Grant thornton healthcare east

1. 9th Healthcare East on “Creating smart hospitals, developing smart facilities to fit in smart patients” 20 September 2014 Kolkata The Eastern Highway – Progressing towards smarter health for all

2. 2 CII-Grant Thornton The Healthcare industry 04 The East India story 10 News-wise 19 Deal space and funding mechanisms 23 Conclusions and recommendations 31 Appendices 35 Contact us 47 Contents

3. It‟s robust times for the Indian healthcare sector as it evolves from being a provider of trained manpower to the rest of the world to a provider of world-class care. So much so that India is poised to become a preeminent Asian nation in the business and has begun to pique interest from larger international strategic operators. Things look bright for the sector over the next few years. More and more people are warming up to the idea of health insurance (private as well as state-funded). This can mean only one thing: further penetration of affordable healthcare across the country. Further shots in the arm will come from fiscal benefits, technological advancements and policy changes. It‟s an environment tailor- made for India to hone its global competitive edge in the healthcare sector. Areas of concern remain, though. The demand for healthcare delivery and services remains healthy, but marred by wide inter-regional disparities. Rural India is particularly underserved. Nowhere is it better demonstrated than in the eastern half of our country. There is a huge surge in the number of new hospitals and diagnostic centers in the region as well as in the flow of investment to cities such as Kolkata, Bhubaneswar and Ranchi. Yet the lack of infrastructure and skilled workforce are clogging up the growth trajectory. In this paper, we seek to map the current state of affairs in the healthcare delivery space in the eastern states, explore recent trends in the sector, identify key areas requiring immediate action and offer recommendations that can ensure equitable access and quality healthcare to all. Foreword CII-Grant Thornton 3

4. The Healthcare industry: An overview

5. Government of India has articulated a reform oriented agenda to kick start the economy and attract foreign investment. It is focusing on inclusive growth, regulatory reforms and a transparent policy environment that would enhance the ease of doing business in India. Overall healthcare market in India The healthcare sector in India is the third largest contributor to the economy in terms of revenue and potential for employment generation. The Indian healthcare sector encompasses hospitals, pharmaceuticals, medical technology and health insurance. Among the primary sub-sectors, hospitals and pharmaceuticals account for the largest revenue generation, contributing as much as 71% and 13% of total revenues, respectively. Hospitals, along with the pharma segment, are expected to be worth US$81.2 billion by 2015. Government of India has taken steps in this direction for several sectors and industries. Announcements in the new Budget are likely to make the tax regime rational, simple, non-adversarial and conducive to investment. In addition, the promised infrastructure development and modifications to the Companies Act, 2013, will boost growth. In all this, however, the long-standing demands of the healthcare sector remain unaddressed till date. Healthcare delivery (Hospitals and Diagnostics) Estimated size: US$ 32 billion Includes government and private hospitals. Diagnostics include businesses and laboratories 01 Pharma and Biotech Estimated size: US$ 16 billion Includes the manufacture, extraction, processing, purification and packaging of chemical materials to be used as medication for humans or animals 02 Medical Insurance Services Estimated size: US$ 10 billion Includes health insurance and covers an individual's hospitalisation expenses and medical reimbursement 04 Medical Technology Estimated size: US$ 4.4 billion Includes establishments primarily engaged in manufacturing medical equipment and supplies such as surgical, dental, orthopedic, ophthalmological & lab equipment 03 CII-Grant Thornton 5

6. Economy, demography and industry Indian economy: average annual growth rate over the past half century • During the ‟50s, ‟60s and ‟70s: 3.5% • During the ‟80s: 5.7% • During 1990-2005: 6.0% • During 2005-10: Averaging at 8.9% • During 2010-11 (8.9%), 2011-12 (6.7%) and 2012-13 (4.5%) Cost advantage of the healthcare sector in India • Lower costs – infrastructure, operations and manufacturing • Costs incurred for manpower are 15% lower than in the US • Low cost of clinical research has made India a hub for R&D for international players • The rising numbers of middle class, ageing population and growing healthcare awareness are also factors contributing to growth in this sector Unparalleled demographics • Over 1 billion population; 52% below the age of 25 • Median age of population will remain 30 years even till as late as 2025 • Workforce (15-59 year age group) in India would grow to approximately 325 million by 2050 • Today‟s youth in India is expected to drive tomorrow‟s boom 6 CII-Grant Thornton

7. Healthcare market drivers Decreasing physical activity, increasing consumption of unhealthy food, longer average life span, rising income levels as well as increasing consumption of tobacco and alcohol have led to a rise in the incidence of a heterogeneous group of diseases, including cardiovascular disorders, chronic respiratory conditions, diabetes and cancer in the Indian population 1• Only 230-240 million of the 1.2 billion Indian population has some form of health insurance. This leaves the field wide open and a tremendous scope for growth • Private insurance coverage will grow by nearly 15% annually till 2020 2The Indian Medical Tourism Conference and Alliance (IMTCA) has predicted that the Indian medical tourism industry will contribute over 25% of the total GDP of the country over the next five years 3Over the past two decades, a number of Indian private sector companies have set up hospital facilities and clinics. Prominent among them are Apollo, Max, Fortis, Global, Manipal, Care, Columbia Asia and Narayana Hrudayalaya. An estimated total of 150 facilities cater to those seeking top-of-the-line medical treatment. Please note that 70%-75% of total healthcare is provided by private players in India4With a rapid rise in the income levels of the middle class and the rich, there is an increased awareness about healthcare, increased spend on healthcare and increased demand for healthcare facilities 5 Heavy disease burden Private health insurance Medical tourism Privatisation of healthcare Income levels and awareness CII-Grant Thornton 7

