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AHEAD FOUNDATION ADVANCING HEALTH, EDUCATION AND DEVELOPMENT FOUNDATION

HEALTHCARE ISSUES AND OPPORTUNITIES AND WHY INDIA WILL PLAY A PIVITOL ROLE

9/15/200 8

AHEAD Foundation Healthcare Issues and Opportunities Paper www.AHEADfoundation.us

H E A L T H C A R E I S S U E S A N D O P P O R T U N I T I E S PA P E R


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Asia Health, Education And Development Foundation

AHEAD’s c harter provides the opportunity to pursue variety of projects and needs that come under its’ ser vice areas of Advancing Health, Education and Development. This paper introduces the history of AHEAD’s founding and how it led to opportunities it is pursuing in healthcare as it was envisioned at that time. The issues identified still set a context for decisions made today as AHEAD seeks fulfill it c harter.

Repor t Cover Photo:

Cover Photo Photographed by Donne Ashlock ~ 2009 The shortfall in quality infrastructure in India is not hard to notice. It symbolizes the many areas where both need and opportunity is represented in the underdeveloped and developing world. This is not so at the Bangaluru (Bangalore) International Airport (BIAL), a justified symbol of India’s pride and ability to step into the new world of able development, expansion and sustained economic growth. A modern and an architectural statement to where India is headed, the Bangalore airport symbolizes that India can build a future with new sustainable and to even world-class benchmark standards. It is an Indian can-do statement that applies to more then just transportation infrastructure but how it can leap over road traffic to air when doing catch-up. Healthcare included. This photograph seems to properly symbolize AHEAD’s vision to play a role in this new world for them. A vision that is more than an opportunity to do something good, more than a chance to create something sustainable and offer a new global player contributor to healthcare reform. It symbolizes an opportunities to partner in projects that can be a global standard in a land that has had less and in its aspirations to capture its future with excellence and can help raise the tide in a place that has more to do with our future then may at a glance seem possible.

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Eyes of India: His eyes that stare from his world at me, a “Westerner” who is comfortable in my air-conditioned luxury, symbolizes the reach the developing world makes for the developed West. In his world I have everything and he has nothing. Today he lifts his fingers to his lips in the universal language of hunger and his quest is food, soon it will be medicine, education and the Western tools to harvest his home-field advantage of raw free enterprise. While today his needs cause him to reach towards the West, soon, the West will be coming to him as it seeks tomorrow’s greatest global scarcity – educated, empowered youth. Don Ashlock Managing Director, AHEAD Foundation

AHEAD HEALTHCARE ISSUES AND OPPORTUNITIES PAPER AND WHY INDIA WILL PLAY A PIVITOL ROLE

PAPER SUMMARY This issues paper is at first glance about healthcare and opportunities in India specifically. Yet it is also about impacting global healthcare generally. The paper brings to the forefront some of AHEAD Foundation’s history, the issues that shaped the foundations charge as well as related significant strategic opportunities. Additionally it is the author’s personal invitation to the reader to action and involvement.

AHEAD has interests in each of the service arenas introduced in its name: Advancing Health, Education and Development Foundation, for which AHEAD is an acronym. AHEAD’s interests have been shaped by its founding commission to design a development plan and

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Asia Health, Education And Development Foundation

identify capital to build a healthcare system from the existing resource of 35 properties, 12 of which represent existing Adventist mission hospital operations, 11 in India and 1 in Nepal. They comprise property holding a combined estimated market value of 3 billion USD in wellpositioned markets and a pivotal equity resource in a development plan capital raise. As the equity contribution portion of a financing strategy they suggest a capitalization resource that could be as high as 15 billion dollars assuming a 1:5 leverage ratio. Other factors such as demand, ability and reach of operating partners suggest a healthcare development plan of this size is feasible. The AHEAD Foundation, founded in the US in 2008 as a companion institution to the Ashlock Educational Trust and it’s sister healthcare holding trusts began in the 1920’s when Franklyn Ashlock and his colleges began work in India. AHEAD first responded to a request to steward an initial donation of property for a new hospital in Patna, Bihar, India. Shortly this was followed by an invitation by the Seventh-day Adventist Church in Southern Asia to provide a North American based development office for the development of a Southern Asia Adventist healthcare system managing the trusts hospitals. This was to become AHEAD’s charter initiative that marked the foundations first focus. So commissioned, the AHEAD Foundation faced a formidable charge of creating a development plan and identifying funding for a healthcare and education systems in India incorporating allied health educational and clinical opportunities. This soon included alliances with seasoned and resourced US health care principles who contributed to a vision for a precedent setting in health reform modeling healthcare delivery system and a new world-class medical and dental schools. This was to lead to identifying 400 million USD in development funds1 for new infrastructure and the fulfillment of this vision. i

Western Health Reform But AHEAD believes it’s opportunity to make a difference expands beyond the initial commission that required an understand of health care issues in Southern Asia and how Southern Asia and the West might be productively linked to offer independent strengths for mutual benefit. Intriguingly Southern Asia health care is at the center of issues that will shape global healthcare reform. In fact it can be argued that the future of global health reform and current Western health care

1 All references for this paper, including added references for this comment, are found in the endnotes to this paper. Page 4

investments sustained value may be more effected, if not even dependant on, short-term investments and outcomes in India. This is true in part due to the single asset of India’s unique abundant resource of youth in an otherwise world dominated by an aging population.

