Grant thornton healthcare east

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 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

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

The Healthcare
industry:
An overview

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

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

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

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

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

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!

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
Doctors: 4,373
IMR: Rural: 38 (M), 41 (F);
Urban: 24 (M), 30 (F)
MMR (2010-12): 219
Odisha
Doctors: 16,786
IMR: Rural: 53 (M), 56 (F);
Urban: 38 (M), 40 (F)
MMR (2010-12): 235
West Bengal
Doctors: 62,645
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

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

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.

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

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

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
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

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
organisations
India
Medical laboratories - 503 53
Type of Centre
Number of pending
applicants
organisations
India
JCI - 19 1
Joint Commission International

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.

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

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.

Deal space and
funding
mechanism

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
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

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
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

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.

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

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

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.

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

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.

Conclusions and
recommendations

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

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

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

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

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

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

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

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
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
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

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New Delhi 110 001
T +91 11 4278 7070
BENGALURU
“Wings”, 1st floor
16/1 Cambridge Road
Ulsoor
Bengaluru 560 008
T +91 80 4243 0700
CHANDIGARH
SCO 17
2nd floor
Sector 17 E
Chandigarh 160 017
T +91 172 4338 000
CHENNAI
Arihant Nitco Park,
6th floor
No.90, Dr. RK Salai
Mylapore
Chennai 600 004
T +91 44 4294 0000
GURGAON
21st floor, DLF Square
Jacaranda Marg
DLF Phase II
Gurgaon 122 002
T +91 124 462 8000
HYDERABAD
7th floor, Block III
White House
Kundan Bagh,
Begumpet
Hyderabad 500 016
T +91 40 6630 8200
KOLKATA
10C Hungerford Street
5th floor
Kolkata 700 017
T +91 33 4050 8000
MUMBAI
16th floor, Tower II
Indiabulls Finance Centre
SB Marg, Elphinstone (W)
Mumbai 400 013
T +91 22 6626 2600
NOIDA
Plot No. 19A, 7th Floor
Sector – 16A,
Noida – 201301
T +91 120 7109001
PUNE
401 Century Arcade
Narangi Baug Road
Off Boat Club Road
Pune 411 001
T +91 20 4105 7000
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judgment by any recipient. This document is not intended to be a substitute for professional, technical
or legal advice or opinion and the contents in this document are subject to change without notice.
Whilst due care has been taken in the preparation of this document and information contained herein,
neither Grant Thornton nor CII nor other legal entities in the group to which they belong, accept any
liability whatsoever, for any direct or consequential loss howsoever arising from any use of this
document or its contents or otherwise arising in connection herewith.

© 2014 Grant Thornton India LLP. All rights reserved.
Grant Thornton India LLP is registered with limited liability with identity number AAA-7677 and its
registered office at L-41 Connaught Circus, New Delhi, 110001
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