In terms of growth, much of it stems from emerging markets and this shall continue. On a long term basis, the case for investment in health care, energy and staples (basic necessities food) is compelling; we in the emerging markets are in a secular bull which will run to at least 2030. Where we stood in 2007, was at pause point; emerging markets had grown at a furious pace. There was a need to pause and build capacity before the next phase of growth commenced; thus a period of earnings regression while industry invests in increasing capacity while sustaining present business should have been expected.
In my view the source of the powerful secular trend in India emerges from staples and this is followed by healthcare, utilities and telecom; these satisfy basic necessities. Other sectors will be major beneficiaries; but always remember from whence the secular power emanates. Because India is so very over populated, all sectors can create huge opportunity. For instance on financials, a bank account per individual in the potential labor pool is massive beyond contemplation. Internet access penetration is also a humongous opportunity. If economic prosperity touches 10% of our population, it creates a market for consumer discretionary items in excess of 100 million people; that is huge in a global context. The infrastructure required to support growing needs makes an amazing opportunity for industrials; roads, bridges, dams, transportation; you name it and the opportunity exists. And this creates massive demand for materials and energy.
On a near term basis I expect the healthcare sector to underperform the broad markets. This is normal for the present phase in the economic cycle. Medium term I remain very optimistic for the sector. There are several sector positives. US healthcare reform is a positive trigger. Rising demand from generics is a positive. FDA drug approval rates are rising. Lifestyles have changed dramatically; lifestyle related disease is a big healthcare opportunity – diabetes, blood pressure, obesity, heart disease are all on the rise. Change in the demographic profile with escalating aging in developed economies is a positive. Several blockbuster drugs coming off patents in the coming two to three years opens up a big market for generics; at the same time development of new drugs have been exceptionally slow for several years – it is time for investment in R&D to start delivering new drugs. The sector (specially IP creators in big pharma) is very undervalued on a cycle and secular basis. But the biggest sector positive is growing need for healthcare in emerging markets. Generics, IP, Hospitals, Health Insurance; you name it and the secular trend is powerful. No doubt there are negatives too; political wrangling in US could lead to sector uncertainty, rising input costs (including chemicals) can squeeze margins; but on balance this sector is poised to deliver very powerful secular returns (15 years to 20 years).
My comments from my sector watch notes on staples apply to healthcare too; I have repeated them below:
"Buy your staples when the sector is undervalued and then let the market take care of staple sector over and under-weights for you; there is no compelling reason to add or reduce positions/share-count to build sector over and under-weights. At present staples as a sector looks cheap on a relative PE, yet I believe these stocks will be cheaper on an absolute basis once money flow shifts to energy and energy outperforms for over a year.
I am not convinced that reducing holdings in defensives following a market bottom is a good idea; the funding for rising positions in cyclical stocks should come mainly from shifting in portfolio allocation between debt and equity. The defensive sectors are not really true market hedges – when there is a recession they will fall too, perhaps to a lesser degree than other sectors, but they will fall nonetheless. The market hedge during bear markets should really come from over-weights to debt because debt will fall as interest rates are cut in response to the recession."
Long Term Fundamentals
Will Malthus be denied --- yet again?
"I think I may fairly make two postulata. First, That food is necessary to the existence of man. Secondly, That the passion between the sexes is necessary and will remain nearly in its present state. These two laws, ever since we have had any knowledge of mankind, appear to have been fixed laws of our nature, and, as we have not hitherto seen any alteration in them, we have no right to conclude that they will ever cease to be what they now are, without an immediate act of power in that Being who first arranged the system of the universe, and for the advantage of his creatures, still executes, according to fixed laws, all its various operations.
...
Assuming then my postulata as granted, I say, that the power of population is indefinitely greater than the power in the earth to produce subsistence for man. Population, when unchecked, increases in a geometrical ratio."
Because population grows at geometric progression while production grows at arithmetic progression; as population outstrips food production, natural disasters, famines, wars shall occur to restore the balance between mankind and nature.
What went right for the world? For one, productivity grew exponentially. On the other part, population growth, while exponential, is showing clear signs of defying the laws of nature - as economies mature, there is increasing evidence of falling fertility which arrests population growth. This together with forced and education based birth control, has somewhat slowed population growth from what it could have been. While population growth is restrained from a peak growth rate, increasing longevity does mean a larger standing army and thus a permanent increase in demand.
On the demand side, while resources are finite, the voracious capacity to consume is not; both manual intervention and a Darwinian response by humanity may help delay the Malthusian correction; in the mean time science shall answer the challenge of increasing productivity to sustain the masses. On the supply side, energy is the fuel which fires the engine of industrial growth. Food is the fuel which fires people; without food there are no people; no demand. On health care, I personally find the Biotech industry utterly fascinating; of course I know nothing about the technical side of things, but I do follow the industry and its pipeline drugs closely from an investor perspective. Humans have such a desire to live in perpetuity, be it through life extensions or reincarnations; an industry which tries to satisfy the human quest for immortality must succeed. That aside, I have always wondered whether an answer to the age old Indian epics lies in Biotech; as in is immortality or reincarnation simply a genetic legacy explained; did Rama truly live for an epoch through advanced medicine or is it simply living through passage of a genetic legacy (with death being the consequence of the maternal line being ultimately extinguished); or hybrid beings (mythological beings like Garuda) a genetic possibility. Ultimately science will provide energy alternatives; science will also provide new technology which shall usher in the next green revolution; so too it shall provide drugs which shall continue to increase longevity.