“the future of existing healthcare investments in the West may be more dependant, than on any other factor, on the investments made over the next five to ten years in health education in India ”


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AHEAD does not face its vision alone. Today’s global marketplace offers a rich resource for partners in healthcare development initiatives in India. Existing healthcare stakeholders in many markets including the West are beginning to look at their future as critically linked to what happens to healthcare investments in India. India’s youth is a significant key to understanding the reasons why. Trained professionals, including technical, managerial and clinical talent will face critical shortages globally over the next two decades. India’s 600 million youth, 400 million aged 12-24, represents the only resource adequate to address this certain and growing shortfall of trained professional youth outside of India. Low birth rates mark practically all segments of the developed world, the West and the “global rest”. Though this shortage has been hidden in North American by a yet soon to retire baby boomer population bulge and slowed economy that has sustained worker presence in job positions, corporate, educational, humanitarian, and healthcare entities have significant motivation to seek the new silk-andspice routes of affiliate alliances to prepare for the future. Failure to timely build bridges now for involvement and investment in India as a resource for future trained global professionals will soon carry a very expensive price for delay. Partnerships in healthcare in India’s robust economy can offer an alternative to the effects of the global economy’s recent downturn and a professional shortfall soon to present itself as baby boomers retire, especially in the Healthcare sector. As a reward, return incentives include both a humanitarian and social as well as strong financial return-on-investment or “ROI”. Investing in India serves the self-interests of preserving existing investments in healthcare delivery systems in the global rest and West. For the student of global trends, it is not a secret how dependant existing healthcare investments will be on what happens in India over the next few years. Hints are more then just on the horizon. With 34 percent of existing medical staff at US hospitals, and 80 percent of cardiologists in the US of Indian origin today, even before the retiring of the baby boomers form the market a picture of the future is already visible. In India are where the youth that will be tomorrow’s workforce and leadership who will shape healthcare reform for the developed world. In their education and training is where existing healthcare investors will find the key to if their investments will suffer or thrive. Physician training will dictate much of the factors of sciences bench-to-bedside translation success that the

West has so heavily invested in over recent decades. Time for the India youth of today will not pause while we discover that today’s aging and traditional educational practices are not scalable enough to respond. We have been built our education models on key infrastructure dependencies that have too slow of a development life cycle to respond in time. Prepared to assimilate new technology and their destiny India youth each day get a day older and will demand their right to embrace their future and respond to the alluring western wage offers a sudden vacuum today’s baby boomers will create with their retirement. AHEAD Foundation was formed and originally tasked with coordinating strategic alliances between India and Western partners to design and implement a development plan for 35 selected healthcare properties. “Cutting ribbons on 35 new and rebuilt world-class technologically advanced medical centers responding to new educational paradigms as a global clinical resource for medical and allied health education would be the immediate successful fulfillment of our this project

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mission” says AHEAD founder Don Ashlock. “But, he continues, “this is only our apparent opportunity. Yes, these ‘clinical training labs’ will serve to help relieve the infrastructure constraint facing India’s healthcare training environments that can train India’s abundant resource of youth to respond to Western and Global needs. Even as grand in scale as our mission may seem, it will be generally too little too late. New innovations in the function of educational institutions will force abandonment of current education methods. The role of technology in education and health care delivery, informatics, will reshape our current way of doing things dramatically. The how we do education that drives our education accreditation will be less relevant then the verification of its comparative efficacy to non institutional dependant learning” ii AHEAD Foundation is seeking partners and thought leaders who desire to look into the future and harness a dramatically different world due to current global realities of an otherwise graying world population that intersect the opportunities for India’s abundant resource of youth. Significant humanitarian and financial returns entice investment. This is a task that is grand enough in scope that it must find a call to action amongst those of influence and commitment, starting with any one of us, one person at a time, wanting to make a difference. It will soon be apparent that the biggest impact of action now, will not be primarily felt in India.

value proposition. Development of MediCities to resolve this dramatic short fall are currently under way representing medical metro-plexus upwards in size from the 3,000 plus bedded hospital under development today in Delhi that will be the worlds largest hospital, to visions even as large as the 50,000-bed MediCitiy being proposed in state of Bihar. If today’s

Six Asia health care issues, expanded on in the body of this paper following this summary, will shape the opportunities:

1. Southern Asia’s Healthcare Shortfall India is responding to a new paradigm and scale of healthcare solutions that is unprecedented. There is a staggering gap of need over current resources in India of over two million new hospital beds between what India’s population and economic growth can support and what they currently have. iii Technologically advanced and complex multi-specialty medical teaching facilities have been targeted as India’s best healthcare Page 6

impressive list of projects in the planning were to materialize, they would still fall significantly short of meeting however India’s current economy’s


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appetite and this is before addressing projections of the growth in how India will server global needs through medical tourism. A major effort to close this gap in ten years would be formidable, even with the support of an Indian robust economy growth rate whose impact will also only exacerbate the problem by doubling the demand in less then 10 years leaving the gap just as wide again. So expectations are that India will see aggressive growth of infrastructure and still require yet a whole new family of healthcare and technology solutions that will have to be infrastructure independent sure to change the paradigms of healthcare and education. New methods of delivery and conclusions of how many hospital beds are required per thousand populations to deliver quality healthcare will be required.

2. The Global Link India’s domestic needs, however, are only a small part of the picture for health and education development opportunities and demand that will impact India. The near future of global healthcare workforce needs has become fatefully dependent on India. The need for trained healthcare professionals, in the ‘graying’ (i.e., aging) West and ‘global rest’, is critically dependent on India’s youth. In the greater global community, which has a growing elderly population who will make 90 percent of their healthcare expenditures in their last ten years of life, an unprecedented expenditure for health care and workforce requirements are ahead. The needed youth base to train and provide such care is absent outside of India. How India youth are trained will dramatically change and affect global healthcare practices, science bench-to-bedside and technology integration into healthcare delivery system will define health care reform. Many who believe that healthcare, as we know it today, is up for dramatic reform, also believe that systemic change will likely happen most through how the next generation of professionals are trained to deliver care. What will be their relationship to technology, informatics, physician extension workers and technology, telemedicine and team collaboration? India resource

of youth is more then a matter of their numbers but includes attitudes towards the West, cultural integration, technology, science training and attitude towards change generally including the physician’s embrace of new corporate governed health care delivery players.

