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National Pharmaceutical Pricing Authority's move to cap pricing of coronary stents would adversely affect well-to-do patients and medical tourism industry in India

After the Delhi High court passed the order to slash the price of stents, National Pharmaceutical Pricing Authority (NPPA), a government regulatory agency issued a order on 13th Feb, 2017. This order came as a boon for the BJP Government which was busy with their UP & BMC campaign. PM Narendra Modi made it sure, that price capping of stents becomes an USP during his election speeches. Neither the Government nor the NPPA took suggestions from doctors, hospitals before issuing new regulations.

To summarise, stents were capped in 2 broad categories.
1. Bare Metal Stents - Rs.7260
2. Drug Eluting Stents and Bioresorbable Vascular Scaffold/Biodegradable Stents - Rs.29600

As of now, Abbott and Medtronic have filed for withdrawal of their premium coronary stents from the Indian market, as it wasn't commercially viable after the price cap. Boston Scientific might withdraw their premium stents too after the completion of their corporate sustainability review. Now Indian patients won't have access to high end stents even if they are ready to spend money. Government has every right to make doctors work for the poor, but they can’t deprive middle and upper class of what they can buy. This is not beneficial for a democracy. This is extreme health care rationing. Bare metal stents could be made of stainless steel, cobalt or platinum. The pricing of these differs.

It's the basic law of economics. If tomorrow, Government decides to put a price cap of Rs.30,000 on smartphones. Then Apple will only sell older iPhone models like SE, 6 and won't sell newer 7, 7S models.

To make matters worse, NPPA has rejected the withdrawal plea of Abbott and Medtronic. They also directed stent manufacturers to have stock for 6 months or face action. Basically forcing them to sell their high end products at a loss. This lame restriction could be easily evaded by importing only basic stents while not importing premium stents. Imagine, Mercedes Benz being forced to sell their high end car for Rs. 10 lakhs. This is borderline insanity, Government can't dictate companies to sell their non-essential, premium products at a specific price. This isn't North Korea.

If Government is serious of public healthcare in India then why does it spend a meagre 1.4% of the GDP on healthcare? Because that doesn't favour their PR based governance. BJP's print advertisement on the eve of BMC election read, “expensive angioplasty stent now cheaper by 85%; decision of a sensible government”. Modi Government isn't interested in reforms and instead prefers managing headlines over economy.

What should the Government have done to help the poor as well as to not harm the middle/upper class?

1. Create 4 classes of stents instead of current 2 classes.

2. Leave the last one uncapped, so those who could afford have access to newer tech.

3. Adopt an ala carte approach, making available stents at Rs. 7000, Rs. 28000, Rs. 85000 and uncapped.

4. Provide first two only through RGJAY and other schemes.

5. Use the expertise of public sector rate contracts and declare the rates at which all varieties of stents can be bought into India. Get these prices in public domain for everyone’s knowledge and information.

6. Audit the procedures in public and private hospitals through a third party.

7. Audit individual cardiologist’s annual performance to know for which class he is working more.

8. Consider SEZs for implant companies to manufacture these high end products in India.

These suggestions were provided by Dr. Sanjay Oak in his article in Mumbai Mirror.

This is how a handbook of bad policy would read. First, impose price controls. Then watch goods disappear from the market. And finally threaten producers with punishment for the shortages that your price controls have created. Multi-speciality hospitals across the country are reporting a fall in foreign patients due to shortage of premium stents. Patients are instead getting operated in Singapore, Bangkok. Thanks to this move, we are now losing valuable foreign currency too. Why is Indian Gov't promoting reverse medical tourism? Undoubtedly we need to care more for our poor, but we can’t at the same time ignore the desires of millions of people who belong to upper and middle class and who are honest tax payers. Why should they be denied a choice?

Today it’s cardiac stents, tomorrow it will be orthopaedic implants, and after that, maybe oncology drugs. There is no doubt that the government’s intentions are laudable and the efforts are an attempt to ensure equitable distribution of medical care and to curb medical malpractices. But the execution is misdirected and mal-aligned. Hospitals may hike cath lab rent per procedure and try to bridge the gap. Surgeons may prefer bypass surgical procedures. All these regulations appear as knee-jerk reactions done to control medical malpractice. I am not claiming here that everything was hunky-dory in the stent and implant business. But, putting a cap on prices is not the answer to the problem.

While Modi led BJP came to power with the slogan of, "Minimum Government, Maximum Governance". Their actions are nowhere near it. Instead the License Raj that we left off in the 1980s, is making a comeback.

