Bridging the Divide - for a Healthy India

Agenda for Transforming Healthcare Delivery in the Northern Region

© Grant Thornton India LLP. All rights reserved.

Contents

03 | Foreword 04 | The Healthcare industry

09 | Healthcare delivery
17 | Healthcare infrastructure 23 | Investment Horizon 28 | Changing trends 32 | Outlook 37 | Appendices 48 | Contact us

© Grant Thornton India LLP. All rights reserved.

Foreword

In a populous nation like ours, with an ever increasing need for healthcare infrastructure and services, the private sector has remained the lynchpin of growth, accounting for more than half of the total healthcare spending in the country. The healthcare delivery sector is characterised by wide regional disparities with rural India being highly underserved. Further, the Southern region has been a change catalyst and far ahead of its Northern counterpart in terms of access, technology, infrastructure and sometimes even, in the quality of service. Against a backdrop of changing demographics and socio economic mix in the Indian population, it is imperative to raise the bar on quality of healthcare service delivery and ensure equitable and affordable access across social strata. Achieving this requires several factors to come together, not least the optimal utilization of existing healthcare resources and the role the government needs to play in the holistic development of a regional healthcare system. In this paper, we attempt to bring out the current state of affairs in the healthcare delivery space in the northern region of India, recent trends in the sector and challenges in executing an effective healthcare agenda, with recommendations and actions for transforming healthcare in North India.

Harpal Singh Conference Chairman & Past Chairman CII Northern Region

Mahadevan Narayanamoni Partner and Practice Leader Healthcare and Life-sciences Advisory Grant Thornton India LLP

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3

The Healthcare industry
Market size and segmentation

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4

5 . Rs 37. only 48% are functional the private sector accounts for 65% of the total number of operational beds.35 million hospital beds in the country. while the public sector spend has been only 1. as per the Health Ministry statistics. in terms of the total health expenditure per capita (in US$).330 crore from the revised estimates of Rs 24. Overall healthcare spending (public and private) accounts for a mere 4% of India's GDP. well below the WHO’s recommended 1:1. All rights reserved. lack of healthcare facilities in the rural areas as well as among those at the bottom of the pyramid is one of the big challenges in delivering scalable healthcare options © Grant Thornton India LLP. India spends the least on public healthcare among the BRICS nations. the Union Budget has allocated larger funds for the health sector.5% across Organisation for Economic Co-operation and Development (OECD) countries.4%. doctor-to-patient ratio for rural India. and over 70% of the spending on healthcare in India. stands at 1:30.000. for FY14.894 crore for FY13 merely 20% of India’s 1.2 billion population is covered by health insurance of the 1. Private sector accounts for more than 70% of this spend. far below the average of 9.000.Glaring statistics our country ranks 112th on the World Health Organisation’s (WHO) ranking of the world’s health systems.

The lack of requisite infrastructure in the semi-rural and rural areas of northern India is one of the key barriers to the delivery of basic healthcare services in the region. Mohali and the surrounding areas have been attracting patients from overseas. The Indian healthcare sector encompasses hospitals. Jammu & Kashmir. Chandigarh. Punjab. Uttarakhand and Uttar Pradesh) continue to battle high rates of infant mortality and incidence of deaths due to dengue. Rajasthan. Among the primary subsectors of the healthcare sector. Himachal Pradesh. All rights reserved. cholera. hospitals and pharmaceuticals account for the largest revenue. The hospital services market.Market size and segmentation The healthcare sector is the third largest contributor to the Indian economy in terms of revenue and employment generation potential. is expected to reach US$81. Haryana. which forms one of the largest segments of the Indian healthcare sector. northern India is witnessing a steady rise in medical tourism. © Grant Thornton India LLP. medical equipment and supplies. pharmaceuticals. The number of hospitals and inpatient beds available relative to the total population of the region is far lower than the national average. Amritsar. Leveraging improved technology and infrastructure of medical institutions. 6 . medical insurance and diagnostics. respectively. the region still lags behind many parts of the country on several healthcare parameters. contributing as much as 71% and 13% of the total revenue. diarrhea and other ailments. 3% 9% 4% 13% Healthcare market in India (% share) 71% Hospital Medical Devices Medical Insurance Pharmaceuticals Medical Diagnostics Healthcare delivery in the North While the healthcare delivery sector in North has been making progress with a number of hospitals and healthcare centres gaining accreditations from National Accreditation Board for Hospitals & Healthcare Providers (NABH). The states (Delhi.2 billion by 2015. A number of cities including Delhi / NCR.

What drives growth? The growing demand for quality care Increasing ability to pay for services Shift in demographics and change in spending patterns Rising penetration of the medical insurance market Gaps in existing and requisite healthcare delivery infrastructure 1 .the skill gap. mobile linkages to rural areas and efficient utilisation of existing infrastructure holds the promise to bridge the gap between healthcare need and supply in several parts of the North © Grant Thornton India LLP. In a nutshell • the key challenges faced by the healthcare delivery sector currently include the following: .ability to leverage technology .8 million new beds to fulfil the targeted 2 beds per thousand people. The demand for quality healthcare services outstrips the supply from the public healthcare system which becomes an opportunity to be a key growth driver for the private healthcare sector. This trend is already underway in Tier I cities. 2 3 4 5 With the rising middle class population. which has begun to witness the proliferation of specialty hospitals and healthcare centres. including those in northern India. the average real household disposable income is likely to double from 2005 to 2025 leading to an increased expenditure on healthcare. by the end of 2025. the country will require an additional 1.ability to leverage existing infrastructure (nursing homes/ clinics/ excess capacity in hospitals) . The rise of health conscious consumers who can afford quality healthcare is expected to also fuel the demand for specialised healthcare services/delivery. shortage of doctors and trained staff • deployment of technology. 7 . It is estimated that.limited success under the PPP route .access to affordable real estate . All rights reserved.

provide infrastructure and financial support mobile healthcare units to form the link between the interiors and the nearest facility rural public infrastructure must remain at the forefront of healthcare policies preferential land allotment/ subsidies where there is infrastructure gap cutting down the risk of deaths in maternal and perinatal conditions increase public health spending streamline drug purchase stocking distribution arrangements low-cost day care surgery models at government hospitals continued focus on development of medical colleges and institutions © Grant Thornton India LLP. before allowing for more link ASHA‟s to the nearest facilities.Recent policy initiatives To increase access and utilisation of quality health services by the rural population. The initiative entails the provision of a trained female community health activist in every village in the country. 8 . Government of India's Ministry of Health and Family Welfare (MoHFW) has instituted Accredited Social Health Activists (ASHAs). The female community health activist is a representative of the village and works as an interface between the community and the public health system. improve manpower availability and skills of healthcare service providers and improve accessibility of drugs and diagnostics and service delivery in the rural areas.000. As a part of NRHM. To-do’s • • • • • • • • • • efficiently utilise current infrastructure. the Central Government launched the National Rural Health Mission (NRHM) in April 2005. All rights reserved. NRHM has helped upgrade health infrastructure. The scheme will cover over 779 Indian cities and towns. as well as several Tier I cities. which will focus on slums and urban poor. NUHM will cover all cities and towns with a population of more than 50. The Centre is also planning to launch the National Urban Health Mission (NUHM).

operating models and recent trends © Grant Thornton India LLP. 9 .Healthcare delivery Key players. All rights reserved.