3. Human Resource Transfer Industry

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Since India will continue to be the only resource whose youth population is of adequate scale to matter and which fortunately culturally prepared to respond, it will provide the trained healthcare professionals of tomorrow to meet the rest of the world’s needs. This is true weather they need is brought to them through technology or they are brought to the need world. Educating that will proceed transferring this abundant resource of India’s youth is estimated to represent a global redistribution of wealth that rivals the wealth shift in the industrial generation from Briton to the US or from the West to the Arabian Peninsula for its 1 trillion USD annual supply of oil. With geographic wage spread as high as a 40:1 ratio, the enticement of the Western wage scale is dramatic. What the West will pay to meet its needs for skilled youth will significantly impact India’s economy. Training to meet this transfer is opportunity ridden in a nation that currently has one of the world’s more sorely unprepared and underdeveloped educational systems.

4. Faith-Based Resources Faith-based and humanitarian organizations hold goodwill, property and a representative presence in governance bodies through their long-lived investment in Indian youth through education service. It is a goodwill that will be needed for a short or near-term response to this growing need for an India-based global healthcare development strategy. AHEAD Foundation’s history with Adventists run schools and hospitals alone, hold property holdings that exceed 3 billion U.S. dollars (USD). These include existing medical and educational operational land use entitlements to support needed aggressive development benchmarks. This illustrates how faith based resources can be significant resource that can help underwrite our intertwined futures. However faith-based and humanitarian organizations do not typically posses the capital resources or developments know how to

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respond on their own. 5.

Stronger Investment Return Incentives

Infrastructure neglect from funding dependant on limited foreign contributions by both church and state have left most faith based medical facilities in India in substandard condition and many have fallen into dire conditions leading to loss of the financial viability to retain trained workforce and are without the capital required to keep them technologically supported. Poor conditions can be quickly changed with good infrastructure investment strategies and the compensation required to retain indigenous leadership. A single seven-million USD capital investment in a failing hospital at the Surat Adventist hospital reported a first-year return on investment of over 30 percent and an 18-million USD operating return by its fifth year. Thus demonstrating the unusually profitable opportunity that investing in India healthcare and allied education upgrades have to offer.


AHEAD FOUNDATION Advancing Health, Education And Development Foundation

6. AHEAD Foundation’s Strategies The healthcare and education development strategic opportunities include: • Retrofitting five hospitals, at a price of 15- to 50-million USD each, with a target of high and immediate economic return.

Adopting out the five additional mission hospitals that will perhaps be better served by a more mission-minded motivation than by a for-profit focus to stronger Western or in country partners. Undertaking plans for not yet developed properties suitable for new small to medium-sized medical and educational facilities in Bangalore, Puna and Manipur in the 30-150 million USD range.

• Establish the capital and implementation plan for two high-value Medi-City sites, which would range from 500million USD to in excess of a billion USD in development costs. Per location. •

are powerful. It is an exciting time to be intentional about sharing in the creation of our future. ~ End of Summary ~

The pages that follow this summary give additional content and understanding to each of these six issues that help define and give wind to AHEAD’s opportunities in the Southern Asia healthcare sector.

Establish and dramatically expand the size and scope of Adventist and other existing healthcare, medical, dental, nursing and technical education resources including a world class new standard in technology integrated delivery models.

AHEAD Foundation seeks the partners needed to respond appropriately to the tasks with which it has been entrusted. Significant financial resource partners have stepped forward to underwrite several medical campuses yet AHEAD’s development and leadership ability to respond remains a limiting factor for these protects success. The scope of opportunity creates a continued call for those drawn to make a difference. Whether, as a potential partner, you are driven more by the profit potential of investing and collaborating, by the prospects of the humanitarian return or the implications on global health from investing today in the incubator of tomorrow’s health professionals the invitation calls. If you seek rewards of legacy proportion for an investment of time or resources, AHEAD faces opportunities that can fill the bill. The financial and social return incentives to underwrite the right alliances

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AHEAD FOUNDATION

Asia Health, Education And Development Foundation

Asia Health, Educatio n and Develop ment Issues & Opportun ities Paper Founded in 2008 by an initiative of the Adventist Southern Asia Division to provide a North Americanbased development office for the Adventist Health System in India, the AHEAD Foundation (originally an acronym for Asia Health, Education and Development) faced a formidable charge. There are resourced potential partners in corporate, educational, capital and finance, humanitarian, management Page 10

and healthcare sectors who want to make a difference and are gaining a growing interest in the new silk-and-spice routes of affiliate alliances. Some alliance partners are motivated in part by seeing development in India as a patch to the Western economy’s downturn or a forward thinking solution to medical roadblocks the West faces in getting what science and technology advances tell us to clinical application at bedside. However to capitalize on these resources the India based Ashlock Educational Trust board, whom manage eleven existing hospitals, one in Nepal and a number new potential healthcare development sites and over a hundred schools, sought assistance. As a result, AHEAD Foundation was founded with a goal to identify and coordinate strategic alliances between India and Western partners to create and implement a development plan for an expanded healthcare system vision of 35 hospitals. A vision that has since grown to be valued more for its potential as This Medi-City, with its H-shaped patient towers, exemplifies the scale of healthcare infrastructure development underway in Asia. This planned development represents an effort to not only set new precedents in size but also to leap forward into worldclass and cutting–edge technologically advanced care. This shift responds to needs created by a paradigm different from the past mission clinic vision of addressing Indian healthcare needs.

an emulation health reform model opportunity as much as a health care service opportunity to Southern Asia. The future of healthcare investments in the West may be more, than any other single factor dependant on the investments made by the West over the next five to ten years in health education in India. Unlike the West hospitals in Southern Asia are more critically and economically training facilities for the future of the global healthcare work force then they are facilities of care. These ‘training labs’ will serve as a critically needed clinical healthcare


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educational system that will professionally develop India’s abundant resource of youth to respond to Western and Global healthcare workforce needs more then their own. In a coming new world, that will be seen by today’s youth, India and neighboring

China combined will represent two-thirds of global corporate revenue with India holding the primary share, and today’s solution investments in Asia will become a foundation for the shape of how we will experience tomorrow’s global healthcare. AHEAD Foundation seeks those who want to positively leverage the changes ahead, which we can now see on the horizon through transition today, with an eye to the double bottom line of significant humanitarian as well as financial investment returns.