There is this niggling thing about the 1993 blasts case that just does not add up. We have Yakub's "confession". We have hanged him. We have evidence about Tiger Memon running the show on the 1993 blasts - manpower, materials, location, the works. What evidence is there against Dawood is not clear to my inexperienced eye. I have not come across anything. Every single interview of Dawood and Chhota Shakeel categorically state that they were framed and completely not involved with the blasts, even in interviews where they claim other crimes with chilling candour "uska kaam kar denge" "ha ha humne hi kya na" "hum smuggling aur gang war karte hain" etc - not the slightest deviation in over a decade. And they have slipped in other places, so rehearsed cunning seems difficult to credit over so long a term. For example, while Chhota Shakeel denied involvement with the IPL, the interviewer successfully used it to goad him into revealing reasons for attempting to kill Lalit .

If there was evidence against Dawood, I doubt that the TV channel research teams would not find it or that the interviewer would not throw it in his face to provoke him further. Still, I understand how Dawood being the bigger don whom Tiger worked for can be presumed to be involved, anyway. And he most certainly left a bloody trail in that got things so hot for him that he had to leave for Dubai well before the blasts - so his killing people in a fit of anger over Babri Masjid is hardly something that cannot be believed. And of course it is believable that the slip ups in the interviews were just a calculated foil for making the denials believable - one thing to confess to attempting to kill gangsters and smuggling money, quite another to admit you killed innocents wholesale in a city where you do "business" (their euphemism for underworld activities).

What is difficult to comprehend is how is how we have reached this point where we hanged someone who *claimed* to be innocent and working to expose the ever since he found out about it and arranged for more accused to return to the country - regardless of whether originally captured or surrendered. I accept that is hardly going to confess that he is guilty (which too many criminals do), but it is less difficult to understand why he would let evidence against himself survive at all - regardless of whether he was surrendering to India or just in the habit of roaming around with proofs on terror attacks. More importantly, even the conviction sees him at best involved with the finances and tickets. 1993 was supposedly Pakistan ISI's first on Indian soil. It is unclear how providing tickets to go to Pakistan implies the person buying the tickets knew what they would be used for. Still, let us say he knowingly did it and was guilty and rightly hanged. Or at the very least knew of it and did not prevent a crime of this magnitude. Complete benefit of any doubt. He's dead anyway. Guilty unless proved innocent beyond doubt makes no difference now.

Over the last few weeks, I have been going through hundreds of articles of coverage of this case. Old ones, new ones, whatever. There is hardly anything on Tiger Memon beyond the confessions of Yakub Memon, and as a mention in articles on after the first year or two when Yakub's confessions were hot. Now this is the man whom we actually have evidence against. And there is this massive silence on him. No particular chases by our intelligence agencies mentioned. No questions in Parliament about his whereabouts, the person who provided concrete proof against him hanged, while his people who planted bombs get life. Dawood is India's most wanted because of the 1993 blasts apparently, yet the person against whom we have concrete proof is never a topic of hot debate. Even our tug of war with Pakistan is over Dawood.

Ajit Doval is fixated on Dawood, as is the state - successive governments, not just Modi. Yakub's hanging comes on the heels of the first attempt on Chhota Rajan's life by Chhota Shakeel since a decade ago in Bangkok. Yet no one seems to have bothered to ask so much as whether Tiger Memon is dead or alive.

Makes one wonder what is going on. Power in India is often seen as silence on crimes and silencing of witnesses. There is no information of crimes of Tiger Memon before or after the 1993 blasts beyond "member of " and the person who is prime witness against him in 1993 blasts is hanged by the state and the state itself has not pursued him with any visible urgency. There isn't so much as a photo beyond 400 pixels and a decade old in the public domain for the person with most evidence against him in the 1993 blasts that have put India on an decades long international manhunt.

Cannot help but speculate whether Tiger Memon is the man who knows too many powerful people in India to be ever allowed to come on the radar.

At 1:52 this afternoon, Majid Memon, a journalist, wrote an article "Yakub Memon: Break the official omerta - In case, state displayed bad faith" about his perceptions about the case and how he had helped verify information Yakub Memon had got with him about the residences of , Tiger Memon and another smuggler, Taufiq Jallianwala, whom the had not known of before. He described videos Yakub had made of their residences, and chaperoning provided by the ISI in Karachi, Bangkok and Karachi again. He described audio recorded by him of Tiger Memon with his associates.