Tier 1 and Metros • patients shift to Tier 1 for advance treatment • OT & ICU usually are present • mostly 25-100 beds • some cases up to 100 – 200 beds Private • • District Hospital Community Health Centre • • Mid-sized Secondary care Nursing Homes Healthcare facilities that require constant medical attention.Healthcare delivery pattern Tertiary care Government • • • • • • super-specialty services mostly in Metros and Tier1 15% = > 300 beds 80% = 200 to 300 beds 5% = Avg 75 beds mix of colleges. 10 . from trained manpower using high-end sophisticated technology Secondary care Government • General Hospital • absence of super specialty services offerings • present in Tier 2. including short period of hospitalisation Primary care Government • primary role to treat ailments that do not require surgical intervention or advance care • services vary across cities • may have ICU and minor OT • up to 30 – 40 beds • located in smaller towns • are also located in Tier I. single and multi-specialty facilities Private • • Teaching Institutions Medical Colleges • • Corporate Hospitals Trust Hospitals Specialised high-end Care. All rights reserved. Tier II and Metros Private • Primary Health care centre • Clinics The basic healthcare facilities for common and minor ailments where prevention is most effective © Grant Thornton India LLP.

Cradle. International Oncology • Orthopaedics: Mewar Ortho. Primary Healthcare • Express Clinics • Nationwide • Vital Healthcare Closest to the concept of a neighborhood clinic.Agarwal's Eye Hospital. which have low affordability among patients • • • • • • Apollo Hospitals Care Hospitals Columbia Asia Fortis Healthcare Manipal Hospitals Max Healthcare Single Specialty Hospital • Eye and Dental: Vasan Healthcare. consisting of all the state-of-the-art equipment required to perform complex surgeries. Nova IVI. EyeQ • Fertility: Cocoon. Primus • Urology / Nephrology: RG Stone.Healthcare service delivery models Health City Brief description Integrated Healthcare Facilities of more than 1000 beds spread across a few acres of land and providing many specialties • • • • • Illustrative examples AIMS (Kerala) Apollo (Hyderabad) Fortis (Gurgaon) Medanta Medicity (Gurgaon) Narayana Hrudayalaya (Bangalore. it forms the first point of contact for routine examination. Centre for Sight. Cloudnine. Dr. Fortis La Femme. All rights reserved. Motherhood. Nephro Plus. 11 . A hub is a high-end facility located in a metro/ tier-1 city. Nephro Life Hospitals focusing on single specialty care services are upcoming healthcare facility models. Kolkata) Hub and Spoke / Multi chain Tertiary care hospital functions as hub and secondary care hospitals and clinics function as spoke. Hosmat. Bourne hall. Emerging Delivery Models • Day Surgery centres (Nova Medical Centres) • Home Health providers (IHH in Chennai) • Urgent Care New service providers are experimenting with different delivery models focusing on low cost. Adiva • Oncology: HCG. day care and other allied healthcare models Share of public and private sector in healthcare delivery services in India 2015 19% 40% 11% 30% Government Hosp Top Tier Mid Tier 2005 • Top Tier >100 beds • Mid Tiers 30-100 beds • Nursing Homes <30 beds 34% 26% 14% 26% Nursing Home © Grant Thornton India LLP. Jaipur. A spoke is traditionally located in a tier-2/ tier-3 city. Axiss Dental. Sparsh.

12 . with funding often from the State/ Centre and affordable/ accessible healthcare meant for the masses • Apollo (tied up with public sector coal companies and in negotiations with Indian Railways) • Fortis (Rajiv Gandhi Hospital. technology to franchisee hospital or clinic. Amethi) • Seven Hills (partnered with Mumbai Municipal Corporation) Healthcare REIT • Germany: Vital Healthcare Property Trust. All rights reserved.Healthcare service delivery models Franchisee Model Brief description Hospital group lends its brand. NorthWest Healthcare Properties Real Estate Investment Trust Global REITs such as Alexandria and Religare Health Trust have entered in India. They are starting to promote asset-backed financing with an aim to address the infrastructure needs of hospitals Top Tier >100 beds Top Tier >100 beds Mid Tiers 30-100 Mid Tiers 30-100 beds beds Nursing Homes <30 Nursing Homes <30 beds beds © Grant Thornton India LLP. • Apollo Hospitals • Max Healthcare Examples Public Private Partnership Collaborative model. Ventas Inc. Target Healthcare REIT Limited • USA: LTC Properties Inc. expertise. Universal Health Realty Income Trust • Singapore: Parkway • UK: Primary Health Properties PLC.

Faridabad (250) • Bone & Joint Hospital (244) • Shri Maharaja Hari Singh Hospital (250) 500-1000 beds >1000 beds • Guru Teg Bahadur • Lok Nayak Jai Hospital (1000) Prakash (LNJP) • Paras Spring Meadows Hospital (1597) Hospital (806) • Maulana Azad • Ram Manohar Lohia Medical College Hospital (984) (2400) • Rockland Hospital (664) • Safdarjang Hospital • St.Kapur Memo Hospital (300 • Deepak Memorial Hospital ( Medical Research Centre (100) • Max Balaji Hospital (134) • Max Super Specialty.Stone Urological Research Centre (39) • Sanjeevani Medical Research Centre (50) • Shree Jeewan Hospital (40) • Vinayak Hospital (39) • VIMHANS (87) • Sonia Hospital (65) • Kukreja Hospital & Heart Centre (70) 100-500 beds • Holy Family Hospital (232) • Institute of Liver & Biliary Science (180) • Jaipur Golden Hospital (256) • Kalawati Kasturba Hospital (350) • Maharaja Agrasen Hospital (380) • Metro Hospital & Heart Institute. Naraina (150) • National Heart Institute (104) • Primus Super Speciality Hospital (120) • Pushpanjali Medical Centre (151) • Rajiv Gandhi Cancer Institute (241) • Park Hospital (170) • Mata Chanan Devi Hospital (207) • Maharaja Aggarsain Hospital (380) • Kalra Hospital (P) Limited (120) • City Hospital (120) • Delhi Heart & Lung Institute (101) • Dr.Competition Dynamics … sub 500 lead the pack! <100 beds • Kalawati Saran Children's Hospital (84) • Pushpawati Singhania Research Institute (75) • R. Gurgaon (150) • Paras Hospitals (250) • Alchemist Hospital (120) • Metro Hospital & Heart Institute. Saket (490) • Artemis Hospital (300) • Metro Hospital & Heart Institute.L. All rights reserved. Stephen‟s Hospital (1600) (595) • Sucheta Kriplani Hospital (877) Delhi • Haryana Fortis Memorial Research Institute. J&K Government Medical College Hospital (1700) 13 .B.G. Gurgaon (500-1000) • Medanta Medicity (1250) • Please note that the above list of hospitals is not a comprehensive list of all hospitals in the respective regions and has been selected based on internet search and featured hospitals in reports and medical websites. © Grant Thornton India LLP.