8. The healthcare value chain Government • District hospitals • Community health centers Private • Mid-sized secondary care • Nursing homes The Indian healthcare delivery sector has seen both public and private participation and comprises multi-specialty tertiary care hospitals, mid-sized secondary care hospitals and basic care driven primary care clinics. Tertiary care Government • Teaching institutions • Medical colleges • Super-specialty services • Mostly in metros and Tier-I cities • 15% = > 300 beds • 80% = 200 to 300 beds • 5% = Average 75 beds • Mix of colleges, single- and multi-specialty facilities Private • Corporate hospitals • Trust hospitals Healthcare facilities for those requiring constant medical attention, including short period of hospitalisation Secondary care • General hospitals • Absence of super-specialty services offerings • Present in Tier-II, Tier-I and metro cities • Patients shift to Tier-I cities for advanced treatment • OT & ICU usually present • Mostly 25-100 beds • Some cases up to 100-200 beds The basic healthcare facilities for common and minor ailments where prevention is most effective Primary Care Government • Primary healthcare centers • Primary role to treat ailments that do not require surgical intervention or advanced care • Services vary across cities • May have ICU and minor OT • Up to 30-40 beds • Located in smaller towns • Also in Tier-I, Tier-II cities and metros Private • Clinics 8 CII-Grant Thornton

9. Healthcare service delivery models Health City Brief description Illustrative examples Integrated healthcare facilities of more than 1,000 beds, spread across a few acres of land and providing multiple specialties • AIMS, Kerala • Apollo, Hyderabad • Fortis, Gurgaon • Medanta Medicity, Gurgaon • Narayana Hrudayalaya, Bangalore, Jaipur, Kolkata Hub-and-Spoke/ Multi-chain Tertiary care hospital functions as hub, secondary care hospitals and clinics as spokes. A hub is a high-end facility located in a metro or Tier-I city, offering all the state-of-the- art equipment needed for complex surgeries. Spokes are traditionally located in Tier-II or Tier-III cities, where patient affordability is typically low • Apollo Hospitals • Care Hospitals • Global Hospitals • Fortis Healthcare • Manipal Hospitals • Max Healthcare Single-specialty Hospital Upcoming healthcare facility models, where hospitals focus on single-specialty care services • Eye and Dental: Vasan Healthcare, Dr Agarwal's Eye Hospital, Centre for Sight, Axiss Dental, EyeQ, Clove Dental • Mother and Child: Rainbow Hospital • Oncology: HCG, International Oncology • Orthopedics: Mewar Ortho, Hosmat • Urology/ Nephrology: RG Stone, Sparsh, Nephro Plus, Nephro Life Davita, Deep Chand, Apex Primary Healthcare Closest to the concept of a neighborhood clinic, and the first point of contact for routine examination • Express Clinics • Nationwide • Vidal Health Emerging Delivery Models New service providers are experimenting with different delivery models focusing on low cost, day care and other allied healthcare models • Day surgery centers (Nova IVI) • Home health providers (IHH in Chennai) • Portea Medical (Home Health) • Top Tier >100 beds • Mid-Tier 30-100 beds • Nursing Homes <30 beds Share of public and private sector in healthcare delivery services in India Abuzz with activity, the sector sees newer models emerge every day, be it integrated health cities, single specialty chains, multi-specialty tertiary care 34% 19% 26% 40% 14% 11% 26% 30% 2005 2015 Government Hosp Top Tier Mid Tier Nursing Home CII-Grant Thornton 9

10. The East India story

11. Further development of super-specialties such as cardio, neuro, transplants, orthopedics and nephrology Continue to be a deterrent in the smooth functioning of hospitals, affecting patient care services Strong need for professionals (doctors, technicians, nurses) conversant both in medicine and technology. Healthcare workers too have to be encouraged to work in primary care centers and an incentive mechanism developed for qualified professionals to work in Tier-II and Tier-III cities Need for super-specialty hospitals Trade unions and lobbying Lack of trained manpower 01 02 03 With real estate, technology, manpower continuing to be key measures for a city‟s potential for development, existing infrastructure needs to be leveraged through technology and mobile units in Tier-II and III cities. Additional capacity should not be built till existing bed capacity has been utilised efficiently. Examples from overseas countries in this regard would be instructive, where hospital infrastructure is owned by Real Estate Investment Trust (REIT) funds Infrastructure and access to technology 04 Insurance coverage and penetration remain abysmal in eastern India (other than RSBY which offers limited support to persons below the poverty line). With a majority of the population living in rural areas, the paying capacity of the people has to be supplemented by large investments in the insurance sector The eastern states fare poorly on several health indicators despite a huge untapped market. Investments in the sector now seem to be gradually increasing, with capacity additions being made, increased complexity of the specialties being offered, patient flow getting higher and the increasing participation of the financing community Inadequate insurance coverage Encourage more private investments 05 06 The road less travelled: The Eastern front Beyond these roadblocks, unlimited potential! CII-Grant Thornton 11

12. Bihar Substantial gaps in sub-centers, with shortage of drugs and equipment in primary healthcare centers, limited manpower and woefully inadequate training facilities Jharkhand Absence of super-specialty hospitals. Predominance of trust-run charitable hospitals and doctor-owned nursing homes West Bengal Kolkata alone is the preferred healthcare destination in this part of the country. The city has established hospitals such as Apollo Gleneagles, Wockhardt (now Fortis), Narayana Hrudalaya, Medica Superspecialty Hospital, AMRI, Ruby Hospital, Desun, Sankara Nethralaya, Vasan, BM Birla Heart Research Centre, the Calcutta Medical Research Institute, Mission of Mercy Hospital, Bhagirathi Neotia Woman & Child Care and Columbia Asia Odisha While the state has the highest number of government hospitals in the country, it fares poorly on health indicators Bihar Population: 100,289,000 Doctors: 38,260 Population served per doctor: 2,621 IMR: Rural: 43 (M), 46 (F); Urban: 33 (M), 36 (F) MMR (2010-12): 219 Jharkhand Population: 32,334,000 Doctors: 4,373 Population served per doctor: 7,394 IMR: Rural: 38 (M), 41 (F); Urban: 24 (M), 30 (F) MMR (2010-12): 219 Odisha Population: 41,453,000 Doctors: 16,786 Population served per doctor: 2,469 IMR: Rural: 53 (M), 56 (F); Urban: 38 (M), 40 (F) MMR (2010-12): 235 West Bengal Population: 91,122,000 Doctors: 62,645 Population served per doctor: 1,455 IMR: Rural: 32 (M), 35 (F); Urban: 25 (M), 27 (F) MMR (2010-12): 117 1 2 4 3 1 2 3 43 The Eastern zone IMR: Infant mortality rate; MMR: Maternal mortality rate 12 CII-Grant Thornton

