India as Global Health-care Provider

WSJ looks at another outsourcing which is taking place:

60,000 foreign patients who were treated at Apollo Hospitals over the past three years. Since its start as a single hospital in 1983, Apollo has grown to 37 hospitals with more than 6,400 beds, making it one of the largest private hospital chains in Asia. Apollo’s emergence as a global health-care provider in many ways tracks India’s economic trajectory over the past three decades. The company has capitalized on the high cost of health-care administration in the U.S. and demands of patients elsewhere, for fast, inexpensive treatment.

Hundreds of Apollo’s data processors work late-night shifts providing billing services and processing insurance claims for U.S. hospitals and insurers. Apollo laboratories perform clinical trials for Western drug companies, such as Pfizer Inc. and Eli Lilly & Co. Apollo even remotely evaluates X-rays and CAT scans.

Apollo’s range of medical services — from the back office to the operating room — highlights the contradictions of the global outsourcing debate. In seeking to provide a wide range of services at a large discount to Western competitors, Apollo is yet another Indian company threatening jobs in the U.S. and other countries. On the other hand, Apollo’s relatively inexpensive medical services have benefited patients from numerous countries. It also has helped India’s overburdened health-care system. India has fewer than one hospital bed per 1,000 people, compared with more than seven in developed countries.

“We’re showing that a field like medicine is very much a two-way street,” says Prathap C. Reddy, 72 years old, a physician who founded Apollo and now runs it with his four daughters from Madras, also known as Chennai. “We can all grow from each other’s strengths.”

Apollo and a half dozen other private Indian hospital companies are adding patient rooms, buying new equipment and installing modern telecommunications gear. Meanwhile they also are setting up marketing offices in cities such as London and Dubai to attract patients, many of whom remain wary of seeking health care in the developing world. Few of Apollo’s patients come from the U.S.

The Indian government sees health care as a growth industry. Public and private Indian universities are churning out 20,000 doctors and 30,000 nurses a year, some of them destined for jobs in western countries. That is roughly triple the pace at which nurses were trained during the 1990s.

In the so-called medical-tourism business, the focus is on big-ticket surgical procedures from face-lifts to liver transplants. Asian countries such as Thailand, Malaysia and Singapore have taken the lead in this field. Promoting health-care services alongside tourist destinations, the countries attracted more than 600,000 patients in 2003 alone, according to officials in Thailand and Malaysia.

Apollo offers cardiac surgery for about $4,000, compared with at least $30,000 in the U.S. Apollo’s orthopedic surgeries cost $4,500, less than one-fourth the U.S. price. Consulting firm McKinsey & Co. says medical tourism could become a $2 billion-a-year business in India alone by 2012; the category is so new it previously wasn’t measured.

Tibco’s BPM Buy

Tibco bought Staffware recently for $217 million. Phil Wainewright provides the context:

So what does Tibco gain from the acquisition? There are several elements that make this look like a good deal:

  • Growth: Tibco’s sales fell last year, Staffware’s grew. In addition, each company’s customers are likely prospects for the other’s products. As discussed above, there are geographic synergies as well as product synergies to exploit.

  • Momentum: Adding Staffware’s revenues will keep Tibco well ahead of its closest EAI rivals, webMethods and SeeBeyond, in the race to achieve 500lb-gorilla status. Tibco executives have made no secret of their desire to become a billion-dollar company. Being seen to lead the sector with a clear strategic direction is an essential ingredient in fulfilling that dream.

  • BPM credibility: When Loosely Coupled looked at EAI vendor strategies last year in Integration: Free at last?, it was evident that Tibco and its rivals saw business process management as their main opportunity for value-add in the future. Acquiring an acknowledged sector leader like Staffware brings Tibco instant BPM credibility that it previously lacked.

    But has Tibco chosen the right BPM specialist to link up with? Staffware’s workflow roots and veteran status lead many of its younger rivals to characterize it as something of a dinosaur, lumbered with the baggage of having had to engineer enterprise-class solutions before the advent of standards-based messaging and transformation technologies. That’s mostly unfair to a company that’s succeeded in keeping its product fresh through two decades of rapid innovation and change in enterprise application integration. But there can’t help but be an element of truth in the caricature, given the company’s background. That Staffware made the ability to define “skinny processes” a feature of its latest product release does suggest by implication that its default processes have tended to be more fat than thin.