He says that the Narsimharao betrayed Yakub Memon due to increasing pressure about being soft on terror and that the various officials - not just of intelligence agencies, but diplomats as well were silent because of a top down omerta and should be granted amnesty from the charge of contempt of court, if they are to testify - B Raman too had hesitated for this reason, as per him.

By 6:04pm, has published an article with statements from CBI officers that deny these claims. Shantanu Sen, who led the operation on the CBI end claims they knew there were differences in the Memon family over the blasts and some of them wanted to return to as they were not happy in Pakistan. He denies that any deal had been struck and that they nabbed Yakub in Kathmandu. He denied that Yakub Memon had been duped and points out that of the 11 family members who came to India, only four got sentenced. His parents got bail and charges against them would be dropped had the matter come to prosecution before they died.

Mr Chattwal, who had been named by Yakub's ex-lawyer as the CBI contact who told them to get bail and later betrayed them, said that he had received no such instructions and that Yakub had not cooperated with the investigation, but that the evidence was recovered from him at the time of the arrest.

A few days earlier, Ujjwal Nikam, the public prosecutor claimed not to know of the mitigating circumstances B Raman wrote of at all.

One possibility is that there is an evil conspiracy on hand, etc etc.

Is the other explanation more simple?

Is this yet another horrendous example of lack of communication between investigating and intelligence agencies? B Raman who headed Pakistan desk of R&AW and oversaw the arrest clearly saw mitigating circumstances. Shantanu Sen who led the CBI investigation was clearly aware of cooperation as his claim of Yakub Memon not being duped demonstrates (if there was no deal, where would a question of duping arise?). On the other hand, Chattwal, who apparently was the CBI guy at the courts end was not aware of any deal and believes the evidence to have been recovered from Yakub at the time of his arrest. Ujjwal Nikam, public prosecutor who asked for the penalty is not aware of any mitigating circumstances at all.

That there was some deal does not take rocket science to understand. If Yakub Memon was not cooperating and had been arrested and evidence against himself recovered, why would he call his family to India? Morever, if Yakub Memon had any evidence proving his own guilt, why in the world would he carry it at all, when he knows the documents he carries will go to Indian authorities? The idea is he came to India expecting justice and mercy for cooperation, not proving own guilt, right?

The 30th approaches and this story only gets murkier.

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When the state takes extreme steps that make no sense, I get curious. 's hanging being scheduled for the 30th of this month, while the key accused of the blasts are still at large is one such bizarre move. So I went around hunting for information on what else was going on. Here are some of the things I found out. They raise more questions than answers.

Chhota Shakeel tried to kill Chhota Rajan in Australia

On the 2nd of July, Times of published a report that described intercepted conversations between Chhota Shakeel and a key Rajan aide, who was convinced to reveal Chhota Shakeel's whereabouts in Newcastle, Australia. Times of India claims to have a copy of the intercept. A team from middle east was allegedly immediately sent to Australia. However, Chhota Rajan had already escaped after receiving a fortuitous tip off. The article also describes the 's relentless determination to eliminate an aged Chhota Rajan who is no longer a threat to them and describes previous attacks by Dawood's men to eliminate Chhota Rajan.

Dawood was involved in Chhota Shakeel's attempt on Chhota Rajan

Another report in the Times of India, also on the 2nd July said that a voice in the background, heard during a pause in the intercepted conversation between Chhota Shakeel and Rajan's aide was that of as confirmed by layered voice analysis. What the voice said is not reported.

This report also gives us an idea of the approximate date of the attempted on Chhota Rajan when it speaks of Chhota Shakeel being on the move for a month since mid-April when he went to Newcastle for the attack on Chhota Rajan. The report presumes he dropped off the radar after the intercepted conversations or the intelligence agencies would have approached the to arrest Shakeel (but not Rajan?).

*********************

Some background: Chhota Rajan was among key men of Dawood's gang before he split from Dawood due to internal rivalry and differences that got cemented after the 1993 Mumbai blasts. After the split, he escaped to Dubai with the help of Indian intelligence agencies in return for information on Dawood Ibrahim's operations. Intelligence agencies have also allegedly helped Chhota Rajan evade attempts on his life since then. Current NSA and then ex- head, Ajit Doval had also been caught once with Chhota Rajan's hit man Vicky Malhotra. Chhota Shakeel is still Dawood's key man. Chhota Rajan and Dawood Ibrahmin have since been bitter and bloody rivals with constant attempts to eliminate each other. Among India's plans for Dawood Ibrahmin remain a possibility for Chhota Rajan taking Dawood out.