13. How the East fares across state-level rankings West Bengal scores over its other siblings in eastern India, being in the first quadrant league of the national state level rankings. Note: The above rankings have been derived using parameters such as Below Poverty Line (BPL) indicators, literacy rates, population density, per capita health expenditure, total government hospitals and beds, infant mortality rates, life expectancy, Primary Health Care/ Community Health Care (PHCs/ CHCs), registered doctors and other available demographic and healthcare indicators. Please note that Manipur, Meghalaya, Mizoram, Nagaland, Pondicherry, Sikkim, Tripura and Uttarakhand as well as the Union territories of Andaman & Nicobar Islands, Arunachal Pradesh, Chandigarh, Dadra & Nagar Haveli, Daman & Diu, Goa, Lakshadweep have been excluded from the above analysis as data for these were inadequate for consolidation. Ranks 1-5 Ranks 6-10 Ranks 11-15 Ranks 16-20 Others City Rank City Rank Kerala 1 Rajasthan 11 Tamil Nadu 2 HP 12 Maharashtra 3 J&K 13 West Bengal 4 Odisha 14 Karnataka 5 Bihar 15 Delhi 6 Assam 16 AP 7 Haryana 17 UP 8 MP 18 Gujarat 9 Chhattisgarh 19 Punjab 10 Jharkhand 20 CII-Grant Thornton 13

14. Health insurance in India Health insurance, which reimburses an individual‟s hospitalisation and medical expenses, continues to be a rapidly growing segment of the Indian insurance industry. Less than 20% of India‟s population has health insurance. Here too, government schemes predominate. The major public health insurance schemes in India include the following: Employee‟s State Insurance Scheme (ESIS), and Central Government Health Scheme (CGHS), available to all central government employees; and the Rashtriya Swasthya Bima Yojana (RSBY), launched by the Ministry of Labour and Employment to provide health insurance for BPL families. Beneficiaries under RSBY are entitled to hospitalisation coverage of up to Rs 30,000 for most diseases that require hospitalisation. Apart from these, there are community-based healthcare schemes like Yeshasvini Cooperative Farmers Healthcare System, Aarogya Raksha Yojana, Rajiv Aarogyashri (in Andhra Pradesh) and Karuna Trust (in Karnataka). These help BPL people avail super-specialty healthcare services. To make RSBY more meaningful to both the beneficiaries and the services providers, we need to relook at the capping. Medicines and diagnostics should be charged as per the actual requirement and a percentage discount on the rate should be established. 14 CII-Grant Thornton

15. Health insurance in India 20% Merely 20% of India‟s 1.2 billion population is covered by health insurance 4% Estimated at US$ 3.7 billion, the Indian health insurance sector accounts for 4% of the overall healthcare market in India 30% Although growing rapidly at a compound annual growth rate (CAGR) of 30.05% in the last seven years, penetration and access remain limited To expand the reach of health insurance, there have been a number of initiatives in recent years to involve various stakeholders. These include coverage for Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) treatments and special provisions for senior citizens, apart from streamlining and bringing under regulation the practices relating to file and use of products, pre-insurance health checkups, etc. Some key aspects relating to IRDA - Insurance Regulatory and Development Authority (Health Insurance) Regulations, 2013, are as under: • All health insurance policies shall ordinarily provide for an entry age of up to 65 years • All individual health insurance shall allow portability • Insurers may provide coverage to AYUSH or non-allopathic treatments, subject to some conditions • Claims shall be settled within 30 days of the receipt of the last „necessary‟ document • All health insurers and Third Party Alliances (TPAs), as the case may be, shall establish a separate channel to address the grievances of senior citizens • A sudden downward revision in CGHS rates in 2013 forced a lot of private players to limit the number of patients under the schemes to contain the losses on such procedures. For instance, complicated cardiac surgery procedures involving costly implants were revised downward by up to 50%. Rates are likely to be rectified in the last quarter of 2015 but patients will no doubt suffer in the interim CII-Grant Thornton 15

16. State healthcare insurance schemes in East India East India: Insurance coverage Broad health insurance schemes offer a modicum of coverage in Odisha and West Bengal. Bihar and Jharkhand are poorer cousins in this respect, with insurance coverage and expenditure on health in both states significantly lower than in the rest of the country. People in these states, particularly in the rural interior, have only the national schemes or community-based health insurance schemes to choose from. A greater variety in health insurance products would only be too welcome. Access to the RSBY scheme, for instance, has not dampened community-based health insurance (CBHI) uptake in these states. Biju Krushak Kalyan Yojana • Launched in 2013, the scheme is intended to benefit farmers and their families, and improve access to quality medical care for treatment of diseases involving hospitalisation, through an identified network of health care providers Odisha State Treatment Fund (OSTF) • Launched in 2011, OSTF provides financial assistance to poor patients suffering from life threatening diseases. For eligibility, the person admitted in Government Hospitals, as in-patient, should be a BPL Card holder or should have annual income upto Rs 40,000 in rural areas and Rs 60,000 in urban areas Odisha West Bengal Health Scheme • Launched in 2008, the scheme provides cashless medical treatment facility to State Government employees and their families • In the new revised scheme, cashless medical treatment up to Rs 1 lakh will be provided to the beneficiaries for undergoing treatment in private empanelled hospitals within the state including in the National Capital Region (NCR) West Bengal 16 CII-Grant Thornton

17. India has no single government authority to monitor compliance and assess the quality of services provided by healthcare agencies through regular medical audits. An increasing number of hospitals, therefore, are applying for, and receiving, accreditation and certification from national and international bodies to prove their quality standards. • Constituent of Quality Council of India • The standard consists of over 600 objective elements and is accredited by ISQua • Accreditation for testing and calibration, and for medical laboratories • Associated with APLAC, MRA and ILAC • Gold standard in global healthcare • The Joint Commission (TJC) is a US- based parent organisation • Based in Geneva, ISO is a voluntary organisation whose members are recognised authorities on standards NABH NABL JCI ISO (National Accreditation Board for Hospitals and Healthcare Providers) (National Accreditation Board for Testing and Calibration Laboratories) (Joint Commission International) (International Organisation for Standardisation) Major accreditation bodies in India NABH Accredited Organisations Type of Centre Number of pending applicants Number of accredited organisations Number of accredited organisations in East India Hospitals 435 229 11 Small healthcare organisations 158 30 1 Allopathic clinics 5 13 0 Community health centers 4 1 0 Primary health centers 11 10 0 Accreditation status CII-Grant Thornton 17