    On the whole, Tibco’s acquisition of Staffware should play well with both companies’ enterprise customer base, and thus with investors. It may even make Tibco an interesting acquisition target for a company like IBM or Oracle. But it may leave the way open for a rival to make a smarter acquisition by buying into the disruptive-technology end of the BPM market.

  • VoIP, Skype and Hype

    Peter Cochrane looks at Skype:

    Could VoIP become a serious threat to the phone companies? Well against the one billion or so fixed lined telephones and over one billion mobiles, Skype has so far seen 10 million downloads and total VoIP service estimates see less than 100 million users. However, such is exponential growth that industry estimates forecast 40 per cent of all calls will use VoIP by 2007.

    Everywhere I go in the US I now see people with PDAs, laptops and headsets making VoIP calls. This has been compounded and supported by the rapid spread of Wi-Fi providing a very powerful platform for users on the move.

    The mode of operation spans the normal fixed/mobile phone behaviour, plus the use of email to establish contact and prompt the use of Skype, iChat, etc.. The more adventurous are also linking screens and working cross platform – with common applications and displays – in a manner forecast a decade ago but still seldom seen on corporate networks.

    I think it would be foolish for any telco to dismiss VoIP and especially Skype. It seems to me that DIY telephony is on the march and will soon be on the scale of Kazaa.

    But we should also remember that there are limitations to the performance of IP networks and thus to VoIP or indeed any real time service. The reality is the internet is fundamentally ill-conceived and ill-equipped for the support of real time services of any kind. If you try VoIP you will no doubt be pleased by the quality of the voice connection for at least some of the time. The snag is that for a significant proportion of the time you can find that the quality is extremely poor.

    When you make a traditional telephone call a direct and dedicated connection links two telephones for the transmission of those bits throughout the call. This is referred to as circuit switching. On the other hand, when you send an email message via the internet your bits are transmitted in discrete packets that are often routed very differently, packet by packet. So the arrival times of packets can be widely distributed and vary on a second-to-second basis.

    For the internet to rival the telephone network it has to have an over-capacity to ensure that communication between two fixed points can be nailed down and held reasonably stable for the duration of a real time service such as a telephony or videoconferencing.

    Is this possible? Yes. What is more, it is possible at about 10 per cent of the cost of the old telephone network. Bandwidth is the cheapest commodity we now manufacture and its provision in IP networks is trivial compared to the telco environment.

    Is there is a downer in all this? I think there is and it comes in the shape of the virus, Trojan horse, worm and spam. Over 50 per cent of todays in-use internet capacity is being consumed by these negative activities. For VoIP services to become universal we will have to see some constraint put on rogue activities. Alternatively, we will have to provide and waste bandwidth on a huge scale.

    Steve Stroh looks at the big picture:

    In an April 26, 2004 cover story in Forbes titled Into Thin Air, authors Scott Woolley and Quentin Hardy offer a refreshingly clueful (for the general business press) look at the grim prospects of the conventional telecommunications business, rehashing the now familiar story of how wireline carriers are facing severe competition to their conventional voice services from Voice Over Internet Protocol (VOIP).

    But the authors venture into new territory, spotting a nascent threat to the supposedly bright future of wireless telephony carriers… VOIP over Wi-Fi. Excerpt:

    Last year American home users bought 12.7 million Wi-Fi transmitters for their computers, says research firm In-Stat/MDR. That poses a ready audience for a second major threat confronting big carriers: Voice over Wi-Fi, which lets callers use free airwaves to gain wireless access to the Internet. A home or office Wi-Fi network for a laptop’s wireless Internet access provides a ready-made pathway for Wi-Fi-enabled phones. Voice over Wi-Fi threatens to steal traffic from the cellular business (with $88 billion in annual revenue in the U.S.), already a harshly competitive world where per-minute prices have fallen by half in the last three years. Few users now have Wi-Fi phones, since currently the phones only work in places like San Antonio Community Hospital that have thorough Wi-Fi coverage. (Leave the hospital, the phone stops working.)