HP • Indus Hospital (90) • Delek Hospital (45) • Mahatma Gandhi Medical Services Complex Khaneri (360) Please note that the above list of hospitals is not a comprehensive list of all hospitals in the respective regions and has been selected based on internet search and featured hospitals in reports and medical websites. Phaco Surgery Centre (30) • Dwarka Orthopaedic Hospital (30) • Jaipur Hospital (93) • Khandaka Hospital (30) • Shubh Hospital. Gurdaspur (20) • Garg Mission Hospital (30) • Jattinder GH Hospital (50) • Modern Hospital (32) • Seth Hospital (30) • Sibia Healthcare Private Limited (26) • Tagore Hospital & Heart Care Centre (24) • Vidya Memorial Kanwal Hospital (35) • • • • • • • • • • • • Silver Oaks Hospital (149) Fortis Hospital (279) Ivy Hospitals (180) Apollo Hospital (350) BBC Heart Care Pruthi Hospital (300) Fortis Escort Hospital (133) Indus Super Specialty Hospital (115) Ivy Hospital-Multi Specialty & Cancer Research Institute (180) Kidney Hospital (125) Nagpal Super Speciality Hospital (100) Nova Heart Institute and Research Centre (200) Max Super Speciality Hospital. All rights reserved. Jaipur (110) Santokba Durlabhji Memorial Hospital (375) Soni Hospital (225) Mathura Das Mathur Hospital (493) Sudha Hospital.Jaipur • Mahatma Gandhi Hospital (624). Malviya Nagar (350) Mahaveer Cancer Hospital (250) Rukmini Devi Jaipuriya Government Hospital (100) Rungta Hospital. Talwandi (50) • • • • • • • • • • • • • • • Mahatma Gandhi Medical Hospitals (750) • Mahatma Gandhi Hospital (820). Malviya Nagar (100) Saket Hospital. Virendra Laser.Competition Dynamics … sub 500 lead the pack! <100 beds 100-500 beds • Mukat Hospital & Heart Institute (100) • Ivy Hospital (180) 500-1000 beds • Government Specialty Hospital (500) >1000 beds • Post Graduate Institute of Medical Education and Research (1402) Chandigarh • Government Medical Hospital and College (60) • Cosmos (60) • Bahri Hospital.Jhodpur • Umaid Hospital (700) • Narayana Hrudayalaya Hospital (1000) • Sawai Mansingh Government Hospital (1563) © Grant Thornton India LLP. 14 . Mohali (200) Fortis Escorts (210) Soni Medicare (225) Sahai Hospital (100) Fortis Life Line Hospital (100) Fortis Escorts Hospital. Talwandi (350) Ramsnehi Chikitsalaya Avm Anusandhan Kendra (300) • Christian Medical College • DMC Ludhiana (1326) & Hospital (850) • Guru Nanak Dev • Shri Guru Ramdas Hospital (1158) Hospital (992) Punjab Rajasthan • Dr. Mansarovar. Vidhyut Nagar (40) • Maitri Hospital.

All rights reserved. A. Sikandra (100) • District Hospital (118) • Lady Lyall Hospital. © Grant Thornton India LLP. Noorie Gate (331) • Pushpanjali Hospital and Research Center.M. Vaishali (400) • Gangasheel Hospital (100) • Shanti Gopal Hospital (102) • Yashoda Super Speciality Hospital (106) • District Hospital (172) • Divisional Railway Hospital (185) • Kulwanti Hospital and Research Center (100) • Nirmal Hospital (150) • Chandani Hospital (152) • Mariampur Hospital (194) • Regency Hospital Limited (225) • Ajanta Hospital (100) • Awadh Hospital (102) • Chhatrapati Shahuji Maharaj Medical University (226) • Mayo Hospital (300) • Neera Hospital (160) • Kailash Hospital & Heart Institute (325) • Vinayak Hospital (150) • Kailash Hospital & Heart Institute (325) • Vinayak Hospital (150) 500-1000 beds • Institute of Mental Health and Hospital. Billochpura (838) • Sarojini Naidu Medical College (976) • Moti Lal Nehru Hospital (1000) • District Deen Dayal Upadhayay Hospital (500) • Jawaharlal Nehru Medical College.U (1000) • Jeevan Jyoti Hospital (500) • MLB Medical College and Hospital (700) • Command Hospital (544) >1000 beds • Ram Raghu Hospital (1047) • LLR Hospital (1615) Please note that the above list of hospitals is not a comprehensive list of all hospitals in the respective regions and has been selected based on internet search and featured hospitals in reports and medical websites. Uttar Pradesh 15 .Competition Dynamics … sub 500 lead the pack! <100 beds • Sri Ram Hospital (50) • Bhola Hospital (40) • Heartline Cardiac Care Hospital (50) • Happy Family Hospital (62) • Jain Hospital (30) • R K Devi Memorial Hospital (45) • Fortis Hospital (75) 100-500 beds • Asopa Hospital. Delhi Gate (350) • Jeevan Jyothi Multi Speciality Hospital (400) • Kamla Nehru Memorial Hospital (306) • Nazreth Hospital (300) • Priti Hospital (108) • Pushpanjali Crosslay Hospital.

© Grant Thornton India LLP. “We aim to keep our capital and operating costs low and operate our centres in an environment of patient centricity –quality surgeries. NGOs and private sector) should be aligned to make a full chain from ground up… We have a mass enabler already – in the form of ASHA . technology advancement and safe infrastructure” Dr Manish Chhaparwal Mewar Ortho provides high quality. quick discharge. All rights reserved. The chain has recently secured private equity funding from India Equity Partners. clearly define the functionalities. fast turnaround care for patients in Tier II cities. use mobile units for connectivity to B&C cities and a national network will be in place” Dr Naresh Trehan Medanta Medicity. provide access to technology. where there is a dearth of orthopaedic and allied care facilities. has changed the face of surgery in India across multiple specialties.Industry speak “We need to re-write the blueprint for Health India… All three segments (public health systems.upgrade their skills. Dr Amit Sachdeva Axiss Dental is currently a North India focused chain of dental centres providing orthodontic and implantology solutions. envisioned as a health city. Mewar has recently completed its first institutional round of equity funding from Matrix Partners. 16 .

17 . mortality rates © Grant Thornton India LLP. All rights reserved.Healthcare infrastructure Public health. disease profiles.

All rights reserved.Zonal characteristics of Healthcare in India • inadequate infrastructure and facilities as compared to South • metro cities still preferred as medical tourism destination • more hospitals opening up. This makes projects unviable and attracts less investments • resistance from skilled staff to settle in this region • high number of private nursing homes but very few multi-specialty hospitals East • • • • • Chennai is also known as the Mecca of healthcare delivery top seven out of the ten PE healthcare deals were in South India in 2012 higher concentration of super specialties and average bed size greater than other zones better infrastructure hospitals such as Vaatsalya Healthcare. Apollo and Global are entering rural markets and establishing secondary care hospitals in view of lower investments and higher profitability South • good multispecialty hospitals are concentrated in Maharashtra and Gujarat • wide rural-urban gap in health infrastructure facilities both in terms of quality and quantity • district-wise variances (Mumbai and Pune have better population to facility ratios) West © Grant Thornton India LLP. At least 80 hospitals in Uttar Pradesh have recently applied for NABH accreditation North • least developed among all zones • inadequate and low-end infrastructure and facilities • hospital projects in Tier II towns getting funded by borrowings from banks which carry significant amount of interest. 18 .

