At multiple points over the past five years, it has seemed like the country has collectively lost its mind over a joke. Not the whole country, to be fair. Just courts, politicians, random uncles on WhatsApp, and news anchors, focusing on slightly problematic words rather than poverty, infrastructure, safety, and just about a million other things that are probably more important.
And so I decided to flag one of those million things. Not because I hold some moral high ground. Some of this is probably some misguided patriotism. Most of it though is self-serving. Like someone who cares about his portfolio and needs the country to do well for his portfolio to be alright.
And importantly this is not about the next three years, but the next thirty.
Young for now
India is young. Not Nigeria young, but with a median age below 30, the country is yet to reach its mid life crisis. This though, will not last forever.
Fertility rates have dropped and life expectancies have risen and so in another thirty years, our age structure is expected to change quite a bit.
Somewhere around 2050, our working-age population is expected to peak and then start declining. Similarly, the number of people above the age of 65 is expected to exceed the number of children below the age of 15.
This has all sorts of economic ramifications, many of which you might have already heard. “We need to get rich before we get old” and so on. All of that is true, but I want to highlight something more specific. A child born today will be in their mid-twenties in 2050. The people who will have to carry the country through its ageing years are children or teenagers today.
Which is why I want to flag what this means for healthcare, starting with children.
Keeping kids alive
Child mortality is a grim metric, obviously, but it’s probably one of the most useful ones too. Largely because multiple things need to happen to keep a child alive. Do people have clean water? Enough food? Access to healthcare, vaccinations and sanitation? Do doctors have the supplies they need? Can an ambulance make it in time in an emergency? Do people have enough money to keep a child alive?
India has made progress here, but still it’s quite a high number. As of 2024, for every 1,000 children born, around 27 do not live to see their fifth birthday. (UN IGME)
Surviving isn’t the bar
And survival is the low bar. More than one in three Indian children under five is stunted, meaning too short for their age because of poor nutrition early on. (NFHS-5) But it goes beyond height. Poor nutrition at an early age, has lifelong consequences.
A study that followed over a thousand children in Mauritius found that kids showing signs of malnutrition at age three were more aggressive at eight, and by seventeen showed about 51% more violent and antisocial behavior than their well-fed peers. The researchers’ explanation was simple. Poor nutrition held back brain development, which showed up as lower IQ, which then showed up as behavior. (Liu et al., American Journal of Psychiatry, 2004)
And then there’s the body. Children who are undernourished early and put on weight quickly later in life tend to be at higher risk of diabetes and heart disease as adults. (Victora et al., The Lancet, 2008)
None of this means a stunted child is doomed. Plenty of people beat the odds. But in a country like India, with its unimaginable scale, base rates matter. A child who doesn’t get adequate nutrition today is, on average, more likely to earn a little less, struggle a little more, be a little less productive, and need a little more medical care in the future. And all of this happens to be coming at a time when India will need its workforce to be more productive, and its healthcare system to do more with limited resources.
The bill has arrived early
Unfortunately, we tend to assume that healthcare bills will pile up when we’re old. Sixty-five and above. Reality seems to be a little different.
Chronic conditions can develop much earlier, often going undetected for years. And the numbers in India are already quite something. An ICMR-INDIAB study estimated that, as of 2021, around 101 million Indian adults had diabetes, another 136 million were prediabetic, and roughly 315 million had hypertension. (ICMR-INDIAB, The Lancet Diabetes & Endocrinology, 2023)
These aren’t illnesses you treat once and forget. They’re subscriptions. The sort that you can’t really cancel, and the ones where the bills usually increase as you age.
And even if we can pay, someone has to treat them. India has and will continue to have a doctor and nurse shortage.
And we aren’t just talking about general physicians. We’ll need more specialists and super-specialists, too.
These things take time. You can’t fast-track a decade of medical training just because you suddenly realise you need more doctors. And an ageing population is only going to add stress to an already stressed system.
Who pays for all this?
Unfortunately, we do. Out-of-pocket spending has come down considerably over the past decade, which is genuinely good news. But it still accounts for nearly 44% of all health expenditure in India. Which means that for many households, a hospital visit isn’t just a medical issue. It’s a financial one, too.
Why an investor (and citizen) should care
This is where the self-serving part comes in.
To start with, if you’ve ever wondered why Indian hospital and diagnostic companies trade at such hefty valuations, a good part of the answer is everything above. More people getting older, more chronic illness, more insurance, and nowhere near enough beds or doctors. The market is paying for a structural story that plays out over decades. (Or at least that’s how I look at it)
But this goes beyond understanding one sector. It’s about the economy as a whole. The number of people working, and how productive they are, are two key drivers of economic growth. And both are affected by healthcare.
Sick people work less, or stop working altogether. Unhealthy children can grow into less productive adults. And families that spend their savings on hospital bills have less money to put towards homes, education, businesses, etc.
While a country is young, it doesn’t really feel the brunt of this. A young population is a forgiving one. Ageing takes that cushion away. As the share of working people shrinks, each of them has to be more productive just to keep things steady. That’s exactly when a weak foundation starts to show.
And most importantly, a lot of this is time sensitive. The people entering the workforce around 2050 are children right now. Poor nutrition today can’t be fixed in 2050. You can’t fix a stunted 35-year-old with a better tax regime.
So what can be done?
Well, I’m certainly not a healthcare expert, so nothing I say here should be taken too seriously. Think of it less as a policy proposal and more as an investor noticing a pattern.
And the pattern is this: a lot of what India needs has already been done. Just not everywhere.
Take cleanliness. If you visit Indore, you’ll find people complaining that the city isn’t as clean as it was a few years ago. Which is hilarious, because it’s probably still ten times cleaner than Pune. (Not statistically, obviously, just by the eye test.) Indore has topped the national cleanliness rankings for years, not because it discovered some secret technology, but because it got the boring stuff right.
Something similar shows up when you look at child mortality. Kerala does considerably better than the rest of India, with rates comparable to those of some developed countries. Which makes you wonder. We know that some things work. So why are we still struggling to make them work everywhere?
I don’t have an answer to that. But I’d like to think someone is trying to find one. Because for the sake of the country and, of course, my portfolio, a little more outrage over these things, and hopefully a little change, would probably be more useful than the next round of drama over a stand-up comedian.
Disclaimer: Not investment advice, not medical advice. I’m an investor with opinions, not a SEBI-registered advisor or a doctor. Please do your own research.