries are, you know,
#
jumping at it and using it and giving us 10 years of data to show it is safe
#
and what is the health impact on it.
#
But I feel like one should track this and see that space evolving.
#
And if there are things which are more conclusive,
#
perhaps we should adopt it.
#
And so that is one thing which I do.
#
I have tried some supplements in the past,
#
but I am not I'm not so big on supplements as a systematic thing.
#
I feel few things which are
#
things which the science currently shows is exercise,
#
not so much for weight loss, but for healthy aging and and stress levels.
#
So I do plan to take a less stressful life going forward.
#
I and to relax, as I was saying, to slow down a bit
#
and to invest in mental health and relationships.
#
And those have been things which do matter.
#
And yes, nutrition, gut microbiome, all last 10 years of human
#
gut microbiome project has been vast amounts of data.
#
And, you know, yes, it's there in the mainstream right now.
#
There's a lot of good nutritionist and doctors which are talking about it.
#
So it is very evidence backed.
#
So I do tend to read a lot of the evidence and try to incorporate
#
some of that in my life.
#
More importantly, I don't stress.
#
I'm trying to make lesser stress in my life and invest in a relationship.
#
So the other thing which I have thought more about is just we need to plan
#
for long in case if we live long, we need to plan for finances differently.
#
It cannot be that in 65 years of age or 75 or 85 years of age, we can.
#
Not we can think we are done and imagine being broke and senile.
#
So perhaps the idea that we should retire at 40 is is or
#
55 or 40 is attractive, but we should, as you said, think about a longer,
#
healthier working life.
#
I do find life is interesting.
#
There's so many problem statements.
#
There are so many interesting ideas.
#
There's so many interesting people.
#
And yes, some days the world seems dark
#
and the world seems stuck.
#
And I'm like looking at the health view or the economics view when I feel,
#
oh, no, are we moving in the right direction?
#
But I feel like things are getting better.
#
So I'm also in the camp that, you know, health disease burden
#
has in many areas come down in some areas, it's becoming worse.
#
But quality of life is much better than King's 400 years ago
#
for most of citizens in this planet.
#
So I feel like I'm not in the despondent camp, but as
#
healthy lifespan extends, one has to keep the mind alert.
#
So it'll be different things which will.
#
You know, as I was discussing with something, perhaps
#
many of the things which plagues us today in fifties and sixties and seventies
#
around cancer care, heart care, all of these, perhaps there'll be solutions.
#
And some of them already have solutions in the next 20, 30 years.
#
I think the brain and keeping the brain
#
not senile is something which we should do.
#
And it has been shown that if we keep
#
learning new things and we keep experimenting,
#
you know, there's, you know, there's more resilience.
#
So I feel like the it's a it's not a bad place
#
to keep being interested in the world around.
#
It's quite vast and interesting.
#
That's how I think about it.
#
Wise words. Good to know.
#
I mean, I'll let my listeners know that during lunch, Amrita was saying
#
that her policy towards Ozymbic is wait and watch.
#
Let the Americans kind of go through their five year cycle and then we will see.
#
And if they're still standing, we can think about it, which is wise.
#
I mean, there are a few things that I am convinced are incredibly important
#
for long term health anyway.
#
So I try to practice them, which are basically intermittent fasting,
#
get enough exercise and critically get enough sleep.
#
I would recommend Matthew Walker's book, Why We Sleep.
#
And I think that is underrated.
#
So sleep, exercise, ideally resistance training.
#
Though there I'm just, you know, preaching and not practicing properly.
#
And intermittent fasting is like the things that I am convinced about.
#
I will also ask you, you know, double click on one aspect of it,
#
which is, you know, Dylan once said he not busy being born is busy dying.
#
Right. And you said about how you've got to keep learning all the time,
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keep thinking all the time during lunch.
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Dear listeners, Amrita also confessed that her problem,
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she states as a problem, I am deeply jealous of it, is that she has hyper focus.
#
So when she starts focusing on something, she cannot stop.
#
She won't be able to sleep because she is concentrated so hard
#
in a state of, you know, deep immersion into something.
#
And I'm like, oh, my God, that is not a problem.
#
But I understand why you might consider it a problem.
#
But how are you busy being born to, you know, use Dylan's this thing
#
that, you know, you used to read three books a day as a kid.
#
Do you do you make like what are the things in your life
#
that you are intentional about?
#
You already said relationships and I'm guessing, you know,
#
things like mental health in terms of just calming yourself, avoiding stress.
#
What are what are the things you're intentional about
#
in terms of renewing yourself in terms of learning?
#
Do you, you know, sometimes look at something and it's attractive
#
and you say, OK, let me set out to learn this.
#
And if so, what is the kind of process?