856. 2011. Haryana are also lagging behind the WHO recommended norm of one doctor per 1000 people 1 2 3 Population: 12. 39 (F). Within the northern region.926 Doctors: 11.621. Press Information Bureau. Urban – 29 (M). 34 (F) MMR (2007-09): 318 Population: 16. Urban – 27 (M).353.477 Doctors: 57900 Population served per doctor 3477 IMR: Rural – 61 (M).116. 64 (F). 47 (F).548.081 Doctors: 4100 Population served per doctor 6184 IMR: Rural – 51 (M). Uttarakhand.200 Population served per doctor: 1120 IMR: Rural – 43 (M).Healthcare Indicators J&K 1 Himachal Pradesh 2 3 Punjab Haryana 4 Delhi 6 Rajasthan 5 Uttarakhand 7 UP 8 The total number of doctors registered (allopathic) in the country till 31st July. 67 (F).235 Doctors: 46800 Population served per doctor: 358 IMR: Rural – 32 (M). The current doctor-population ratio in India has been worked out to be approximately 1:2000.A Northern Tale . Urban – 35 (M). Urban – 44 (M).509 Doctors: 800 Population served per doctor: 8571 IMR: N/A MMR (2007-09): N/A Population: 27.012 Doctors: 28500 Population served per doctor 2408 IMR: Rural – 58 (M). Medical Council of India (MCI).56. states such as UP. All rights reserved.400 Population served per doctor: 721 IMR: Rural – 36 (M). Urban – 28 (M). 29 (F) MMR (2007-09): 172 6 Population: 25.065.236 Doctors: 38. Figures of Medical Practioners are related to doctors registered with State Medical Councils.752 Doctors: 3300 Population served per doctor 3066 IMR: N/A MMR (2007-09): N/A Population: 199.704. 45 (F) MMR (2007-09): 359 Source: Ministry of Health & Family Welfare and National Health Profile. 19 . 42 (F) MMR (2007-09): 153 7 8 Population: 68. Urban – 29 (M). 29 (F) MMR (2007-09): N/A Population: 10. © Grant Thornton India LLP. 52 (F).581. 42 (F).753. 37 (F) MMR (2007-09): N/A 4 5 Population: 6. 2011 is 8.

it is evident that there exist significant inequities in healthcare access within the states of the northern region. disease prevalence vary across states. 2011 © Grant Thornton India LLP. Hospital Bed 3122 809 Number Beds Number Beds Haryana Himachal Pradesh Jammu & Kashmir Punjab Rajasthan Uttar Pradesh Uttarakhand Chandigarh Delhi 61 97 1212 2905 93 53 6667 5574 61 78 380 515 666 1 - 1820 2360 13754 15450 3746 50 - 31 135 446 346 29 3 126 2125 8063 12236 40934 4219 570 43109 11099 27704 68621 197271 9511 1328 16955 120641 130066 83076 229118 13685 342000 134563 2813 2658 2640 3499 1194 2206 393 Source: National Health Profile. 20 . Table 1: Number of Government hospitals and beds in rural and urban areas . Densely populated areas such as Uttar Pradesh and Rajasthan are ranked poorly as the average population served per government hospital bed is significantly higher as compared to other northern cities such as Delhi and Punjab which have better access healthcare quality and infrastructure. The Jammu and Kashmir Government is planning an investment outlay to the tune of Rs 140 million to establish two hospitals in Kulgam and Anantnag districts. Kerala and West Bengal perform far better in public infrastructure as compared to their Northern counterparts such as Uttar Pradesh and Bihar.North India North Indian states Rural Hospitals (Government) Urban Hospitals (Government) Provisional /Projected Population as on reference period in (000) 24597 6856 Average Population Served Per Govt. All rights reserved. patient profile. healthcare spend. States such as Karnataka. Hospital 159721 45707 Average Population Served Per Govt. UP Health Systems Strengthening Project has been launched by the State Government with World Bank funding worth Rs 800 crore.Public Healthcare Infrastructure Although healthcare choices.

All rights reserved.News bytes Some recent activities in the healthcare sector in the northern region © Grant Thornton India LLP. 21 .

and Jalandhar and has recently acquired two brownfield ventures in Chandigarh and Jodhpur. 22 . Mandsaur. Jharkhand. ASG Eye Hospitals has raised Rs 50 crore from Sequoia Capital to support expansion in central and north Indian states including Madhya Pradesh. Haryana as well as a 500 beds hospital in Greater Noida (Uttar Pradesh) ASG Eye Hospitals. Bareilly. Rockland Group will open a multi-specialty 505 beds hospital in Manesar. The fund will support the expansion plan of the hospital Besides undertaking the construction of a new 300bed hospital at its Medcity campus.News bytes Some recent activities in the healthcare sector in the northern region Fortis Healthcare (India) plans to launch four hospitals including one in Himachal Pradesh to be operational by 2013. as part of its plans to strengthen its nationwide presence. Apollo Hospitals Group launched its first Apollo Cosmetic Clinic in North India. Rajasthan based group of super specialty eye hospitals. a Rajasthan based group of super specialty eye hospitals has recently raised Rs 50 crore from Sequoia Capital. Moolchand Healthcare has also earmarked Rs 100 crore for acquisitions in the pathology and diagnostic segment © Grant Thornton India LLP. Immediate expansion plans for Mewar Ortho include setting up a 100–bed centre of excellence in Udaipur while also increasing its footprint in Central India with centres in Sirohi. Chittorgarh and several more. All rights reserved. As a part of its expansion plans over the next couple of years. Uttar Pradesh. Chhattisgarh and Bihar Metropolis Healthcare has made investments of Rs one crore each in Tier II and Tier III cities such as Lucknow.

Investment Horizon Deal trends. All rights reserved. options – public and private route © Grant Thornton India LLP. 23 .

not easy for mid-cap companies 2 Mezz/ Debt High fixed cost. restrictions on deal structures due to FDI regulations.Private Funding Options Establishing and growing a hospital business requires intensive planning and large capital outlay. 1 Capital Markets Depends entirely on market conditions. 24 . which makes it imperative for players to pursue new avenues to meet their capital needs. All rights reserved. there is usually no other option © Grant Thornton India LLP. restrictions on deal structures due to FDI regulations 6 Angel Investors For very early stage deals. limited number of providers 3 Private Equity Growth Capital – Most active in today's market 4 Overseas Listing Depends on market conditions 5 REIT Limited number of operators.