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Asia Health, Education And Development Foundation

Background On a multi-day train ride from Calcutta to Delhi, AHEAD Foundation founder and American entrepreneur and educator, Don Ashlock, felt a compelling conviction driven by the mental scenes of his previous weeks in India. He felt pulled by the humanitarian need, the call to get involved personally as a desire not to drop the opportunity to make a third generation link of a family heritage of investments in India. The scale of opportunity on the spice continent that has drawn adventurers and held the intrigue of the West for centuries is flanked by an optimistic atmosphere of expectation and opportunity that can not be missed.

Preceded by his parents and his grandparents, who 81 years earlier traded the hills of Tennessee for the hill country of Assam in NE India as their home to dedicate their lives to make-a-difference work, Don Ashlock retraced their journey on this Asian continent from east to west and north to south. Schools, clinics and hospitals now dot the map where his parents and grandparents once served in a land where, from afar, expeditions and armies once plundered and England sought with some success to transplant the British version of western civilization in its era of colonial expansion, which today represents society foundations that India and North America share in common. However, it was a different world on a train ride in 2008 than it was just one and two generations prior, when Mahatma Gandhi conferred with his grandfather and Jawahar Lal Nehru met with his father as they sorted out and shaped a new post-colonial independent India. At that time, the rise of denominationalism in American religious scene and interests in India as a mission field offered the strength of consolidated resources from the affluent Western churches to a country where a education system remained out of reach for much of the population. Today youth of India, as a result, still often seek mission schools as their best education option as a ticket to step up out of poverty and to access the Western wage scale. In contrast to that time, the Western economy and denominationalism faces an era marked by reduced investment strength. The signs of India’s great needs still hold a residual presence, but they now share the landscape with one of the worlds fastest growing economies. A market that represents one of the purest statements of democracy and with an unprecedented global share of energetic, optimistic and educated youth. Ccanes that would once seem more at home in Dubai, cell phone towers, coal trucks, motorcycles, modern luxury cars now however share the landscape with rice fields and produce carts drawn by elephants, camels, water buffalo or low-gear bicycles. Of a certainty, more now then ever, India is a land of contrasts. AHEAD founder, Don Ashlock found himself asking in what format could he make his 3rd generation family contribution. Seeing the fruit from the seed planted by his parents and grandparents 50 and 80 some years previous represented for him a powerful call. Page 12


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Need is still apparent in this bustling land of a billion people. This is abundantly transparent even though they are now being sized by the global market as much for their potential consumer strength as for their great needs. Historically characterized as the world of only the rich and the poor, and mostly the masses of poor, India offers the polarity pull of both the humanitarian need and economic opportunity. Yet now, in this optimistic and arguably the fastest growing free economy in the world, where a middle consumer class, matched with an upper middle and wealthy class, combine to make a formable block with purchasing power that represents a significant population segment that has reached over 360 million. The emerging India’s abundant resource of youth are typified by these youth at the Adventist middle class sustains an Surat Metas Hospital school grounds housing educational programs for 6000 aggressive growth in students who attend school at the hospital campus education programs where healthcare and education agenda are linked in a single investment in a venture to consumer demand that do its part to resource a share of the global growing demand for a healthcare stretches an aggressively workforce. Its success typifies the opportunity and invites cloning. developing supply chain. Retracing the footsteps of his heritage and visiting the hospitals, schools and service organizations planted one and two generations earlier, left Mr. Ashlock with a desire to not be the broken link as the next generation a family heritage chain of contribution. From this desire and the successive events that lead to a gift of land, a commission to address the Adventist healthcare and allied education development needs as well as confirmation of support from resourced Western healthcare developers, AHEAD became the opportunity to push into yet another generation of investment in India.

1. The Scale of India Healthcare India is responding to a new paradigm and scale of healthcare that is unprecedented. There are two factors underlying this shift:

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1. They recognize their free market will demand a catch up in healthcare resources to the other developing countries, both in updating existing infrastructure and in responding to their overwhelming shortfall in the number of hospital beds needed. There is a staggering gap of over two million new hospital beds between what India’s economy can support and what they currently have. 2. There is a predominant philosophy that the quality of healthcare offered increases with the size and scale of treatment hospitals and the proportional increased availability of technological advancements at complex multi-specialty medical teaching facilities.iv

With this in mind, major corporate hospital groups in India and the West are making significant investments in setting up state-of-the-art ‘health cities’, called Medi-Cities, in major locations in India. Approximately 15 to 20 new Medi-Cities will commence operations or be well under construction by 2012 according to the Health Report done by Earnest & Young (access this study by web link below). The scale of such cities defies the Western model of thinking when it comes to healthcare infrastructure and development. Medi-Cities range from 2,500 to 5,000 beds, often ten times the size of their Western counterparts. The new Bengal Medi-City currently under development pushes this scale envelope even further with a vision of a 50,000-bed Medi-City. The Ranchi Hospital built in 1948 by AHEAD Foundation Advisory Board Member Dr. Robert Shearer yields only a small graduating class from its nursing school each year but represents a historical investment in allied health education by early Adventist

The magnitude of this undertaking is even greater, considering the absence of utility and community support infrastructure taken for granted here in the West which must become an additional integral part of any development project. Transportation, entertainment, residential neighborhoods and supporting retain and merchant communities are all elements that make a healthcare project of this size similar to constructing an entire Western city. Technopack, a medical research resource sees Medial Malls as a piece of the growing effort to drive new solutions to close the gap of need and availability for healthcare. v

2. Youth The Global Link As large an undertaking as MediIndia’s growing upper middle class and wealthy constituency, who demand City plans are, the corresponding Western or higher medical care standards, represent a population base larger Page 14

then the total U.S. population. Given that, the gaps in available doctors, nurses and beds graphed here is staggering. The magnitude of healthcare professionals required just to address India’s own needs are only compounded by the trend that 4 out of 5 healthcare professionals educated in India leave to serve the West. This number is likely to increase even more with stronger economic incentives for them to leave India as the global ‘graying’ challenges increase.