18. A very small percentage of accredited hospitals and healthcare organisations in India are located in eastern India. Almost all of these organisations are based in metros and Tier-I cities such as Kolkata, Ranchi and Bhubaneswar. Many public hospitals and centers in Tier-II cities have been successful in obtaining ISO certification. However, ISO standards are not as stringent as those of NABH, NABL and JCI. NABL Accredited Organisations Type of Centre Number of pending applicants Number of accredited organisations Number of accredited organisations in East India Medical laboratories - 503 53 Type of Centre Number of pending applicants Number of accredited organisations Number of accredited organisations in East India JCI - 19 1 Joint Commission International 18 CII-Grant Thornton

19. News-wise

20. News-wise The Odisha government, along with National Thermal Power Corporation (NTPC), is setting up a medical college and hospital in Sundergarh district at an investment of Rs 350 crore. The medical college will have 100 MBBS seats, as per the norms prescribed by the Medical Council of India (MCI). The hospital will have a capacity of 400 beds. Not a single government medical college has come up in Jharkhand in the nearly 13 years since the state was formed. The state has only three medical colleges, producing doctors with just bachelor degrees. These are the Mahatma Gandhi Memorial College (MGM) in Jamshedpur, the Rajendra Institute of Medical Science in Ranchi and the Pataliputra Medical College Hospital (PMCH) in Dhanbad. None of them offer super-specialty courses. Employee‟s State Insurance Corporation is investing about Rs 1,100 crore in upgrading hospitals and building a new medical college in Odisha. In addition, they are setting up a 500-bed super-specialty hospital, as per MCI guidelines and upgrading an existing 50-bed hospital in Rourkela to a high-tech hospital with 100 beds. To improve access to healthcare services for four million people and expand medical infrastructure through public-private partnership (PPP), the Jharkhand government has appointed the International Finance Corporation (IFC) as its consultant. IFC will help the state government to develop Sadar Hospital into a 500-bed facility for secondary and tertiary care, train government staff and identify private players who can provide advanced radio-imaging and pathological services. UK-based Sun Consulting & Investments plan to invest Rs 425 crore in a super-specialty hospital in West Bengal. They also plan to build a medical college. The company will form a joint venture with the local Camellia Group. It will purchase 10 acres of land from the government for the medical college, while the super-specialty hospital will come up in Rajarhat across 2.5 acres. Kolkata-based Emami Group is also set to invest around Rs 1,000 crore for a 450-500 bed hospital in Rajarhat. 20 CII-Grant Thornton

21. The „Ananya‟ programme in Bihar uses mobile phones to provide healthcare services. Run by British Broadcasting Corporation (BBC) Media Action in collaboration with the Bill and Melinda Gates Foundation, Ananya offers a „Mobile Academy‟ training course in eight of Bihar‟s districts. The course seeks to enhance the health workers‟ communication skills and teaches them 10 life-saving health behaviours. A multimedia service - Mobile Kunji - provides information on health issues. A Durgapur-based group, The Mission Hospital (TMH), aims to establish a super-specialty hospital in the Tupudana Industrial Area, on Ranchi‟s outskirts. Land lease formalities are already underway. The government plans to open eight more medical colleges in Jharkhand, in addition to the existing three. These medical colleges will come up in Chaibasa, Dumka, Bokaro and Palamu. The West Bengal government recently approved several sops for government employees, including cashless health insurance. The Bihar government has directed the Indira Gandhi Institute of Medical Sciences (IGIMS) and the Indira Gandhi Institute of Cardiology (IGIC) in Patna to mentor different district hospitals for treating heart patients. In the first phase, intensive care units (ICUs) for heart patients will be set up across the 17 district hospitals. Medica Superspecialty Hospital plans to add a 350-bed unit and cancer treatment centre to its 400-bed facility in Kolkata. The new facilities are part of Medica‟s expansion plans in eastern India, which include 12 new hospitals in several districts. News-wise CII-Grant Thornton 21

22. News-wise The Bihar government has issued a directive for all hospitals to be computerised and for all PHCs to maintain registration and treatment records of patients at out-patient departments (OPDs). This is aimed at keeping a track of medicines prescribed on a daily basis, as well as the number of doctors and patients at OPDs and PHCs. Canara Bank is providing financial aid to the Orissa Trust of Technical Education (OTTET) and Biocon Foundation for a unique PPP with the Odisha government. The project aims to deliver e-healthcare for the underprivileged and rural communities of the State. West Bengal is all set to establish three new medical colleges in the state. Operated on the PPP model, the colleges will come up in Krishnanagar in Nadia, Cooch Behar town in Cooch Behar district, and Tollygunge in Kolkata. The Krishnanagar and Cooch Behar projects will be executed by the State government in partnership with the Camellia Group. The Tollygunge project will be rolled out in partnership with the Techno Group. Tata Hospital has opened a new wing for cancer care in Kolkata. An investment of Rs 340 crore has gone into this facility with 160 beds. The hospital has spent Rs 4 crore in subsidy for poor patients. It plans to add another 250 additional beds at an investment of Rs 200 crore. It will have three more advanced radiotherapy machines, each costing Rs 12 crore. 22 CII-Grant Thornton

23. Deal space and funding mechanism

24. During the period 2011-2014 YTD (Year till date), most of the PE activity was centered around the south, with companies in eastern India attracting very little interest from PE investors. This was a trend across all sectors, and healthcare and pharma were not immune to it. Private Equity (PE) deals landscape in the East 24 CII-Grant Thornton North 2011 2012 2013 2014 YTD Volume 107 92 110 127 US$ mn 2458 2293 2935 2196 Pharma/ Healthcare Volume 5 8 16 5 US$ mn 42 125 512 36 East 2011 2012 2013 2014 Volume 14 6 15 7 US$ mn 354 30 118 137 Pharma/ Healthcare Volume 1 1 5 2 US$ mn 3 5 45 10