14 Table 4: PE deals in the hospitals sector in north India (2010-2013) Investor SONG Investment Advisors Temasek Holdings Helion Venture Partners. we are seeing consolidation. which is driving increasing corporatisation of that market. given their attractive unit economics and capital efficiency metrics.Deal Street Table 3: FDI inflows in healthcare sector (April 2000 to December 2012) Sector Hospital and diagnostic centres Drugs and Pharmaceuticals Medical and surgical appliances Amount (US$ million) 1. Government of India 20 5.3 - Source: Department Of Industrial Policy & Promotion (DIPP). etc. are areas we expect to see significant transaction activity in 2013. paediatrics. Eye care. and beyond.783 584. pathology. orthopaedic surgery. This is enabled by a few players with access to significant amounts of capital and with ambitions/ plans to expand rapidly without going through the typical 3 year + maturity period for greenfield projects. All rights reserved. maternity. Nexus Venture Partners Sequoia Capital India Equity Partners Matrix Partners India Investee Eye Q Max India Eye Q Moolchand Healthcare Axiss Dental Mewar Orthopedic Amount (US$ million) ~ 26. dental care.4 Source: Grant Thornton Deal Tracker The data includes deals till March 2013 The healthcare delivery market is very interesting and active from a transaction point of view. Chains of single specialty hospitals and diagnostics businesses are to continue attracting significant interest from PE funds as well as strategic players. low-end imaging. some divestments as well already). In multi-specialty hospitals. having made several acquisitions in India and Overseas (and interestingly.35 9. 25 . © Grant Thornton India LLP. Fortis has been an active player.542.

Policy Initiatives Union Budget 2013-2014 National Health Mission (NHM) Creation of a new integrated NHM with an allocation of Rs 21. sanitation workers. rag pickers and mine workers Tax Initiatives Subsection (11C) in Section 80-IB. taxi drivers. training and research Rs 4.727 Crores has been allocated. the Government is granting Tax Holiday to hospitals starting their operations in rural belts between 01 April 2008 to 31 March 2013 Medical Education Infrastructure Development Intends to enhance its investment outlay in the infrastructure development to over Rs 46.650 Crores provided to AIIMS-like institutions commissioned in September 2012 for developmental activities © Grant Thornton India LLP. 26 .74 trillion during the next five years To improve medical education. Additional funding of Rs 1. All rights reserved.239 crores National Program for Healthcare of Elderly Allocation of Rs 150 Crores to National Programme for the Health Care of Elderly (implemented in 100 selected districts of 21 States) Rashtriya Swasthiya Bima Yojana Health insurance covers under extended to include rickshaw pullers.

All rights reserved. Delhi. especially in tier I and tier II cities in the North © Grant Thornton India LLP. Rajasthan.Fostering Partnerships Public/ Private Boost As per estimates. neurology and joint replacements. there exists huge opportunities for fostering partnerships between the public and private sectors as well as the various private sector players in the healthcare space to deliver quality healthcare to the Indian population The healthcare and life sciences sector attracted 18 investments worth US$98 million during the year The development of industrial corridors across Delhi. healthcare and life sciences sector became the second most preferred investment destination among the venture capital investors A large number of biotech and pharmaceutical players are partnering with domestic players in Haryana. Uttarakhand to strengthen their market standing Demand-supply mismatch is likely to create enormous investment potential across specialities such as cardiology. Haryana and Rajasthan is expected to boost investment to the pharmaceuticals and healthcare sector of the region During 2012. 27 . debt financing/ bank loans from nationalised banks contribute over 50% of long-term financing for hospitals With the Planning Commission intending to augment the public health spending up to three times during the 12th Five Year Plan. UP.

All rights reserved.Changing trends Improving healthcare delivery © Grant Thornton India LLP. 28 .

training to medical personnel in the use of new diagnostic and surgical equipment. at competitive costs • aids in better retrieval of information by doctors resulting in informed and swift decision making • relatively lower storage space requirement • low cost of maintenance over the traditional medical libraries • facilitates bidirectional electronic sharing of patient data between external laboratories. All rights reserved. HER. • educating the general public about the various essentials of healthcare • advocating a shift from curative to preventive healthcare • enables hospitals to ameliorate the inconveniencies of using existing paper records • ensures efficient data storage. prescriptions. data recovery. medical colleges. • used to capture billing data including patient demographics. (Source: Gartner). previous consultation records. history of various drug allergies. which is used to seamlessly manage the whole process of healthcare delivery right from the entry of the patient to his discharge.The technology impediment Lack of data of outcome is key cons Technology progression is set to change the face of healthcare delivery in the country. from US$53 billion to US$57 billion. images. data backup. data portability and data maintenance. basic training and various intricacies of in-patient care to nurses. etc. IT enables the development of new models of care delivery and payment reform by bringing in better billing transparency and building capacity in line with the demand. a tool to capture basic patient data such as patient medical history. Spending on Information Technology (IT) products and services by the healthcare providers in India will increase by 7% between 2012 and 2013. 29 . This non-traditional collection of tutorials and information in the form of text. external provider and the home provider practice The Electronic Medical Record (EMR) Signifying the digital format of a patient medical record. practices or specialists outside the home provider practice. healthcare sector firms. billing data. • help in scheduling of appointment and report generation © Grant Thornton India LLP. Mobile healthcare (m-health) Use of mobile phones to improve the real-time collaboration between healthcare service providers and patients EHR serves to overcome the limitation of EMR. etc. information of insurance payers. and improving the experience of care for patients and families. by controlling costs. these are mainly set up in hospitals. etc. essentially. etc. Table 5: Technology in healthcare Technology in healthcare Digital Health Knowledge Resources Brief description Advantages/ Uses • relatively lower storage space requirement • low cost of maintenance over the traditional medical libraries Archived medical and scientific information. healthcare centres. research institutes. the EMR is. etc. audio or video is currently being deployed to provide frequent training programmes to doctors. that patient medical records cannot be sent electronically to any other sources such as laboratories. E-learning platforms • training patients who use self-diagnostic kits • training the users of device implants • training the various stakeholders in the use of new IT applications in healthcare such as EMR. encompassing various modules associated with the innumerable departments and functions in a hospital. HIS is an electronic platform. The Electronic Health Record (EHR) Hospital Information System (HIS) • • • • • • • rooting out inefficacies in the system reducing costs offering a higher quality of patient care improving patient medical data integrity avoiding duplication of data minimising transcription errors ensuring real time data access for doctors and other healthcare service providers PRACTO An online practice management software that facilitates storage of healthcare records such as patient demographics. insurance details etc. standardising quality of service delivery.

messages and reminders regarding consultations and medications to AIDS patients. including the World Summit Award for eHealth. © Grant Thornton India LLP. known as the “Teledoc” project. The project. The committee also advocates adoption of mobile health solutions to enhance real-time collaboration between patients and providers and between providers. 30 . All rights reserved. has won widespread acclaim globally. a healthcare venture on the outskirts of Delhi. In a recent report for the 12th Five Year Plan. The application is used to send healthy living tips. the steering committee on health has recommended connecting all the district hospitals to tertiary care centres by telemedicine using applications such as “Skype” which facilitate audio-visual interactions.Tele-docs and Tele-medicine A novel idea implemented by Haryana Jiva International. improvement in the rate of transmission of data and information between the various stakeholders and promotion for the adoption of preventive healthcare across the various Indian states. Grameen Foundation has rolled out an m-health service for AIDS patients in India. It deploys a GPRS enabled Java application to enhance the reach of medical care to rural parts of the region.