An article in the Daily Mail News from November claims NSA Ajit Doval is forming links with ISIS to encourage an ISIS - TTP collaboration to destabilize Pakistan.

Given that Indian Intelligence agencies are unlikely to leave copies of intelligence intercepts lying around in public places or something, Times of India clearly got the tip off from them about a failed operation "early in the year" - as in, the news was not fresh.

Yasin Bhatkal could get help from Damascus

On 3rd July, 2015, a report in the Times of India stated that Yasin Bhatkal had told his wife that he would get help from Damascus to escape jail. This would seem unrelated to the Yakub Memon issue, except... Yasin Bhatkal used to allegedly be financed by Muzzaffar Kola of the Dossa gang which reported to..... Dawood Ibrahim.

Last year, Yasin Bhatkal's lawyer had received threats from underworld don Ravi Pujari who is currently said to be in Australia and is close to.... Chhota Rajan. Yasin Bhatkal had hardly made any news for months before this.

Chhota Shakeel reveals that Dawood Ibrahim wanted to return to India after 1993 blasts

On 4th July 2015, Times of India published a report of a telephonic interview with Chhota Shakeel in which Shakeel alleged "When we wanted to come back after 1993, you people, your government didn't allow. Bhai had himself spoken that time to Ram Jethmalani, that too in London... baat ho gayi thi... But your ministry... that Advani played the game,". This naturally led to a flurry of accusations and denials.

Other Chhota Shakeel quotes from the article:

"When agencies can hear me plotting against him (Rajan) and know where he is, why don't they get him picked up? Has he not killed people? Is he not a criminal?"

"Every time a new government comes, they make the first statement about us. Usko leke aayenge... ghus ke laayenge... Kya halwa hai? Bakri ka bachcha samajh ke rakha hai kya? Lana hai toh usko (Rajan) lao na,"

"He ran away like a mouse," Shakeel said. He claimed that not one but three key members of Rajan's group had crossed over to his side because of their confidence that they would be taken care of. "I look after even the family of Rajan's aides who had been killed by members of D-Company," (On the attack planned on Chhota Rajan reported by Times of India on the 2nd)

"Haven't killed anyone in Mumbai in the past 5-6 years. I don't want to kill innocents. He (Rajan) brings shooters from UP and gets people killed in our name. I want to continue my business. I invest money and take it back." From another report of the same interview.

On Chhota Raja's image as a Hindu gangster "This is 's job. Take him in the army, send him on the border if he is a patriot. (Patriot hai to army me le lo na... border pe bhejo na! Mulq ke liye kaam karega. Hindu don ka concept logo ka... media ka hai. He has killed all Hindus for money,"

On whether he thinks Indian intelligence agencies are soft on Chhota Rajan "We don't care. They can support him all they want, we will find him and kill him."

* An earlier interview by Chhota Shakeel to Rediff (after their first attempt on Chhota Rajan's life in Bangkok) establishes that the D-Company sees him as a traitor who grew large with their favor and betrayed them as well as stole gold from them.

** The part about Chhota Rajan killing Hindus in India is true. Among recent high profile murders is that of Jyotirmoy Dey, an investigative journalist working for MiD DAY. He is wanted in India in many criminal cases related to extortion, , smuggling, drug trafficking and film finance.

*** Dawood Ibrahim and Chhota Shakeel are no saints either.

Chhota Rajan still in Australia

On the 5th of June, Times of India published another news report citing an unnamed source in the intelligence agencies that Chhota Rajan was still in Australia and had not left Australia (as reported in previous piece). Chhota Shakeel also was apparently aware of this fact and had not called off his hit men tracking Chhota Rajan in Australia.

Yasin Bhatkal claims threat to life and demands 24/7 surveillance

On 6th July, 2015, Yasin Bhatkal pled before a special court for NIA cases for CCTVs to be installed in his and for constant surveillance not only in jail, but also when being moved to court and back for hearings. Outside the jail, he pulled a letter from his pocket and threw it at reporters standing there. In the letter, he denies telling his wife about any help from Damascus or for escaping jail and fears that he could be killed in an encounter staging his escape.

refused to entertain a plea to bring Dawood Ibrahim back

8th July, 2015. The Supreme Court dismissed a plea by a previous Madhya Pradesh to bring Dawood Ibrahim back to India and that a special investigating team headed by SC judge be set up to probe why indian authorities were unwilling in bringing tje don back to country to face trial in various cases.