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need for trained healthcare professionals to serve such new installations in India in the future is even greater. That need, however, is topped still further by the significant and growing need for trained healthcare professionals in the West and the global ‘rest’. It is here that a critical link between India and the West emerges in the greater developmental challenge of healthcare education. The demand to operate the dramatic expansion of more than two million new beds coming to India’s healthcare facilities is eclipsed by a further escalation of the needs of the West and ‘rest’ of the globe to fulfill their medical human resource gap. The shortfall in healthcare professionals represents a critical mega-trend that will greatly define the global landscape for both the near and far future. The writing is already on the wall; doctors from India now represent one-third of the medical staff in U.S. hospitals today.

Due to the ‘graying of the planet’ (‘graying’ refers to the majority of population reaching the end of its life span), the world as we know it will shift. China, a major population center, is ‘graying’ because of its largely successful one-child policy. Japan is ‘graying’, with the average family having 1.1 children due to social expectations. Europe has also followed suit with a low number of children per household. The U.S. is ‘graying’ as the ‘baby boomers’ come of age without having reproduced their numbers in offspring, similar to Japan. The drop in U.S. population growth due to family size has been masked by a large increase in the immigration population, which is mostly Spanish speaking and who’s youth are not proportionally entering the professionally trained population segment. The significance of this influx to this discussion is that the immigrant population has largely swelled the pool of laborers as opposed to professionals, where there will be a growing shortfall of unprecedented proportions in the next 20 years. On a ‘graying’ planet, after all, there are no youth to train before you open the discussion of what carrier paths they are electing to pursue.

Global ‘graying’ will mark three major shifts that will work together to compound global challenges and opportunities and compel the critical Asian-American link.

1. A huge exiting of the professional work force is a natural product of ‘graying’, as baby boomers retire. Adventist today offer allied healthcare education today at their hospitals such as nursing training at this Adventist hospital and nursing school and college in Nezvid. This is a platform of existing operating entitlements and property that offer Adventist Health Page 15 Systems an asset resource for planning a significant education solution undertaking and plan.


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2. ‘Graying’ creates a healthcare demand growth bubble. With 90 percent of healthcare costs spent in the last ten years of life, this major population segment will create a massive growth in healthcare needs and primarily from those who will make demands on the available system by those with the capital resources to pay for it -- the U.S. and the West. 3. As the “graying” population leaves the work force, an unprecedented vacuum is created in the absence of replacement resources in the face of a “youth-less” West or the global “rest”. There are simply too few youth to be trained as replacement professionals.

While the rest of the world does not have the youth to train, India does. With India’s abundance of over 600 million youth under age 25, the future of India and the West are as dramatically linked as the Arabian Peninsula has been to the West due to the oil needs of the past decades. India’s young people filtered through a highly competitive education system have a ravenous appetite for education, including those building-block disciplines important to healthcare, like math and the sciences that have fallen too out of vogue among Western youth and their education institutions. India’s youth are multi-cultured, English speaking and raised in a society with a social and legal system that is as heavy with British heritage and influence as that in the West. Pro-Western attitudes amongst India’s youth are at 72 percent, unmatched anywhere else in the world, including the US.

So the West and the ‘rest’ of the globe will If you are reading this in MSWord Select this Picture to Link to India’s depend on, and compete for, India’s youth to Landmark 2007 Healthcare Development Report by Ernst & Young meet their demands. At the same time, India will have the fruits of an unprecedented continuous run of economic growth, feeding on its own internal demand to keep its educated youth at home. The future of the West, especially global healthcare, is hinged significantly on its investments in the future of healthcare professional education

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in India and South Asia. As an additional enticement to invest in this reality, healthcare education is growing into a lucrative industry. The West and the ‘rest’, including China’s emergence as the globe’s greatest consumer market, will have both the will and the money to demand the healthcare they require. India will be able to respond. Such will be the make-up of a long-lasting critical dependency between the West, the ‘rest’ and India.

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India’s youth eagerly embrace the education that is their ticket to accessing the West’s wage scales.

3. Human Resource Transfer Industry Since India is, and will continue to be, the only resource whose youth population is of adequate scale to matter and which is contextually and culturally prepared to respond, it will provide the trained healthcare professionals of tomorrow to meet the rest of the world’s needs. A new industry is being born to facilitate this transfer and is worthy of consideration.