no-frills hospitals Brief description Enable cutting back the extraneous costs associated with healthcare and diagnostics for the middle and lower-middle classes focus on a single target patient group or discipline comparatively lesser capital expenditure and operating costs than multi-specialty hospitals specialised training ensures higher success rates and efficiency these centres focus mainly on minimally invasive surgical procedures after recovering from a surgery. 31 . rising income levels and changing lifestyles are driving the focus towards wellness and preventive healthcare these centres encompass Ayurveda treatment centres. as well as functions such as finance and management are often shared between the different speciality hospitals mostly. Table 6: Non-conventional healthcare delivery models Model Low cost. pharmacy and wellness services to coordinate management of access to appropriate primary healthcare assists in broadening the market reach given that the senior living sector in the country comprises of nearly 100 million people. facilities such as blood banks. which plans to establish low cost hospitals in Mysore. etc. refers to a single campus having wellness centres. multiple single speciality hospitals. elderly people are offered various facilities including full time/ visiting professional personnel. dietary counselling facilities. alternative medicine centres. etc. the Apollo Hospitals group has also adopted this model to set up 250 low cost „Apollo Reach Hospitals‟ hospitals in Tier II and III cities. imaging centres. clinical laboratories. diagnostic. the senior living sector will grow to nearly 173 million in such centres. a patient is fit to be discharged within 24 hours low cost of surgery owing to lower capital cost and reduced time required to break-even higher incentives for doctors and healthcare professionals use of modern anaesthesia and painkillers enables the patient to recover consciousness quickly after surgery and recuperate at home overnight stay in the hospital is not required by the patient a patient recovers from surgery and is deemed fit to be discharged within a couple of hours of surgery integrates primary care. health cities are located on the outskirts of cities Specialist hospitals Day care surgery Ambulatory Surgery Primary care networks Senior Living Centres/ Hospitals Wellness Centres Health cities © Grant Thornton India LLP. medi-spas. it is a largely untapped sector as per Association Senior Living India (ASLI).Non Conventional Delivery Models In addition to Narayana Hrudayalaya. All rights reserved. most of whom are independent and financially stable. Siliguri and Bhubaneshwar in the near future. by 2025. as well as medical and entertainment facilities increased discretionary spending. educational and training institutes. centres of excellence (COEs).

All rights reserved. 32 .Outlook Strategic recommendations © Grant Thornton India LLP.

funds and services are equitably allocated. Inspiration and learning from southern states such as Kerala and Tamil Nadu which have successfully brought about effective changes to their healthcare regime. Do not build additional capacity until the existing bed capacity is not efficiently utilised. Success stories • GVK Emergency Management and Research Institute (EMRI) – a not-forprofit professional healthcare services organisation • B. Baroda. is coming up with 5 hospitals in Tier III cities. operating on Build -Operate-Transfer (BOT) mode.Transforming Healthcare . utilised. 33 . CHCs and super specialty clinics/hospitals • Ayush Graham Bhawali Project. Forecasting and Assessment Council (TIFAC) and Birla Institute of Scientific Research (BISR). Technology Information. Siliguri and Bhubaneshwar © Grant Thornton India LLP. established in Nainitial • A joint venture of the Apollo Hospitals group and the Government of Karnataka. Challenges (s) • lack of requisite infrastructure • Recommendations Adopt PPP model to permit private sector to expand the coverage of healthcare delivery and provide diversity of services. Unani and Siddha medicine to serve as “independent care providers” in a rural setting • inefficiencies in • launching secondary care public healthcare hospitals in less developed Tier system in semiII tier III belts of the country urban and rural • link the deeper regions through areas mobile vans.Agenda for action It is imperative for the sector to not only raise the quality of service delivery. the Rajiv Gandhi Super-Specialty Hospital in Raichur. by undertaking strong action on social determinants and making comprehensive efforts to enhance the efficiency of public health system respectively. Bhavnagar and Jamangar • skill gap. especially in rural areas • improve the outlay for establishing Government medical institutes • improve the training methods • train the district head in ASHA • • • Tamil Nadu State Government has undertaken a pilot project to train and certify the practitioners of indigenous medicines such as Ayurveda. the Uttarakhand Mobile Hospital and Research Center (UMHRC) to offer healthcare services diagnostic facilities to poor and rural people residing in the hilly terrains of the state • UP State Government considering adoption of PPP to launch district hospitals. distributed and accessed. which already has presence in Tier II cities. All rights reserved. Ahmedabad. The chain also plans to open 25 more hospitals in Tier II and Tier III cities within the next 2-3 years • besides 10 centres in Delhi/ NCR. and the public sector to ensure equitable access to quality healthcare Undertake pilot programs first to assess effectiveness and acceptance of this model. Karnataka • Gujarat Government has signed a MoU with GE Healthcare for upgrading the existing medical technology in the state and for setting up diagnostic imaging centres in five medical colleges and hospitals in the regions of Rajkot. Eye Q also operates a customised model in rural areas • Apollo Hospitals group has set up 250 low cost „Apollo Reach Hospitals‟ hospitals in Tier II and III cities • the UP State Government has sectioned 150 medical mobile units under NRHM to improve the accessibility to medical services in the remote places • Narayana Hrudayalaya plans to establish low cost hospitals in Mysore. the ability of the healthcare sector to institute an effective healthcare policy will be critical to define the manner in which the nation‟s healthcare resources. can go a long way in assisting the northern regions of the country in devising a robust healthcare structure. but also ensure equitable access of basic healthcare to the dramatically increasing population and gear up its capabilities to tackle the changing disease incidence profiles. • Fortis healthcare. Braun has signed a MoU with the Government of Andhra Pradesh to build and operate 11 dialysis centres in the state • Government of Karnataka partnered with the Indian Space Research Organisation (ISRO) and Narayana Hrudayalaya to launch the Karnataka Telemedicine Programme in the state‟s underserved areas • A three-way partnership among the Government of Uttarakhand. developed. Going forward.