    While the authors are to be applauded for having picked up on VOIP over Wi-Fi… they missed the larger trend entirely, that VOIP/WI-Fi phones used in enterprises and homes won’t stop working when leaving the “private” Wi-Fi coverage of an enterprise or home. In places like Dartmouth College in New Hampshire, the city of Cerritos, California, the Auckland, New Zealand metopolitan area, Spokane, Washington, and soon Silicon Valley, ubiquitous Wi-Fi coverage will be available. (Each of these examples are existing deployments of “Metro Wi-Fi” by different vendors.)

    Then again, I can’t really fault the Forbes editors for not “finishing the story”. The threat of VOIP over Wi-Fi potentially destroying tens of billions of dollars of market value of wireless telephony companies is plenty frightening to Forbes’ audience of corporate and investor readers… the idea that such value destruction is actually in progress is probably too terrifying to commit to the pages of Forbes.

    New Tech Areas

    NYTimes asks if technology can grow bigger and not just older. It also suggests some areas to look forward to:

    “Growth was synonymous with tech investing in the 1990’s,” said David Readerman, a senior analyst at Marsico Capital Management. “That relationship has been broken.”

    Which markets will prosper? Mr. Readerman, who began his career in 1983 as a personal computer software analyst, just returned from a trip to South Korea, where he studied the frontiers of wireless and broadband technology in a market far more advanced than the United States. Throughout Asia, as well as Europe, the market for high-end mobile phones with cameras, color screens and other features is booming.

    Such surging sales, Mr. Readerman noted, helped Motorola triple its quarterly profits, while Nokia reported disappointing results because it could not keep up with the demand for high-end phones. And he pointed to Qualcomm, the creator of one of the main digital cellphone technologies, which reported last week that its quarterly profits jumped more than fourfold. Qualcomm’s technology, known as CDMA, is used in cellphones to send and receive music, video and data services. “When you look beyond a PC-centric view of technology, there are some very interesting opportunities,” Mr. Readerman said.

    Other fundamental shifts are taking place. “There is potentially a huge transition from technology being sold as a product to technology being sold as a service,” said Roger B. McNamee, general partner of Integral Capital Partners.

    After all, he noted, the popular Web sites for shopping and search are services. The stellar quarterly earnings of, Yahoo and eBay show that the march of the Internet is continuing, despite the dot-com collapse. And the imminent initial public offering of Google is the most eagerly awaited I.P.O. since Netscape sold shares in 1995, touching off the Internet boom. The other notable Silicon Valley offering expected this year,, also fits the technology-as-service theme. It markets sales-force automation as a utilitylike service over the Internet, instead of a software product.

    There is also a basic overhaul of computing under way in corporate data centers, according to Mark Stahlman, an analyst at Caris & Company. The trend involves building more powerful, efficient and secure data centers by lashing together swarms of computers using low-cost microprocessors and clever software that can divvy up work across hundreds or thousands of machines. That vision of virtual computing, Mr. Stahlman said, is being pursued by big companies like I.B.M., Hewlett-Packard and Sun Microsystems and little-known start-ups like Azul Systems, Vieo and Cassatt.

    “It represents a huge shift that will play out over the next 5 to 10 years,” Mr. Stahlman said. “Things are up for grabs in that market, and there is plenty of opportunity.”

    Sergey Brin, Steve Gillmor and Gmail

    Steve Gillmor in conversation with Google’s co-founder Sergey Brin in eWeek on Gmail:

    Gillmor: Obviously, there are privacy implications of Gmail that I do want to touch on, but I’m just as interested in the opportunities for programmability of this technology. If you could establish an API for this, that would be something really spectacular.

    Brin: That’s an interesting idea. I haven’t thought too much prior to your mentioning it now, but there are certainly a variety of processes that I have in the past done with Unix, because I can basically program it to do all kinds of things with my e-mailforward certain messages automatically, erase other ones automatically, trigger programsand it would be interesting to consider doing those here.

    G: Much in the same way that you’ve established keyboard shortcuts, you could establish macros, etc.

    B: Yeah, that’s a very good point. One thing I’ve been talking to the team about is to be able to save your searches and have easy access to them. For example, I have a search that I often useshow me the unread messages in my inbox that were sent to me directly rather than to a mailing list that I’m on. I use that one pretty often, but it would be nice to have it to save and maybe have it attach to a label or something like that.