25. PE deals landscape in the East Deal activity in the Indian healthcare sector has historically been driven by PE investments. While interest level from PE funds continues to be high, we are increasingly seeing strategic players, particularly international, participating in transactions in India. This is a good development from the perspective that such operators will hopefully be able to bring in best practices from other parts of the world. Mahadevan Narayanamoni, Partner, Grant Thornton India LLP CII-Grant Thornton 25 West 2011 2012 2013 2014 Volume 127 123 151 125 US$ mn 2486 2298 3893 2502 Pharma/ Healthcare Volume 4 8 16 7 US$ mn 7 107 219 194 South 2011 2012 2013 2014 YTD Volume 125 180 176 133 US$ mn 3476 2756 3126 3228 Pharma/ Healthcare Volume 8 21 35 20 US$ mn 209 669 648 337

26. The PE factor: Not all quiet on the Eastern front An assessment of hospital/ healthcare deals during 2009-2014 YTD presents the following trends: - Of the 44 multi-specialty hospital fund raises in India, only four have been in eastern India - Of the 33 primary healthcare deals, including diagnostics, home healthcare and rural healthcare, only one was in eastern India - Of the 40 single-specialty hospital deals, only four were in this region In all, the east Indian states have contributed only 8% to the overall hospital/ healthcare deals since 2009. Key healthcare investments in East India Year Investor Investee Sub-sectors US$ mn 2010 Aureos Capital India BSR Super Specialty Hospitals Ltd Multi-specialty hospital 10.0 2011 Sequoia Capital, Elevar Equity Glocal Healthcare Systems Pvt Ltd Multi-specialty hospital 3.2 2012 Matrix Partners Enhance Aesthetic and Cosmetic Studio Pvt Ltd Dermatology & Cosmetology 5.5 2013 Ennovent GmbH; Ankur Capital Advisors ERC EyeCare Pvt. Ltd. Eyecare N.A. 2013 Swedfund International AB; Deutsche Investitions- und Entwicklungsgesellschaft mbH; Quadria Capital Medica Synergie Pvt Ltd. Multi-specialty hospital 25.7 2013 Angel funding through the Intellecap Impact Investment Network iKure Techsoft Pvt Ltd Primary healthcare N.A. 2013 Lighthouse Funds Suraksha Diagnostic Pvt Ltd Diagnostics centre 9.0 2013 SIDBI Venture Capital Ltd Glocal Healthcare Systems Pvt Ltd Multi-specialty hospital 4.0 2014 Samridhi Kanungo Institute of Diabetes Specialities (KIDS) Diabetes specialities 2.9 2014 Arun LLC, Mumbai Angels iKure Techsoft Pvt Ltd Primary healthcare 0.1 2014 Matrix Partners Hearing Plus ENT Clinic N.A. 26 CII-Grant Thornton

27. Fund fare India is one of the largest emerging markets in the healthcare industry. The rapid rate of growth in the healthcare industry and factors like demand-supply gap, need for better infrastructure, high capital intensity, limited availability of manpower, etc have led companies to seek innovative funding techniques over conventional fundraising methods. Tier II and Tier III cities resort mostly to conventional funding techniques for healthcare facilities. The high interest rate on such bank loans makes it unfeasible to fund and sustain such projects. This is true for most states in the east and is one of the major reasons for the slower growth of healthcare in this region. Presently, debt financing is the predominant source of capital for healthcare enterprises. While non-bank financial companies (NBFCs) have, for long, provided such debt financing, now several private sector commercial banks have incorporated a separate healthcare portfolio in their line of services. • Government budget for rural and urban health • Focused healthcare schemes • Incentives and subsidies • Debt and structured finance • Private equity • REIT • Corporate houses • Capital markets • Angel investors/ NRIs Public Private CII-Grant Thornton 27

28. Fund fare There are various models available under the PPP mode. Several have already been implemented, while some are in various stages of implementation. The expectation from the government is usually in support for land and funding whereas private players contribute across the entire spectrum of real estate development, medical operations and equipment supply. An underlying theme of the PPP route is that concessional healthcare treatment would form an integral part of this ecosystem. PPP funding and other collaborative models A schematic representation of a collaborative model Concessional land bank Real estate developer Medical operator O&M (Other than medical operations) Ancillary (equipment/ pharmacy/ radiology) Fixed lease rental/ share of profits Private land or lease rentals for long term lease Maintenance charges Per use payments Share of profits 28 CII-Grant Thornton

29. Fund fare Whether land and building or equipment, funding for healthcare delivery primarily centers around hospital infrastructure. Innovative new models like REIT may go a long way in reducing financial challenges and capital outlay for basic healthcare infrastructure. Most healthcare operators concur that access to medical instruments and technology is not a problem, financing them is. Import duties being prohibitively high, importing high-end equipment is a challenge for smaller hospitals. Land and building • Most medium-sized hospitals operate out of leased properties. It‟s the larger greenfield hospitals that come up on owned land • A fortunate few get access to government allotted land to build their own facility. However, an accessible and feasible location automatically hikes up the capital requirement of hospitals, particularly in key cities. A lot of the current land ownership is with charitable trusts, which often makes structuring and financing options difficult • Hospitals set up on owned properties can take long-term bank loans against land as the guarantee • Shop-in-shop model is another key trend, with single-specialty outfits in radiology, cardiac and the traditional eye and dental care tying up with larger hospitals and sharing rent or revenue - Refurbished equipment too, is becoming a feasible option for players who cannot afford first-hand imported equipment. 1 Equipment • Equipment is another major capital outlay for hospitals, especially for tertiary or quaternary care establishments. Different specialties require different levels of equipment-related expenditure. Though we have more cost-effective indigenous medical devices and equipment now, large hospitals still prefer to import high-end devices at a significant cost. Equipment financing typically happens via: - Bank loans - Lease or sale and leaseback arrangements - In some cases, the equipment maker installs the equipment and collects a guaranteed consumable fee upon use of equipment and later transfers it to the hospital at negligible cost (largely for high end laboratories, diagnostic and radiology) equipment. • Refurbished equipment too, is becoming a feasible option for players who cannot afford first-hand imported equipment 2 With rising real estate prices (especially in the cities), asset light models are becoming the most viable for emerging healthcare organisations. For tertiary and higher secondary care, the government must provide land and other civic amenities at discounted rates and actively facilitate entry of healthcare entrepreneurs. CII-Grant Thornton 29