such as mobile prescriptions and remote diagnoses. and consumer-targeted applications to encourage health and help prevent illness • poor reach of healthcare services to underserved/ unserved areas • inadequate accessibility to specialty care for rural and semiurban patients • scope for timely diagnosis and treatment • availability of overall healthcare facilities at a single location • strategies to boost medical tourism • set up a national task force to promote the adoption of Telemedicine. in partnership between Karuna Trust with the National Health Insurance Company and Government of Karnataka © Grant Thornton India LLP. These centers have been put under the country's new pharmaco vigilance programme. integrated multi specialiy healthcare service.unintended side effects. as well as to define the standards of implementing telemedicine solutions to healthcare delivery • Sir Ganga Ram Hospital operates a telemedicine unit across three centres in the underserved areas of North India . Jaipur. provides comprehensive healthcare services to patients • Narayana Health City. Rashtriya Swasthya Bima Yojana (RSBY) has today become one of the world‟s largest medical insurance programmes.Gohana in Haryana. spread over an area of 100 acres. The scheme has also been chosen by the United Nations Development Programme (UNDP) and International Labour Organisation (ILO) as one of the top 18 social security schemes in the world • Community Health Insurance Scheme.Transforming Healthcare . human (effect of monitoring of medication on human life) or patient outcomes economic (in terms of the cost of care). education and research and life sciences under a single roof • Chettinad Health City in Chennai. wellness services. such as mobile data collection and wireless transmission of health data. will be established as 5. such as remote access to e-mail and health information systems. OTRI also transferred microscopic images for monitoring the levels of cholera-causing bacteria in the river • Government of Karnataka partnered with the Indian Space Research Organisation (ISRO) and Narayana Hrudayalaya to launch the Karnataka Telemedicine Programme in the state‟s underserved areas such as Chamrajanagar • set up health cities which can act as the hub for smaller spokes/ nursing homes/ clinics. Mobile Applications to meet a specific need of medical workers. some of which could prove fatal. (assessing therapeutic results technology and such as blood pressure and practical tools involving extensive use of for effective technology). Dasmal in Himachal Pradesh and Kaithun in Rajasthan • Online Telemedicine Research Institute (OTRI) tapped this technology for providing telemedicine links for tele-consultation in Bhuj.000-bed health cities across the North Indian cities such as Delhi. Gujarat after the earthquake in January 2001 • OTRI also transferred cardiology and radiology-related data of over 200 ailing pilgrims during the Kumbh Mela festival in Uttar Pradesh. launched in Karnataka. • Apollo Health City. • Mobiles for Disease Surveillance ‒ ‒ ‒ ‒ standard Mobile enterprise services used by healthcare workers. offers varied medical services and facilities including preventive care.000 to each below poverty line category household in the country. etc • affordability of healthcare services in rural areas • set up health insurance programs in rural areas • with a coverage value of Rs 30. 34 . estimated to be operational by 2013. As a part of this initiative. All rights reserved. patient outcomes and provider performance • Domestic • India has put in place 22 monitoring centres to combat adverse drug reactions (ADR) -. established in Hyderabad.Agenda for action Challenges (s) Recommendations • International Players Success stories • lack of • oiutcomes could be clinical infrastructure. applications that play a direct role in the provision of care. Increasing quality of healthcare delivery in the long term can be achieved only through a robust mechanism to track outcomes and take corrective actions wherever outcomes are not in line with desired levels • Novartis is investing innovative technologies which involve the use of sensor-based and digital packaging technologies which serve as telemonitoring applications • GE patient monitors help manage Clinical Information Logistics by capturing and presenting accurate information to help improve decision-making.

mandatory affiliations with existing government district hospitals and other private players. • link existing infrastructure through technology and mobile units to Tier II and Tier III regions • integrate healthcare delivery with technology that will redefine healthcare and reduce costs • refrain from mere additions in bed capacity and focus on efficient utilization of current infrastructure • focus on emerging healthcare delivery models that provide affordable and quality healthcare in Tier II and Tier III Cities. technology and establish linkages to hospital infrastructure in larger cities/ towns pilot programs to test the PPP model to establish effectiveness before a roll out preferential allotment of land to private sector players to overcome the rising real estate costs preferential allotment of land to private sector players to overcome the rising real estate costs ease of norms for setting up medical and institutional infrastructure by relaxing minimum requirements. • build more health cities that provide ease of access.Transforming Healthcare . 35 .Agenda for action Role the Government can play • • • • • • • • • granting Healthcare an Industry Status expand the scale and scope of Rashtriya Swasthya Bima Yojana encourage health programs that focus on preventive health care ease visa norms to boost medical tourism empower the ASHA representative and grant resources. All rights reserved. © Grant Thornton India LLP. promote medical tourism with real estate support from the government. • encourage usage of re-furbished equipment in district and tier II hospitals which significantly reduce the cost burden of the private sector without compromising on quality. Strengthening the PPP model Establish Structured Framework Ensure multi stakeholder participation Run a pilot to test efficacy Financially viable proposition for all stakeholders Priority redressal of medico legal issues Improving payment mechanism and cycles Viable exit options for stakeholders Continued financial and operating support Private Sector Focus • work towards creating a regional focus rather than focusing only on top tier cities.

disease prevalence and general medical technology are key drivers fueling the demand for healthcare in the Northern Region. well defined policy framework of this clinical pathway is critical for the creation of a holistic and interlinked regional healthcare system. A clear. Develop adequate infrastructure and provide institutional support by regular and continuous training of medical doctors and other skilled manpower to service the sector Infrastructure support Reducing the real estate burden and providing support for setting up infrastructure across the entire spectrum of this regional ecosystem. Healthcare continues to remain one of the most promising sectors for the Indian Economy for the coming decade and thereafter. every doctor/ representative at the bottom of the clinical ecocystem shall decide on what activities can be done at the primary centre level. Combined with innovative delivery models and technological interface to bring regions together. © Grant Thornton India LLP. Developing a clinical pathway Depending on the need and complexity of surgical intervention. Tier III cities by creating a timetable of periodic mobility of professionals across deeper regions. what needs to be referred to relatively larger hospitals/ nursing homes and finally acute needs which may need to be referred to specialty hospitals with skilled professionals. All rights reserved. smaller hospitals/ nursing care to larger hospitals in Tier I and Tier II cities. keeping in mind the level of clinician support (doctor availability and referral channels) that are available in and around such regions. Skill enhancement Overcome resistance of skilled medical professionals in moving to Tier II. Reach A regional focus can be maintained either through the current state wise institutional framework or by channelizing the existing ecosystem of district/ civil hospitals.A regional health strategy A regional approach for developing sustainable health systems is the only means to address the ballooning healthcare need of the Northern Region. Spreading out delivery models on the basis of the population profile of regions and doctor availability will ensure equitable allocation of healthcare resources across all regions Integration Integration of primary care and hospital based infrastructure to provide seamless. uniform and pro-active care. Keeping the drivers in mind Ageing population profile. 36 .

Deal summary © Grant Thornton India LLP. All rights reserved. 37 .Appendices Healthcare Indicators.

38 .000 Live Births Source: National Health Profile.8 71.7 68.6 67. All rights reserved. 2011 51 43 36 58 61 32 52 47 39 64 67 42 Rural Female 35 28 27 29 44 29 Male 42 37 29 34 45 29 Urban Female © Grant Thornton India LLP.9 69.8 70.9 69.9 69.7 67.2 2016-20 Female Infant Mortality Rates North Indian states Male Haryana Himachal Pradesh Jammu & Kashmir Punjab Rajasthan Uttar Pradesh Uttarakhand Chandigarh Delhi Note: Per 1000 live births Source: National Health Profile.6 66 2011-15 Female 71. 2011 68. 2011 Projected Levels of Expectation of Life at Birth North Indian states Male Haryana Punjab Rajasthan Uttar Pradesh Source: National Health Profile.7 66.5 Male 72.3 72.Appendix 1: Health Indicators – North India Maternal Mortality Rate North Indian states Haryana Punjab Rajasthan Uttar Pradesh 186 192 388 440 2004-06 153 172 318 359 2007-09 Note: Per1.00.9 70.5 73.

Appendix 2: Healthcare Indicators Number of registered allopathic doctors and dental surgeons in North India Allopathic doctors North Indian states 2010 Haryana Himachal Pradesh Jammu & Kashmir Punjab Rajasthan Uttar Pradesh Uttarakhand Chandigarh MCI Delhi 4100 800 11200 38400 28500 57900 3300 37000 2011 2010 1740 772 1090 6996 364 8152 451 675 2011 1740 772 1090 6996 364 9441 451 675 Dental surgeons Source: Ministry of Health & Family Welfare Figures of Medical Practioners are related to doctors registered with State Medical Councils. © Grant Thornton India LLP. Figures of Dental Surgeons are related to doctors registered with Central/State Councils. 39 . All rights reserved.