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The industry that captures this human resource of professionally trained youth and transfers it from the spice continent to the West and “rest” represents an unparalleled economic shift. The costs of this new human resource transfer industry are only poorly foreshadowed by the technology and call center industry that emerged late in the last century. This industry’s potential impact on the U.S. can be illustrated by comparison. While China has become the global leader in manufacturing, India has become its counterpart in service industries. Yet while “made in China” has had its impact, manufacturing represents only 11 percent of Consider that there will soon be 600 million young the U.S. economy, with small exported profit adults raised, if even in a hut, with a satellite dish margins. The service industry, on the other to foster a jealous appetite for the life of the West. hand, represents 66 percent, with wide Should only a third seek the West’s world of margins. While China has figured out how to comparative abundance introduced by slice off a small piece of the profit pie in Hollywood, the economy of manufacturing transactions, India has figured transferring that talent to the West is out how to take the lion’s share in the service staggering. With wage increases as high industry. Being first to the table in serviceas a 40:1 ratio, the enticement of the industry play, India has put itself in the Western wage scale is high.vi How position of also brokering the supply of its motivated would you be to get a job that neighboring competitive service providers – would pay you in a year what your life the youth of other South Asian and times earnings at your current job pays developing countries. Whether it is exporting for the same skill set? A little math shows the service across the Atlantic or Pacific or bringing the youth to North America for The success of the Surat Adventist Hospital renovation project demonstrates that required hands-on services, as is the case pulling together the capital for infrastructure upgrades and right operational with much of healthcare, the real supply partners for a hospital can be significant as the Metas hospital (here pictured) demonstrated with a five year yield following renovation of 18-million USD in source on a scale that can matter is in surplus operating funds. India. And matter it will. that current revenue gained from bringing in healthcare professionals on a small scale today will Page 19


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create a continental transfer of wealth that rivals the wealth shift from the West to the Arabian Peninsula seen currently to supply oil at 1 Trillion dollars plus a year. Such a shift will not only bring wealth to those who facilitate or broker the transfer but will impact the lifestyle options for India’s populace by rewarding those who provide these services either abroad or to the West from home thanks to brain trust portability through technology.

Economists are already speculating on the large potential slice of the world’s consumer demand that India will represent. India, as the significant beneficiary of this transfer of wealth will have new dollars to underwrite their desire to leapfrog their current shortfall in healthcare, both in technology and in capacity. Add up all the support industries, the expatriate tendency to support causes back home, and the unprecedented new appetite of the rest of the globe for healthcare, and you arrive at a potential transfer industry of over a trillion U.S. dollars a year, paid for by the West, which will forever change the spice continent .

4. Education and Healthcare Faith-based organizations have played a significant role in India’s past development, in

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both healthcare and education. With a collapsed education system, Indian youth have found both the education they need and a link to understanding and speaking in Western English through Christian mission and private education. Christian faith is on the rise in India and feeds a growing faithbased education system. This growth, however, has primarily been in lower education, and the need for higher education is huge.

If a faith-based ministry or for-profit private enterprise chose to take on just a 2.5 percent share of the professional medical training required to meet India’s own needs, there would need to be a medical campus capable of handling 28,000 medical students, with projections as high as four out of five graduates l headed to the West. The demand for nurses and other allied health professionals would easily add up to an additional number of eight to ten times this size. Choosing to take on this responsibility will be both socially responsible and a wise investment to protect Western health holdings and a politically stable future globally.

We are not used to thinking in terms of our future being dependent on, or even substantially shaped


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by, our mission holdings or foreign investments. Today, faith-based ministries do not have a constituency stepping forward to grapple with the role, scale, need, imperative or opportunity of such proportions. Fortunately, Wall Street, vendors, educational thought leaders, politicians and others in the West and globally is becoming aware and is available to form alliances that can help us catch up. While churches are currently thinking about how to remodel 50- to 100bed mission clinics in a soft economy while facing a dwindling donor base, others are protecting their future by laying plans with India. The future is in the forming of 5,000+bed hospitals, larger schools and greater technology leading to Medi-Cities which require a frame of reference to which the West is not accustomed.

Those who invest in global educational infrastructure today have a channel to the mind of the youth and are winning hearts and minds one youth at a time. It is worth asking however, who is it that is and will be investing in establishing this valuable channel. Will it be those who foster an ideological risk that fosters a disenfranchised youth to purchase a machine gun headed for a training camp or promotes a worldview of civil participation. In today’s world, it is with high stake consequences whom it is that will invest in the education infrastructure that will prepare the next generation, those on whom the West will depend, not only for healthcare, but also for its leadership.

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Asia Health, Education And Development Foundation

4. The Private and Faith-Based Role While Christianity is still a small minority in India; mission healthcare investments there have generated something of value to current efforts. The AHEAD Foundation has been asked to undertake development for 11 existing Christian mission hospitals and 5 future sites. Having already invested 75 to 100 years throughout India serving humanitarian needs and teaching yesterday’s youth who are now Indian thought leaders in its schools, the trusts, private, church and mission organizations who established these facilities has an established presence, with both hard assets -- including real estate, operating hospitals, and indigenous leadership -- and soft equity with local governments and community good will. This will be beneficial when land is needed and when development tasks that need national and local community support are addressed. The Ashlock Educational Trust and sister health care trusts operate schools and hospitals on land that is debt free and represents over a billion US dollars in current market value as land acquired in a pre colonial error on urban outskirts now represent prime congested city real estate. Wall Street, corporate and development investors realize this and are seeking church leadership with whom to partner. Rarely has the once humble mission based organization been in a position with such leverage, engendering both economic opportunity and

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responsibility.

Christianity’s growth of good will has been strong, including the large growing constituency of youth seeking education who have generations of looking to mission schools for a way out, and there has been worldwide church support for development of lower education mission schools in small communities all over India. The U.S. dollar goes far in rural third-world education. Yet, even with this support tuition pricing for Christian k-12 education, higher education has made access to healthcare professional training beyond the reach of the students leaving these lowereducation classrooms. As a result, higher education opportunities are filled by the affluent Hindu and Islamic communities, creating a religious filter affecting the healthcare professions and as this paper makes a strong case for will impact with both Indian and global leadership consequences for the future (a “cultural filtering effect”). In Western terms, however, the per-student Indian tuition price tag is very inexpensive, and that is where services will be delivered. Healthcare employers in the West are already paying two to four times the price of a health education in India to headhunters, just to recruit nursing and other specialized staff then it would take to cover the training bill in India. It is not then whether the West will pay, but when we will pay -- before or after they are trained -- and this the above introduced “cultural filtering effect” will have huge consequences for the global rest.