Daya Nayak suspended

9th July, 2015. Daya Nayak of the 83 encounters and disproportionate wealth and dubious dealings was suspended after he refused to go to Nagpur after he was transferred, citing a threat to his life.

warrant for Yakub Memon

On 15th July, 2015, a TADA court signed a death warrant for Yakub Memon, even as his mercy petition was pending in court.

Supreme Court turns down Yakub Memon's mercy petition.

22nd July 2015 Supreme Court turns down Yakub Memon's mercy petition "paving the way for his hanging" as expressed by the media.

White House Bar was demolished

28th July 2015, The White House dance bar, run by Ganesh Kamath, understood to be affiliated with Chhota Rajan's gang and owned by Meenakshi Singh, widow of Chhota Rajan's affiliate O P Singh, was demolished.

Supreme Court turned down Yakub Memon's curative petition

29th July The Supreme court turned down Yakub Memon's curative petition. The governor turned it down as well. The President's decision is awaited, but the indications are that the MHA is recommending against it. Other eminent persons are seeking an audience for another petition.

Yakub Memon hanged

30th July 2015. Yakub Memon was hanged early in the morning, on his 53rd birthday in Nagpur jail.

Is Yakub Memon's death warrant a message?

Numerous reports indicate that after the came to power this time, the gangwar is heating up again (if at all it ever cooled). Ajit Doval has a long term mission of bringing Dawood Ibrahim down. The D-Company, on the other hand seems to have stepped up the heat on Chhota Rajan, perceiving him to be an asset of the Indian intelligence (apart from their usual issues with him).

Yakub Memon is the brother of Tiger Memon, though the only place his name appears in relation with the underworld is the case where he's now got the death sentence. Both gangsters and their gangs have extensive networks in India. For example I later discovered from a source that the illegal White House dance bar, where the journalists were attacked and Raghavendra Dube got killed is a front for Chhota Rajan's activities. The source speculated that the journalists could have been attacked for trying to extort advertising revenue (as the too had accused) from the biggies of extortion, so to say. Four aides of Chhota Rajan were arrested from Dahisar by Mumbai police for extorting 15 crores from a businessman.

Ram Jethmalani stated that opposed the move to bring Dawood Ibrahim back to India when he had offered to return, fearing that their connections with him would be exposed. Sharad Pawar claimed that he refused Dawood Ibrahim's offer to return because one of the conditions of his return was that he would not go to jail! Apparently it was one thing to break a promise to Yakub Memon, sidekick with dubious culpability in actual attacks and quite another to bring the kingpin Dawood Ibrahim to India under false pretenses and then break a promise. South Africa had provided a RAW officer intel on fake identities used by Dawood Ibrahim as early as 1994. V Balachandran shares that the Indian government took his report and sat on it to date.

The Sunday guardian reports that according to US intelligence, 26/11 would not have been possible without Dawood Ibrahim's extensive network and contacts in India. Yet not only did an investigation into the Indian angle never happen, the sole attacker captured was put to death in a clandestine manner. Various people had raised questions around this at various times, from the Mossad conspiracy angle brought up by Great Game India blog to questions around Karkare's death and random anomalies like reports of a woman accompanying an attacker or white skinned attackers. Who was being protected and why?

Chhota Rajan indeed owes his survival to Indian intelligence agencies who are rumored to even tip off his people about raids by Mumbai police and seem to be counting on him to eliminate Dawood Ibrahim, even as threats, murders and crimes by his people in India mount. India has never issued a red corner notice against him, regardless of his crimes. Maharashtra government had briefly made a noise about asking to issue a red corner notice against him in the wake of the high profile murder of Jyotirmoy Dey by his hit men, and that news appears to have sunk without a trace, since. Indian intelligence clearly knew where Chhota Rajan was, when Chhota Shakeel called the hit on him. Yet the news reports only indicate that Shakeel would be arrested with the help of Australian government if he hadn't dropped off the radar. Why was there no question of Chhota Rajan being arrested?

These are both dangerous gangs that have committed crimes in India engaged in a blood feud.

Is the Yakub Memon death warrant or Yasin Bhatkal's claim of threat to his life in a staged encounter, coming on the heels of Chhota Shakeel's attempts on Chhota Rajan a message "to whomsoever-it-may-concern" to lay off Chhota Rajan "or your people could die"? Is it a way of getting Tiger Memon to pressure his associates to back off from their chase of Chhota Rajan?

More importantly for India, is our system becoming a pawn in a gang war?

Note: I am no expert on the underworld, and this is merely a compilation from news reports in the public domain.