#
And can you give me some examples of such rabbit holes?
#
So, you know, about relationships that's come very late in my life,
#
last three, four years, I am that hyper focused, distracted person
#
who gets immersed in whatever I'm doing.
#
And I often get complaints from all the people in my life
#
that I don't respond, I don't call and I forget things.
#
And like that's come from deeper reflections and evidence
#
that in the end, what matters is the people, you know, and the people you like
#
and not really the accomplishments or being so excited
#
by the hyper focused activity which you're doing.
#
So it's I would say I'm one on ten.
#
It's more intentional that I want to do better on this.
#
And so I would say to all my friends who are listening,
#
I will try to get to two or three soon.
#
So that's more intentional in recent years that I've reflected on it.
#
On what are the things which I try and do intentionally?
#
Again, maintaining my health is more intentional effort.
#
I don't always 100 percent.
#
I like to think and debate things in my head rather than always do them in real life.
#
But I do want to be intentional about protecting my health, given my family history.
#
So I am, you know, mortally scared of falling ill and at some stage I will fall ill.
#
But I do try and at least manage the worst of what could be.
#
And I read a lot about it in my free time.
#
I follow up all the researchers in the West and I I want to arm myself
#
with latest information as much as I can.
#
I fell really into thinking about economics.
#
Just along the way, and that is another area which I'm intentional about.
#
And I try and sort of think more about that.
#
And I have thought, should I go and study?
#
But I don't think I'm that person who will I'll learn more through empirics
#
and through debate and through reading on my own and talking to interesting people.
#
And that's the approach which I have taken.
#
I can get very hyper focused.
#
There was a period in my life where I want, I don't know why,
#
I suddenly wanted to learn about cosmetics and skin care.
#
So I went into the science of all the latest in skin care and all the molecules.
#
And what was happening in Japan was Korea, was US, was five, six years ago.
#
And there was a period a few months where I was just constantly researching
#
what had happened in that industry, more skin care than cosmetics.
#
It's not like I'm a great person who uses a lot of skin care.
#
It just, it caught my fancy and any big D.I.L.s from that.
#
Yes, what the Baz Luhrmann's song says, yes, sunscreen is extremely important.
#
If you can apply it three times a day, do that, because effectiveness is for two to four hours,
#
depending on what sunscreen you are using.
#
Again, I'm not a dermatologist, so please take all the necessary...
#
Are moisturizers good, like this one I'm holding up?
#
Yes, you know, Japanese would tell you hyaluronic acid is better for moisturizing your skin
#
and it gets into micropores and really nourishes the deeper layers of your dermal layer.
#
So there are many, many forms of moisturizers.
#
I cannot see hyaluronic acid in your...
#
It's more like a regular body lotion.
#
One of the things which has been scientifically shown to me is that
#
scientifically shown to have improvement in aging skin is retinol across 30 years.
#
It's, again, I try to look for things which have been tried and tested.
#
So, you know, you get 200 rupees ka retinoin in pharmacies here.
#
Again, I'm not frisky right now.
#
And you have to apply it or...
#
So basically on your face, take a pea size and apply it on your face, avoid your eyes
#
And there'll be flaking for the dead...
#
It basically increases your cell turnover on your face and you will have a lot of flaking.
#
But essentially your newer, younger layers will come out.
#
And you should not do it very often.
#
Maybe start with once, one night a week.
#
And after a few weeks, add another night a week.
#
After six months, go up to three or four nights a week.
#
And then you're doing it all day after a while.
#
No, it's only at night.
#
You wash your face, you put retinoin and you put moisturizer and then you sleep.
#
So retinoin, sunscreen, moisturizer, nourishment, omega-3s, exercise.
#
Those are the cheapest and most effective things.
#
There are many other things you can layer on.
#
Niacinamide and vitamin C, many, many things.
#
But I went to very expensive, then I cut it down to the very basic.
#
Sunscreen, retinol and a good, decent moisturizer.
#
It doesn't need to be so complicated, but a decent one is good enough.
#
If you're indoor most of the day, do you still need to put sunscreen?
#
Yes, because we get a lot of ambient light and the tube light, other things.
#
And it does make a difference.
#
I don't do this on an everyday basis, give people advice on skincare.
#
You should write an essay on this.
#
No, no, it would be fascinating.
#
And are shampoos bad for you?
#
I have not researched hair care.
#
So I tend to get hyper-focused on certain things.
#
Yeah, no, I picked up this La Cotidie daily shampoo from Bath and Body Works.
#
And it says daily shampoo, so I'm using it every day.
#
But I vaguely remember hearing that you're not supposed to put shampoo every day.
#
Yeah, it depends on the season and it depends on your hair type.