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Asia Health, Education And Development Foundation

6. North America’s Role Leadership that is focused on the demands on greater mission objectives has neither the resources nor the will to budget for the development and planning for their existing assets in healthcare. They believe the West can help and has the will and motive to do so. Meanwhile, the healthcare industry in the global ‘rest’ is creating links with India to resolve their own growing gap in human resources. North America has the capital, industry/business leadership skills, mission-/humanitarianmindedness, and both financial and human resource need-based incentives to get involved with the development of healthcare in India. It may now be time for

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independent, congregational and nondenominational church communities, as well as private, for-profit, non-religious organizations and the social-minded, to take the torch so gallantly carried by Western denominational faith-based organizations in the past and carry it forward into a new world dependent on Asia’s resources.

Need has historically been the compelling draw for Christian mission healthcare, and the current need only increases this pull. However, neglect and economic crisis have caused the medical facilities in India to fall into dire disrepair, due to poor management and the capital costs required to stay up to date. Patients check in for life-saving care at old mission medical facilities that do not have the personnel, equipment, or conditions to provide appropriate care for loved ones with whose lives they have been entrusted. Facilities in need of primary infrastructure, which have suffered financially and repeatedly failed to meet payroll obligations, are left with only residual staff unqualified for the tasks of care required. Communities have shown up in mob force to express their anger and feelings of betrayed trust when a community member’s life has been lost. The time to remedy this situation is now, to protect the goodwill and equity created over decades by generations who gave their lives in selfless service.


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AHEAD’S OPPORTUNITIES AND PAPER CONCLUSIONS STEPPING FORWARD The issues that surround AHEAD Foundation’s charge of healthcare development in Southern Asia have large implications for healthcare in the “rest” of the world outside Southern Asia and no less significantly for the West. The issues and the opportunities they suggest have been discussed in this paper in the context of a request, first extended to one person to participate that lead to the development of AHEAD as an organization. While for AHEAD’s fonder the invitation was personal, a call with two generations of pull, it has the ability to be a call for a wider audience. It was a request from trusties who were reaching outward for development capital and assistance in drafting a plan as they realized stewarding the future of the schools and hospitals they managed was large enough to welcome help. But their need triggers recognition that they also sit in the crossroads of a fate that reaches beyond their world to ours. The more pressing need was the future of the operating hospitals, the undeveloped properties and a need for a healthcare system vision. But as this paper seeks to unfold their requests sits in a bigger context of global trends in healthcare and in its future workforce. This includes the significance of what role the West and the rest will take in addressing this workforce training options and makes this a discussion about healthcare one about healthcare workforce training that will effect a world watching healthcare reform form a front seat. It may be argued that each reader of this paper and those whom they may love may significantly touched by how this global drama plays out. For health is not an optional arena of life. The scope of where and how AHEAD will be able to make a difference will be shaped by those who choose to participate. ___________________________________________________

Investment Incentives & Resource Depletion

The recent transformation of one of the twelve AHEAD Foundation charter related hospitals acts as a powerful model for enticing alliance and finance partners. The transformation at the Surat Walkart Adventist Hospital has demonstrated that poor conditions can be quickly changed with capital investments and that the indigenous leadership is capable of the task. A sevenmillion U.S. dollar (USD) capital investment in a failing hospital in

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Surat, the Indian West coast diamond-processing capital, yielded a first-year surplus operation revenue return on investment of over 30 percent, with 18-million USD in surplus operating revenue by its fifth year. As a Christian Faith based branded hospital even operating in a strongly alternate faith fundamental and characterized antiChristian community, the mission and goodwill returns have been equally high. Dedicated mission-minded management professionals have built laudable reputations and relationships, creating a community standard and beacon both in education and modern world-class healthcare at what is now the best facility serving the surrounding metro community of 12 million. Throughout India, there are fewer barriers to developing land currently occupied by existing mission hospitals where possession goes back to colonial error title transfers when more current challenges were not yet

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prevalent that threaten the security of investments in land. Creating and securing investment for new institutions from scratch, which requires local and national government support and licensing face a higher threshold for patience investment returns. In today’s global investment atmosphere shorter distances to return is a significant advantage. Early conclusions seem worth note. Southern Asia Adventist Health Systems, who have turned to AHEAD Foundation for help, alone, possess development land that has a cumulative value of over 3 billion USD. This includes five operations that are targeted as high-return investment opportunities and two sites that would be ideal locations for health cities. Land assets can make up the critical owner-equity contribution required to access Western capital resources and can be very scarce in the major population centers that are ideal to new parties seeking to benefit from the healthcare and health-education ‘gold rush’ in India. These assets, however, cannot be taken for granted. Development delays for such properties create a risk of encroachment by local governments and communities. Intrusion demonstrated by losses at the Lang Memorial Academy site in Bangalore, where 80 city-hemmed acres sit like a Central Park of undeveloped land amongst a growing cityscape. The government has taken 30 of the 80 acres, each one precious in a Medi-Cityscale development, for a freeway onramp to tie a new modern airport to India’s own growing Silicon Valley via a new suspended highway. Local squatters have taken an additional six acres. Failure to develop land in India is perceived as a social responsibility failure if not a social or moral crime against society and the justification for adverse judicial decisions against landowner rights. The value of this land, based on an recent offer of 11 million USD an acre, represents a loss of 330-million and 66million USD respectively - a costly reminder for failure to act that, if land assets are not developed in a timely manner, the land will be lost. Offering a church constituency a well-thought-out plan for valuable church property is not an easy undertaking.


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However, it is a critical venture that cannot be delayed without costs.