In terms of global demographics, India's population shall not plateau until 2050. In China, population growth remains on an uptrend through 2030, at which stage it is expected to plateau. In terms of comparison, the opportunities for growth now are unrivalled, perhaps the closest comparable being the rebuilding of Germany, Japan and much of Europe after World War II. This time round, the growth drivers shall be the building of the under-developed world generally and China and India in particular.
Fundamentally, the era of low inflation is over. China as the factory of the world served as a catalyst to usher in an era of low multi decade inflation levels. While the story of China remains untold, the inflation impact has been played out. This does not mean we now usher in an era of hyper inflation; but it does mean that the world needs to adjust to a higher long term inflation rate of 4% (which is really a simple mean reversion rate in a historic context) compared with targeted rates of 2%. In addition to sound business and demographic fundamentals, this expectation is in itself supportive to energy, commodities, health care and staples (agricultural commodities), which are historic beneficiaries during times of rising inflation. Of the four, energy & commodities carry the highest degree of cyclical risk - my view is that we are approaching a cyclical peak within a strong secular bull. Health care carries new drug development risk coupled with patent expiry & generic competition and for this reason while long term fundamentals remain sound, health care has not displayed the typical defensive characteristics as financial markets run past a cyclical peak; yet health care services remains a source of growth and opportunity. Staples remain my favorite; a traditionally defensive sector, with immense growth potential and a natural tendency to profit during periods of higher inflation. Within Staples, food as the fuel of humanity deserves most attention. While there is a degree of cyclical risk associated with fertilizers (agricultural chemicals such as nitrogen and potassium); alternative areas such as seeds, warehousing, food storage and distribution etc. remain solid; seeds remain my favorite - it is my belief that the marriage of biotechnology & agriculture shall produce the next denier of Malthus.
Health care in India has been neglected for many a year. India can expect the health care sector to grow by over $45 billion by 2012. During 2005, India health care was sized at $22.8 billion; the table below illustrates where India was in 2006 and where she strives to be in 2012.
The sector has grown at an annualized rate of over 16% over the recent past years and employs over 4 million people; by 2012, it is expected to grow from 5.2% of GDP to 7%. During this period public spending is expected to double from 0.9% of GDP to 2% of GDP. The public commitment to health care is apparent through policy actions which include; tax and service tax incentives, reduced import duties to 5% and significant increases in public spending; including a commitment to increase spending on health and family welfare by 22% to $3.7 billion. The government contribution to health care is 21% of the total; while this spend can be expected to grow it is the private health care space which can be expected to grow exponentially. Growing population, changing demographics, rising disposable income, urbanization and changed lifestyles together with insurance are the key growth drivers; the health care delivery systems is where the nation needs to build capacity; for without the capacity there can be no growth.
The demographics are indicative of an exploding Indian population through 2050. Today, we cannot meet the needs of the populace; despite an increase in facilities, it is expected that by 2012 India will need at least an additional 750,000 in-patient beds. The WHO recommends 3 beds per 1,000 people as a sensible ratio of in-patient beds; in India today we can provide at best 1.5 beds per 1,000. Today India has 229 medical colleges producing 25,000 Doctors per year, 136 medical schools enroll 6,000 post graduate trainees annually. There are an estimated 660,801 Doctors and 1,371,121 Nurses in India; but with an exploding population, India's needs for qualified medical professionals are immense; we need over a million additional nurses and an additional 500,000 doctors by 2012. Investment in nursing and medical schools is required; 106 of the 229 medical schools in India are private; integration of such educational institutions with major hospitals groups is one way to success. With the demographics expected, this area shall remain one of growth for many years to come.
Statistics tell a story; one of growth; consider this illustration of where India is and whence they must get to. Hospital infrastructure needs to almost triple for India to have facilities consistent with other mid income Countries.
| | India | Low Income (e.g. Sub Sahara) | Mid Income (China, Brazil) | High Income (US, Western Europe) |
Beds/000 | 1.5 | 1.5 | 4.3 | 7.4 |
Doctors/000 | 1.2 | 1.0 | 1.8 | 1.8 |
Nurses/000 | 0.9 | 1.6 | 1.9 | 7.5 |
Nationally, for hospitals, over the years 2005 to 2007, the government bodies and investment agencies shall invest $7 billion in the hospitals infrastructure; this is not enough; the requirement is for at least $25-30 billion and this leaves an $18-23 billion $ demand led opportunity in the hands of the private sector. In terms of consumer led demand, the private spend on health care delivery was at $20 billion in 2001; it is expected to growth to $50.2 billion by 2011 and to $78.6 billion by 2012. In terms of physical medical infrastructure development, the investment required goes from $7.8 billion in 2006, to $38.8 billion in 2009 and $78 billion in 2012.