30. Debt financing Fund fare External commercial borrowings (ECBs) ECB financing has so far been mired in countless regulations and approvals, which is why only a handful of healthcare players consider it as a funding option. This might change soon, with RBI looking at relaxing certain regulations to promote ECBs as an accessible fundraising route for healthcare delivery and large pharma projects. • Although large and small players alike prefer debt financing, most medium and relatively smaller players in the healthcare sector currently rely solely on fundraising from banks and financial institutions • The role of banks is imperative in facilitating healthcare growth. However, the focus is largely on Tier-I cities, and with secondary and tertiary care segment only emerging in Tier II and Tier III cities, the high interest on bank loans is discouraging. The risk assessment of healthcare ventures is another concern for those seeking to expand their presence in these regions. On the positive side, healthcare expenditure in these regions is rising and a flourishing corporate presence will only encourage lending institutions to extend credit 30 CII-Grant Thornton

31. PE and other avenues of financing Fund fare Individual investors In recent years, rural and semi-urban markets have witnessed a spurt in the growth of nursing homes catering to primary healthcare, diagnostic centers and medical centers/ clinics emulating the hub and spoke model. Largely the entrepreneurial effort of doctors and specialists, they are funded by individuals owning family businesses. While these investments are key to bringing the hospitals to a certain scale and size, they need to be complemented by other funding routes to propel healthcare delivery to the next level. Private equity It is estimated that around 20% of new PE or Venture Capital (VC) funds will be directed at healthcare services. With no dearth in delivery models to choose from, these investments have come in single centre large multispecialty hospitals aiming to add new centres, as well as in corporate hospital chains, hub-and-spoke model hospital chains, shop-in-shop model hospital networks, primary healthcare clinic chains, single-specialty centres/ chains (eye, dental, orthopaedic, cardiac, nephrology), etc. Foreign investors and capital markets Currently, regulated by the Consolidated foreign direct investment (FDI) Policy, foreign investment up to 100% is permitted through the automatic route in the healthcare services sector. However, the lack of transparency, the comparatively lower quality of service and assets, the absence of large facilities for healthcare and the low numbers of listed hospitals act as inhibiting factors for foreign investors. CII-Grant Thornton 31

32. Conclusions and recommendations

33. Conclusions and recommendations Compared to South and West India, East India continues to somewhat grapple with inadequate healthcare infrastructure, poor population-to-bed ratio and low percentage of public healthcare spending. The region requires a concerted effort to improve access to quality healthcare and deeper penetration in remote areas. Rewarding doctors and hospital operators with higher incentives for working in remote areas may be one tool. There is also a need for a single-window mechanism that supplements the capabilities of the collaborating forces like the government, the private sector and not- for-profit organisations, and forms an effective PPP model that ensures quality and curative healthcare services to all. Leveraging IT and technology further can bring the masses closer to affordable healthcare. Build adequate training facilities and overcome resistance of trained staff to work in Tier II and Tier III cities The skills demand-and-supply gap needs to be plugged urgently through better education and training avenues. This can be achieved by: • Offering doctors higher incentives to work in remote areas • Renewing focus on the setting-up of medical colleges and training institutes • Designing specific courses for healthcare delivery and services Develop patient-centric innovative healthcare models • The healthcare model needs to be nurtured in the collaborative environment of public, private sector and non-governmental organisations (NGOs). The real challenges lie in primary and secondary care. These are the areas each of the collaborators must focus on Apply technology and non-conventional delivery models to healthcare • Technology can serve as an enabler to measure outcomes and patient satisfaction, while also facilitating systems to send reminders for basic health statistics • Enable technology to do the first-level patient care rather than involving semi-skilled workforce • Integrate home-based healthcare with technology and satellite/ internet reach to the healthcare specialist Leverage the strengths of the private sector (centers of excellence, efficiency and quality) to make cost of delivery economical • Build more health cities that promote medical tourism with infrastructure support from the government • Corporate players, being the fountainheads of innovation, need to venture into formats that involve lower in-patient hospital stay, higher bed turnover and lower operational costs CII-Grant Thornton 33

34. Efficiently utilise existing infrastructure • Leverage existing infrastructure through technology and mobile units to Tier II and Tier III regions • Limit focus on additional capacity (in larger cities) until existing bed capacity has been efficiently utilised • Encourage overseas models of REIT fund involvement in developing further infrastructure Focused efforts to promote medical tourism • Government bodies, private and public healthcare operators and industry bodies should collectively endeavour to create the right logistics framework and brand image of healthcare services in the East to attract floating medical travellers from neighboring countries such as Bhutan, Bangladesh and Burma • Ensure that India‟s northeastern states, which already view the East as a healthcare hub, continue to avail quality healthcare in the larger eastern states Adopt PPP model to permit private sector to expand the coverage of healthcare delivery and provide diversity of services • Establish simple PPP models (Ambulatory services and dialysis test centers) where the model of engagement is clearly defined both in terms of deliverable and monetary mechanism • Make the PPP model viable without subsidisation or cross-subsidisation • Create well defined roles in terms of who has the risk bearing capabilities and who manages information in the value chain Set-up state health insurance programmes in rural areas • Make public spending on healthcare independent of other general economic growth/ downturn • Learn from the experience of other Southeast-Asian countries on how to ensure good health outcomes at lower per capita income • Set-up health insurance programmes in rural areas to ensure widespread reach • Broaden the scope of public insurance schemes like Arogyashree and RSBY • Allocate funds towards controlling non- communicable diseases (NCDs) and diabetes Conclusions and recommendations 34 CII-Grant Thornton