AHEAD F O U N DAT I O N ’ S NEEDS AHEAD has taken on the challenge of identifying finance and alliance partners for the development design of a planned future for the Southern Asia’s Adventist healthcare and healthcare education ministries. This gives AHEAD Foundation a chartered role holding significant implications and opportunities. The Southern Asia Division of the SeventhDay Adventist Church has immediate underwriting needs both for the development of the existing 12 operating hospitals and sites selected for future healthcare campuses. The list of development tasks identified include: • Healthcare Infrastructure location selection: Identifying and properly matching available technical and financial

resources offered for infrastructure development with the priority hospitals and projects needing new infrastructure. •

Healthcare Workforce:

Developing a solution for a professional workforce that can properly steward the projects that are being planned, including the establishment of an India based medical and dental school as well as greatly expand existing nursing and technical schools. • Develop AHEAD’s Support Capacity: Identifying and resourcing the AHEAD healthcare development staff. AHEAD’s commission is not a small undertaking and will require a dynamic professional team.

• AHEAD Funding: AHEAD needs to identify those who share its vision and who can bring resources to underwrite the development opportunities AHEAD faces. It will require team players and resources. Currently it depends on a few resource projects and investments who’s earnings, along with founding member contributions, address AHEAD’s current operational needs. But the charter it has been entrusted have made it a steward of opportunities and a future for 12 hospitals that response will require more then it currently can respond to. In order to address responsibly the healthcare initiatives that this paper calls for, AHEAD will need to identify additional skill sets, funds as well as attract partners of resource. The opportunity, responsibilities and issues deserves proportional response.

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Asia Health, Education And Development Foundation

AHEAD needs people of vision willing to invest a combination of their talent, time and treasure for a cause that will have such a significance global impact.

Invitation AHEAD Foundation seeks alliances to underwrite and augment its development tasks in order to respond appropriately to the charge with which it has been entrusted. A state of the art, world-class healthcare system that could immerge from the current Adventist run hospitals and education operations in Southern Asia is potentially of a scope and scale to exceed collectively 35 -40 properties and a 15 Billion dollar investment. The assets on hand and double bottom line of both global impact and economic return create a compelling draw to match the capital required. Such an undertaking will require and create significant make-adifference and business development opportunities. Page 28

There is plenty of motivation to pass around. Healthcare development will likely be driven more by factors in the field of educational and professional healthcare workforce training requirements, needed to address a growing global shortfall in healthcare resources, then in the laudable task of healthcare services for the communities they will serve. The number of international, private and public investors with interests in both the healthcare sector and the India market are significant. AHEAD seeks affiliation with those drawn by this task.


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Addressing the development gap will require professional attention. Whether you, or potential sponsors and affiliates are driven more by the profit potential of investing and collaborating or by the prospect of the high humanitarian and global impact return, AHEAD charter can deliver a rewarding opportunity for those who choose to participate. The economy in the West is forcing a new look at the lure of international high growth economies including the ancient Silk Road with its robust economy. Investments in India

healthcare offer economic, social, humanitarian, global stability and ideological implications and returns that will shape a global future in more then just healthcare and have affect on every developing society over the next 50 years. But the changes will be set in the next few years. The biological clocks of India’s youth will not wait for a long-term solution. AHEAD partners who are prepared to get involved at this early stage of the AHEAD Foundation’s development can greatly influence the broad opportunities its commission has captured and discussed in this paper. Are you asking how you can get evolved? I would love to hear from you.

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i At the time this paper was written this statement was not included. For the benefit of later readers it was added to strengthen the point that resources exist to reward the efforts invested by those who chose to invest. In 2010 this paper was shared with individuals interested in seeing healthcare reform in the West that also believed that investments in India represented an important part of the West’s future and offered to the Southern Asia Division of the Seventh-day Adventist church funds to began a modernization infrastructure plan. Church governance process has not offered an efficient means of capitalizing on this offer but it has added greatly to the confidence that options exist for moving forward even if the vision requires significant resources. While the reader should recognize the paper sits in the context of thinking from when it was written at the inception of AHEAD’s North America beginnings in 2008 and reflects the more limited vision of the foundation at that time, some additional edits, such as the funding reported in the revision statement this foot not is a reference for, have been made to the paper to keep the papers usefulness current.

ii AHEAD Foundation has commenced the assembling of its Visioning Advisory Board to address the size and scope of its vision and mission within the confines of the AHEAD Foundation and its partner’s resources. Visioning statements such as these are the trial balloons efforts at capturing the foundations target focus and mission. For a update on the Vanderbilt Visioning Lab nominees and developments reference www.myspace.com/AHEADvision

iii For a simple calculation of the needed hospital beds calculate India’s 1 Billion population to the current beds/1,000 population in India compared as a target ratio of beds per 1,000 people currently required to serve parallel similar economies. The different economy markets along with their beds/1,000 is shown in the Global Healthcare Infrastructure table on page 7 of this Issues Paper. For perspective consider that the community of India’s middle and upper class as a partial population segment in by itself a significantly large community and the beds required to meet their demand alone at a more Western ratio of beds/1,000 as well as the professionals required to support the needs of this population segment and the demand growth is formidable. This would be true looking at an exercise in assessing the demand of India’s population proper. However, it would be better to consider also addressing the population of Southern Asia as a region in the scope of what is called pre-petition India referencing the countries that were once apart of colonial India including Pakistan and Bangladesh as well as Nepal and neighboring Burma. This represents a 1.4 plus billion population market suggesting another 40% increase in beds perhaps almost another million beds to service a population area that combined exceeds the population of China.

iv See the 2007 Healthcare Report prepared under contract with the Indian government as an addendum to the annual economic development study conducted as a joint undertaking between Merrill Lynch and Earnest & Young. This direct relationship between the size and complexity of hospital beds and the quality of healthcare in India is represented in the table Patients Value Proposition on page 9 of this Issues Report taken as an excerpt from the power point presentation of the 2007 Healthcare Report. See: IBEF – India Branding Equity Foundation Healthcare Report.

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AHEAD Foundation - Issues and Opportunities  

What happens in India in the next few years will define healthcare's future in the West.

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