#
And the quality of water and et cetera, et cetera.
#
I haven't researched it deeply.
#
So, you know, you've spent a lot of your time here today.
#
Thank you so much for that.
#
You could have been doing something more useful.
#
You could have been walking in the Bombay sun outside, which is not too harsh,
#
Delhi people, not too harsh.
#
And you could have, you know, after putting sunscreen, of course.
#
But so my final question for you, traditional one, I ask all my guests
#
that for me and my listeners, recommend books, films, music, any kind of art at all,
#
which you love so much, you want to share with the world.
#
And it doesn't have to be on health care, by the way,
#
though it can, but it doesn't have to be.
#
I think many people may have already come across Sandman Graphic Novels by Neil Gaiman.
#
But I just like I'm a big fan.
#
I haven't read it in a long time, but I'm a big fan.
#
I think it's wonderful and kooky and.
#
That's it. Yeah, that's it.
#
Another book, I feel, which has really been two books, actually,
#
now that you got me going, Dune.
#
So I read it in my undergrad days and it opened up my eyes
#
because you go past the first book to the third book and the fourth book and it gets weirder.
#
I don't know. You've read all the series.
#
And it was the first time I understood the rise and fall of civilizations
#
in a very visceral manner and how the good becomes bad and how the bad gets overthrown.
#
And the passing of time and the passing of time.
#
So it's a very fascinating book, which is relevant to the world as it is.
#
It's an analogy about oil and rise and fall of civilizations and other things.
#
The second, third, fourth books were not as good, but I thought the whole concept was fascinating.
#
And you said you thought of two books.
#
Yeah, one other was another science fiction, Ender's Game.
#
So again, so the whole series, especially the first three books, is what I have really loved.
#
And again, many people will know this.
#
So the first, I don't stress, spoiler alerts.
#
Yeah, I mean, yeah, OK, spoiler alert, you know, if you've gotten this far.
#
So the first book, Ender's Game, is, you know, what if we were being attacked by some civilization,
#
some alien civilization, how would we defend ourselves?
#
And how do you take children to become soldiers, which are lethal, and then, you know, to defend the planet?
#
But eventually it turns out to be that actually you're the destroyer of the other planet.
#
And just that the switch is crazy.
#
And, you know, because in a way, how children can be brainwashed into mean killing machines.
#
And in some places it does happen.
#
So it was quite a revelation in what is childhood, what is adulthood, what is defense,
#
what is genocide and what if aliens were to exist, how we would react to them.
#
So I found that the whole build up and it also has these elements where there are groups of young boys and girls
#
combating and learning how to grow stronger against each other and the truthlessness with which armies can be formed.
#
And, you know, I am a person who doesn't like being told what to do.
#
And I like agency and freedom for myself.
#
So that whole field was very different for me.
#
But what I really loved was the second book, Speaker for the Dead.
#
And, you know, in the Indian culture, we do not really talk about people in our lives.
#
You know, when someone passes away, we say good things.
#
And it was very striking for me that in the Speaker for the Dead.
#
So Ender, who has become the, you know, kill destroyer of an alien species,
#
renounces the world and sort of becomes a priest-like figure, Speaker for the Dead.
#
And he hops to different planets and he helps different species.
#
So it's a fast forward of time right now, there are many species.
#
And when someone dies, he talks to everybody in that person's family to collect all the stories.
#
And then he does a speaking session, which is all the good, bad and the ugly of that person's life.
#
So it's like a truth narrative, which has a healing power because there's acknowledgement and movement.
#
And I found that to be a very innovative and new and a very touching concept,
#
because we do not, in India, we do not talk about things.
#
There are so many unsaid things which happen and, you know, there's more stories to that.
#
But that aspect of it was, you know, he finds a way to restore that destroyed civilization.
#
But this aspect was very interesting.
#
And there are many other parts to the series, which are fun.
#
So I would say Ender's game.
#
Yeah, you know, I love it how, you know, science fiction, the best science fiction,
#
will often tackle big questions that otherwise literature doesn't.
#
I mean, you know, in normal sort of literature, often everything has been normalized
#
and you're not taking big enough leaps and asking the really big questions and etc.
#
And the very best science fiction does that, which is why it is so sort of provocative and thought inspiring.
#
So thank you so much, Amrita. This was great. This was amazing.
#
You got to come back in 2074. I've calendarized it.
#
You will get a calendar invite in 2064. So thanks.
#
Looking forward to good health span till then. Thank you.
#
Did you enjoy this episode of The Scene and the Unseen?
#
If so, would you like to support the production of the show?
#
You can go over to sceneunseen.in slash support and contribute any amount you like
#
to keep this podcast alive and kicking. Thank you.