    G: Going back to the notion of an API, something like 90 percent of all collaboration applications are actually running on e-mail.

    B: Yeah, I can definitely believe that.

    G: And that’s not necessarily such a good thing, of course

    B: Because it has lots of limitations

    G: Given some of the discussion about privacy and rights, if you could provide API access to those rightswho could read, write, etc. give that to the user, they could then turn around and use that as a way of arranging relationships between themselves and others, essentially bartering their rights, access to their information, in return for information that’s coming to them.

    B: I think that’s an interesting idea. We try to be as upfront as we can be, but obviously if their clients, or Web browsers and whatnot, could negotiate these things for them, then we could be even more upfront.

    G: It would take the conversation, if you will, away from whether it’s the cloud that’s making those decisions and put it in the hands of the user.

    B: That’s true, but to be fair, even as it is, we try to make the decision as clear to the user as possible.

    G: It also compares favorably to my corporate e-mail.

    B: Well, thank you. There are some things that it is currently missing as compared to corporate e-mailfor example, disconnected operationthough we do plan to provide things like POP3 and IMAP support, which should help that.

    But we initially wanted to make sure we have something that was definitely better than all Web mail services, and perhaps, just perhaps, it will also be good enough for a lot of people to use instead of a corporate mail service.

    Or they can use both, because they could just forward their messages to Gmail from their corporate e-mail, or the other way around. That way when they’re traveling and don’t have their computer with them, they can just use the Gmail version, and when they are at their desk, they can still use their corporate mail.

    Manufacturing Advances

    Business Week writes how the factory floor is changing: “Those manufacturers still standing are concentrating on ever-higher-quality products and processes, even if that means tearing up long-standing business practices and shedding workers to survive. And in the wings awaits a new generation of molecular manufacturers — which have more in common with chipmakers than carmakers — aiming to create self-assembling machines on a nanoscale. A focus on quality in the near term helps fuel innovation down the road.”

    TECH TALK: Letter to Arun Shourie (Part 2)

    Dear Sir,

    India stands on the cusp of a revolution. There is optimism all-round and in certain quarters, even fear of the growing prowess of India. This is a good start, but only the first step in what is a long journey. This is an opportunity for change and growth that we in India can simply not afford to lose. There are a billion dreams at stake.

    So, these are my suggestions to you. The goal is not to find fault with what is happening. Rather, it is to provide specific inputs so that you and your government can continue to catalyse the positive forces that have been unleashed in the marketplace.

    1. Develop a 5-year vision for India’s IT and Telecom Infrastructure

    Indias digital infrastructure is not going to be built with incremental policy changes. Over the past two years, the government did well to streamline the telecom policies. As a result, we are now seeing the world’s second largest growth with 2 million new users every month. A similar strategy needs to be taken to promote the use of access infrastructure technologies (wireless and broadband), access terminals, software and information.

    We need to set goals for building out India’s domestic market in infotech and telecom. This is not just for the benefit of these sectors. The real beneficiaries will be Indians as technology spreads to schools, colleges, homes, small- and medium-sized enterprises (SMEs) and rural areas markets which hitherto have had only limited adoption. While the market is expected to take care of providing the solutions, the right policies from the government can act as catalysts and the wrong ones (as I shall outline soon) can act as inhibitors.

    2. Promote use of server-based computing and open-source software platforms

    India is a country with little legacy when it comes to computing. Yes, we have an installed base of about 10 million computers, but that’s a fraction of what it should be. If India needs to rapidly adopt computing across the country, the government should give a boost to two platforms which can significantly reduce total cost of ownership server-based computing (using thin clients) and open-source software. Together, they can help bring down costs by more than 70%.

    As a by-product of the adoption of this new and affordable computing platform, India can also then become a showcase for other emerging markets on how to build out their digital infrastructure. This will also create opportunities for domestic product companies to grow globally.

    Will there be opposition? Absolutely! There are plenty of organisations which would not like to see a change in the status quo. But this is where we need to put our interests first. If India can bring down the cost of computing, we will make technology affordable to entire verticals and markets who otherwise will have to wait for many more years till either the cost comes within their reach or their incomes rise to meet the dollar-denominated prices. India does not have the time to wait we need to lead the way.

    Tomorrow: Letter to Arun Shourie (continued)

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