35. Improve patient outcomes with connected and integrated healthcare • Primary care and hospital-based infrastructure needs to be integrated to provide seamless, uniform and proactive care, keeping in mind the level of clinician support (doctor availability and referral channels) that are available in and around such regions Create an intermix of competencies and proactive collaborative action from all bodies – government, private and not-for- profit • The private sector must work towards creating a regional focus rather than focusing only on top-tier cities • The government must ease norms for setting up medical and institutional infrastructure by relaxing minimum requirements, mandatory affiliations with existing government district hospitals and other private players Conclusions and recommendations CII-Grant Thornton 35

36. Appendices Appendices

37. Appendix: NABH accredited organisations NABH Accredited Hospitals in the East B.M. Birla Heart Research Centre, Kolkata, West Bengal Desun Hospital & Heart Institute, Kolkata, West Bengal Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal Medica Superspecialty Hospital, Kolkata, West Bengal Fortis Hospitals Ltd. , Kolkata, West Bengal The Mission Hospital, Durgapur, West Bengal Abdur Razzaque Ansari Memorial Weaver's Hospital, Ranchi, Jharkhand Aditya Care Hospital, Bhubneshwar, Orissa LV Prasad Eye Institute, Bhubneshwar, Orissa IMS and SUM Hospital, Bhubneshwar, Orissa Apollo Hospitals, Bhubneshwar, Orissa NABH Empanelled Hospitals in the East Hi-Tech Medical College and Hospital, Pandara, Rasulgarh, Bhubaneshwar Kalinga Institutes of Medical Science, Patia, Bhubaneshwar Kalinga Hospital Limited, Chandrasekhar Pur, Bhubaneshwar Raj Hospital and Research Center, Ranchi Anupama Hospital Pvt. Ltd., Ashok Raj Path, Patna Magadh Hospital, Rajendra Nagar Road, Patna Apollo Gleneagles Hospitals Ltd., Kolkata Armenian Church Trauma Center, Kolkata B.M. Birla Heart Research Center, Kolkata Calcutta Medical Res. Institute, Kolkata Cancer Center Welfare Home, Kolkata Dafodil Nursing Home, Kolkata Kothari Medical Center, Kolkata Mission of Mercy Hospital, Kolkata Peerless Hospital & B.K. Roy Research Center, Kolkata Rabindranath Tagore International Inst. of Cardiac Sciences, Kolkata Ruby General Hospital, Kolkata Wockhardt Hospital & Kidney Institute, Kolkata NABH Accredited Small Healthcare Organizations in the East Kashyap Memorial Eye Hospital, Ranchi, Jharkhand CII-Grant Thornton 37

38. Appendix: Health infrastructure State Rural Hospitals (Government) Urban Hospitals (Government) Total Hospitals (Government) Provisional /Projected Population (000) Average Population Served per Govt. Hospital Average Population Served per Govt. Hospital BedNumber Beds Number Beds Number Beds Bihar 1,325 5,250 111 6,302 1,436 11,552 100,289 69,839 8,681 Jharkhand 545 4,879 4 535 549 5,414 32,334 58,896 5,972 Odisha 1,659 7,099 91 9,584 1,750 16,683 41,453 23,688 2,485 West Bengal 1,272 19,679 294 58,509 1,566 78,188 91,122 58,188 1,165 Number of government hospitals and beds in rural and urban areas (01.01.2014*) *Except Jharkhand - Data as on 01.01.2012 Source: National Health Profile, Central Bureau of Health Intelligence 38 CII-Grant Thornton

39. Appendix: Human resources in healthcare Allopathic doctors registered with Central/ State Councils, 2013 (Provisional) State Number of allopathic doctors Bihar 38,260 Jharkhand 4,373 Odisha 16,786 West Bengal 62,645 Dental surgeons registered with Central/ State Councils, 2012 State Number of dental surgeons Bihar 2,807 Odisha 289 West Bengal 3,120 Source: National Health Profile, Central Bureau of Health Intelligence CII-Grant Thornton 39

40. Appendix: Healthcare indicators Projected levels of expectation of life at birth State 2011-15 2016-20 2021-25 Male Female Male Female Male Female Bihar 68.6 68.7 69.6 70.2 70.6 71.4 Odisha 64.3 67.3 66.3 69.6 67.8 71.6 West Bengal 69.2 72.1 70.2 73.3 71 74.3 IMR by sex and residence State Total Rural Urban Total Males Females Total Males Females Total Males Females Bihar 43 42 45 44 43 46 34 33 36 Jharkhand 38 36 39 39 38 41 27 24 30 Odisha 53 52 54 55 53 56 39 38 40 West Bengal 32 31 33 33 32 35 26 25 27 MMR State 2004-06 2007-09 2010-12 Bihar 312 261 219 Odisha 303 258 235 West Bengal 141 145 117 Source: National Health Profile, Central Bureau of Health Intelligence 40 CII-Grant Thornton

41. Appendix: Disease profiles Cases and deaths due to Malaria State 2012 2013(P) Cases Deaths Cases Deaths Bihar 2,605 - 2,249 - Jharkhand 131,476 10 97,215 6 Odisha 262,842 79 216,568 66 West Bengal 55,793 30 28,040 17 Cases and deaths due to Acute Diarrhoeal Diseases, 2013 (Provisional) State Male Female Total Cases Deaths Cases Deaths Cases Deaths Bihar 321,269 15 229,012 9 550,281 24 Jharkhand 47,241 2 31,051 2 78,292 4 Odisha 333,550 122 259,657 79 593,207 201 West Bengal 940,980 184 889,330 118 1,830,310 302 Cases and deaths due to Enteric Fever, 2013 (Provisional) State Male Female Total Cases Deaths Cases Deaths Cases Deaths Bihar 153,597 2 108,194 - 261,791 2 Jharkhand 14,020 4 10,786 3 24,806 7 Odisha 31,885 20 21,858 15 53,743 35 West Bengal 57,482 19 51,213 20 108,695 39 Cases and deaths due to Acute Respiratory Infection, 2013 (Provisional) State Male Female Total Cases Deaths Cases Deaths Cases Deaths Bihar 1,017,177 14 741,478 6 1,758,655 20 Jharkhand 142,647 49 93,817 31 236,464 80 Odisha 820,066 145 632,396 86 1,452,462 231 West Bengal 1,323,201 506 1,191,405 247 2,514,606 753 Source: National Health Profile, Central Bureau of Health Intelligence CII-Grant Thornton 41