In terms of vision of the un-contemplated consider this; China has a health care market size of $137 billion compared with India at $34 billion; this is illustrative of medium term growth potential as the population size is similar and in an economic context, we are in a similar time and place as China was a decade ago. Longer term, consider Germany; their health care market stands at $250 billion for a population which is a fraction of India's own population. Now open the horizons of your mind and consider the potential growth viewing the US market size as a guide; the health care market size in US is mind boggling at $2,100 billion; adjusted for population, in not so bizarre circumstances we could have a health care market size of $6,300 billion in India. A CAGR of 12% annually would bring India to this level by 2050; but of course facilities then available; would lie far short of those required, because the population will have lifted towards peak levels by 2050 (population growth of 2% annually would take us to 2.3 billion by 2050).
In addition to the capacity shortfall; new growth drivers are emerging. Population growth is an important driver of demand, but it is one of several factors coming into play. With increased prosperity, health care awareness is on the increase; this creates demand for preventative health care services; the percentage of working class people is expected to grow from 32% in 2006 to 36% in 2016. Urbanization and changing lifestyles are leading to lifestyle disease; heart disease and diabetes are on the up; this too creates opportunity. In 2006, cardiac, oncology and diabetes collectively accounted for 13% of the hospitalization cases. In terms of value, these three ailments accounted for 36% of the inpatient revenues. These ailments are estimated to account for 16.8% and 20.0% of the hospitalization cases in years 2011 and 2016, respectively. Increased longevity creates a larger standing army to care for and this creates specific demand in geriatrics; at the same time a growing populations grows the need for pediatric services. Rapid changes in technology are creating growth through changes bringing in new previously untreatable diseases into the market; this provides a wide variety of growth opportunities, particularly in oncology, neurology and pain management.
We have market size and margin drivers too. Over 90% of the private health care market ($14.8 billion, rising to $33.6 billion by 2012) is serviced by the unorganized service providers; organized players able to offer affordable quality health care have a major opportunity to increase market share at the expense of the unorganized provider. Healthcare in Urban India is cheap in a global context; the obvious jumps to mind "medical tourism"; what jumps to my mind is different – over time the price gap will close, which means the potential for margin growth in India over and above inflation is high. This table below illustrates the big price gap which provides a medical tourism opportunity today; and as the price gap narrows it paints a pretty picture for domestic India hospital margin growth potential.
$'s | US | UK | India |
Heart Surgery | 40,000 | 23,000 | 6,000 |
Bone Marrow Transplant | 250,000 | 150,000 | 26,000 |
Liver Transplant | 300,000 | 200,000 | 69,000 |
Knee Replacement | 20,000 | 12,000 | 6,000 |
Cosmetic Surgery | 20,000 | 10,000 | 2,000 |
Medical tourism is one of the most lucrative segments of the healthcare sector without doubt. Medical tourism is an area with major potential and this is expected to increase India's share of the global hospital services market quite radically; this market is expected to grow from $350 million per annum now to $1.6 billion in 2012; as must be expected, much of this revenue will be generated by up-market tertiary hospitals. The process has begun; in 2006-07, India was able to attract approximately 150,000 patients to the country, up from 10,000 patients about five years ago. With an annual growth rate of 30 percent, India is already inching closer to Singapore and Thailand, which are established medical care hubs that attract millions of medical tourists each year. Even the Ministry of Tourism recognizes the potential; the Medical Visa term has been extended to three years from 6 months.
Growth in medical insurance is increasing market size; revenue attributable to insurance or third party administrators has grown from 2% in 2001-02 to 16% in 2005-06; it is expected to increase a further 50% by 2011/2012; premium income is expected to be $3.8 billion by 2012. The insurance market size is expected to grow from $680 million in 2006 to near $4 billion by 2012; a growth rate nearing 35% per annum.
Additionally, we have growth from new detective innovations (CAT, MRI PET), new novel treatments (particularly ten therapeutic areas) and medical service delivery systems (polyclinics, super specialty hospitals). These are creating growth and major margin improvement opportunities.
Finally, we have growth from the next R&D cycle. The R&D cycle is typically eighteen years long; from discovery to patent expiry. While the cycle flows, important discoveries tend to cluster around certain dates. For the immediately prior R&D cycle, since 2005 we have seen patent expiry ratcheting up and accelerating and we expect it to continue through 2011; yet we expect the new stars from the next R&D cycle start emerging during 2010 to 2014. Human ingenuity will provide new novel treatments in several fields, be it via progress in biotech, stem cell or other areas of research. There are ten therapeutic areas into which much R&D capital has been deployed; developments will as always need a delivery mechanism; that is a hospital. These therapeutic areas are (a) Allergy & Respiratory, (b) Cardiovascular, Metabolic and Endocrine Diseases, (c) Gastrointestinal & Hepatology, (d) Genitourinary/Sexual Health, (e) Infectious Diseases, (f) Inflammation, (g) Neuroscience, (h) Oncology (i) Ophthalmology, and (j) Pain management - developments in these therapeutic areas will result in future growth opportunities; new treatments drive growth in the market size.