42. References • Central Bureau of Health Intelligence, Ministry of Health and Family Welfare • Internal Grant Thornton Publications • National Health Profile 2013: http://cbhidghs.nic.in/index2.asp?slid=128 4&sublinkid=1166 • http://planningcommission.nic.in/data/dat atable/0814/table_2.pdf • Accreditation: http://www.nabh.co/ • http://www.nabl-india.org/ • http://www.jointcommissioninternational.o rg/about-jci/jci-accredited-organizations/ • Insurance • http://bkky.gov.in/ • http://nrhmorissa.gov.in/OSTF/ • http://www.wbhealth.gov.in/health_schem e.asp?pass_file_id=-1 • http://www.pwc.in/en_IN/in/assets/pdfs /publications/2013/enabling-access-to- long-term-healthcare-funding-in-india.pdf • pwc/IN/in/assets/pdfs/publications- 2012/healthcare_financing_report_print.pd f • http://www.pharmatutor.org/pharma- news/doctors-population-in-india • http://www.hindustantimes.com/india- news/ranchi/jharkhand-doctors-shun-rural- postings-citing-maoist-threat/article1- 1249617.aspx • http://healthcare.financialexpress.com/mar ket-section/1663-ranchi-on-the-radar • http://indianexpress.com/article/india/poli tics/government-plans-10-new-aiims-more- cancer-centres/ • http://www.unicef.org/india/state_profiles _4362.htm • http://www.unicef.org/india/state_profiles _4304.htm • http://www.unicef.org/india/state_profiles _4346.htm • http://www.ibef.org/download/Jharkhand- March-2014.pdf • http://www.ibef.org/industry/healthcare- india.aspx • http://infochangeindia.org/agenda/access- denied/public-health-infrastructure-what- we-need-and-what-we-have.html • http://articles.economictimes.indiatimes.co m/2014-07-10/news/51300758_1_aiims- healthcare-finance-minister-arun-jaitley • http://economictimes.indiatimes.com/articl eshow/41526496.cms?utm_source=content ofinterest&utm_medium=text&utm_campa ign=cppst • http://blogs.timesofindia.indiatimes.com/t oi-edit-page/how-and-why-india-must- introduce-universal-healthcare-coverage/ • http://www.thehindu.com/opinion/op- ed/taking-healthcare-to-indias-remote- tribes/article6370400.ece • http://www.thehindubusinessline.com/opi nion/india-can-be-more-than-a-pharma- hub/article6370230.ece • http://articles.economictimes.indiatimes.co m/2013-10- 27/news/43432740_1_healthcare- infrastructure-12th-plan-period-capital- investment • http://articles.economictimes.indiatimes.co m/2014-07-17/news/51656708_1_infant- mortality-rate-health-officials-health-sector • http://cbhidghs.nic.in/writereaddata/mainl inkFile/Health%20Status%20Indicators- 2012.pdf • http://www.newindianexpress.com/magazi ne/India-has-just-one-doctor-for-every- 1700- people/2013/09/22/article1792010.ece • McKinsey 42 CII-Grant Thornton

43. References • http://gadgets.ndtv.com/mobiles/news/an anya-programme-providing-health-care- services-in-bihar-via-mobile-phone-450605 • http://www.avenuemail.in/ranchi/eight- medical-colleges-opened-jharkhand- cm/31619/ • http://timesofindia.indiatimes.com/city/ra nchi/No-room-for-critical-patients-in- Jharkhand/articleshow/26060133.cms • http://www.biznewsodisha.com/hospitals/ ntpc-to-set-up-medical-college-hospital-in- odisha/ • http://articles.economictimes.indiatimes.co m/2013-11-19/news/44242326_1_esic- state-insurance-corporation-odisha • http://www.thestatesman.net/news/32749- uk-firm-to-invest-rs-425-cr-in-west- bengal.html • http://www.business- standard.com/article/companies/emami- to-invest-rs-1-000-crore-in-cement-hospital- biz-in-bengal-113080701146_1.html • http://www.ibef.org/industry/healthcare- india.aspx • http://news.oneindia.in/2013/05/14/jhark hand-approves-act-to-protect-doctors- hospitals-1216292.html • http://southasia.oneworld.net/news/indian -state-hires-ifc-as-healthcare- consultant?searchterm=#.VAlBHfmSwsd • http://articles.economictimes.indiatimes.co m/2012-08-27/news/33424914_1_ifc- medical-colleges-private-sector • http://www.downtoearth.org.in/content/bi har-district-launches-scheme-provide- emergency-healthcare-through-community- donations • http://gadgets.ndtv.com/mobiles/news/an anya-programme-providing-health-care- services-in-bihar-via-mobile-phone-450605 • http://www.avenuemail.in/ranchi/eight- medical-colleges-opened-jharkhand- cm/31619/ • http://healthcare.financialexpress.com/mar ket-section/1663-ranchi-on-the-radar • http://indianexpress.com/article/cities/kol kata/mamata-approves-cashless-insurance- easy-house-loans-for-state-govt-staff/ • http://www.dailymail.co.uk/indiahome/ind ianews/article-2180676/Bihars-womb- thieves-Private-hospitals-accused-carrying- unnecessary-operations-claim-insurance- money.html • http://www.telegraphindia.com/1130818/j sp/bihar/story_17241417.jsp#.VAlaVfmSw sc • http://timesofindia.indiatimes.com/city/pa tna/Bihars-government-hospitals-in- districts-to-treat-heart- patients/articleshow/23843905.cms • http://archive.indianexpress.com/news/bi har-to-make-phcs-hospitals- webenabled/1166585/ • http://www.telegraphindia.com/1130606/j sp/calcutta/story_16755327.jsp#.VAlKfm O971U CII-Grant Thornton 43

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