All rights reserved.Appendix 3: Disease profiles – North India Malaria cases during 2011 – North India North Indian states Haryana Himachal Pradesh J&K Punjab Rajasthan Uttarakhand Uttar Pradesh Chandigarh Delhi 2011 (Provisional) 33345 247 1031 2693 46457 1162 56438 582 413 Acute Diarrhoeal Diseases cases during 2011 – North India North Indian states Haryana Himachal Pradesh Jammu division Kashmir division Punjab Rajasthan Uttarakhand Uttar Pradesh Chandigarh Delhi 224223 310227 342670 202041 190022 227571 79643 554770 42615 102983 2011 Source: National Health Profile. 2011 © Grant Thornton India LLP. 2011 Source: National Health Profile. 2011 Source: National Health Profile. 40 . 2011 Enteric Fever (Typhoid) cases during 2011 – North India North Indian states Haryana Himachal Pradesh Jammu division Kashmir division Punjab Rajasthan Uttarakhand Uttar Pradesh Chandigarh Delhi 25469 28074 59465 22882 36263 7902 13760 117537 3190 42976 2011 Acute Respiratory Infection cases during 2011 – North India North Indian states Haryana Himachal Pradesh Jammu division Kashmir division Punjab Rajasthan 1275035 1484149 185551 342858 656544 1089640 130283 1183992 49649 198541 2011 Uttarakhand Uttar Pradesh Chandigarh Delhi Source: National Health Profile.

53 10.00 112.LLC 2010 Temasek Holdings 2010 Aureos Capital India 2011 Intel Capital 2011 Helion Venture Partners.09 36.00 10.00 20.00 10.45 4.78 50.57 665.00 21. All rights reserved.87 9.00 50.00 77.74 95. Ltd BLK Super Speciality Hospital Dental Corporation Holdings Ltd.4 286.00 4.91 Value (US$ million) 20.00 Source: Grant Thornton Dealtracker -the data includes deals till March 2013 © Grant Thornton India LLP.00 50. Indian Angel Network 2013 Sequoia Capital 2013 WestBridge Capital Partners 2013 TA Associates 2013 Artiman Ventures Investee Investor Diwan Chand Medical Services Pvt Ltd Eye Q Centre for Sight Max India BSR Super Specialty Hospitals Ltd Sudhir Srivastava Advanced Robotic Surgery Centre Eye-Q Super Religare Laboratories Ltd Super Religare Laboratories Ltd Symbiotec Pharmalab Super Religare Laboratories Super Religare Laboratories Moolchand Healthcare Axiss Dental Mewar Orthopaedic Hospital International Oncology Services Pvt Ltd Consure Medical ASG Eye Hospitals Dr Lal PathLabs Dr Lal PathLabs Core Diagnostics 9.00 9.00 77.30 95.39 44.30 30.00 24.Appendix 4: Deal summary (Diagnostic chains and hospitals) – North India M&A deals (2010-13) Year Acquirer Parkway Holdings Ltd OP Jindal Hospital Vivekanand Hospital and Research Centre Dental Corporation Holdings Limited Dental Corporation Holdings Limited Vrundavan Hospital Super Religare Laboratories Fortis Healthcare International Max Healthcare Institute Ltd Lanka Hospitals Corporation Plc Max Healthcare Institute Ltd Medimart Pharmacy Target Value (US$ million) 685.64 - 2010 Fortis Healthcare Ltd 2010 Fortis Healthcare Ltd 2010 Fortis Healthcare Ltd 2010 Fortis Global Healthcare Holdings Pte Ltd 2010 Fortis Global Healthcare Holdings Pte Ltd 2011 Shalby Hospitals 2011 Fortis Healthcare Ltd 2011 Fortis Healthcare 2011 Life Healthcare Group Holdings 2011 Fortis Global Healthcare 2011 Max India Ltd Surya Healthcare. 41 .28 36. majority owned by Surya 2011 Pharmaceuticals 2012 BUPA Care Services Ltd 2012 Radiant Life Care Pvt Ltd 2012 Fortis Healthcare 2012 Radiant Life Care Pvt Ltd 2012 Fortis Healthcare 2012 Centre for Sight 2012 Shalby Ltd 2013 Moolchand Healthcare 2011 Halcyon Finance and Capital Advisors Pvt.74 10. Nexus Venture Partners 2011 Avigo Capital Partners 2011 Sabre Capital 2011 Franklin Templeton 2012 NYLIM Jacob Ballas 2012 International Finance Corporation 2012 Sequoia Capital 2012 India Equity Partners 2012 Matrix Partners India 2012 Rajasthan Venture Capital 2012 India Innovation Fund.74 174.00 5.Subsidary of Fortis Healthcare Guru Harkishan Hospital-management rights RadLink-Asia Pte Ltd Guru Harkishan Hospital-management rights RadLink-Asia Pte Ltd New Vision Laser Centre Yogeshwar Healthcare Ltd -Krishna Heart Institute Pankaj Apollo Hospital PE deals (2010-13) Year 2010 Asian Healthcare Fund 2010 SONG Investment Advisors 2010 Matrix Partners India Investment Holdings.43 2.64 25.00 13.

India. Russia. Yoga & Naturopathy. Siddha and Homoeopathy.Appendix 5: Abbreviations • • • • • • • • • • • • • • • • • • • • • • • • • • • AHM: Ahmedabad CHD: Chandigarh DEL: Delhi GUR: Gurgaon GZB: Ghaziabad LUD: Ludhiana RAJ: Rajasthan UP: Uttar Pradesh J&K: Jammu and Kashmir WHO: World Health Organisation PPP: Public-Private Partnership ANC: Ante-Natal Care CAGR: Compounded Annual Growth Rate NRHM: National Rural Health Mission NABH: National Accreditation Board for Hospitals & Healthcare Providers MoHFW: Ministry of Health and Family Welfare NUHM: Ministry of Health and Family Welfare OTRI: Online Telemedicine Research Institute TIFAC: Forecasting and Assessment Council BISR: Birla Institute of Scientific Research UMHRC: Uttarakhand Mobile Hospital and Research Centre BOT: Build–Operate–Transfer AIIMS: All India Institute of Medical Sciences AIDS: Acquired Immunodeficiency Syndrome ISRO: Indian Space Research Organisation ILO: International Labour Organisation UNDP: United Nations Development Programme • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • IMR: Infant Mortality Rate MMR: Maternal Mortality Rate GDP: Gross Domestic Product OECD: Organisation for Economic Cooperation and Development BRICS: Brazil. 42 . All rights reserved. Unani. Government of India © Grant Thornton India LLP. China and South Africa FDI: Foreign Direct Investment PE: Private Equity FVCI: Foreign Venture Capital Funds FIIs: Foreign Institutional Investors ADR: American Depositary Receipt GDR: Global Depository Receipt M&A: Mergers and Acquisitions NRI: Non-resident Indian Pvt: Private Ltd: Limited MoU: Memorandum of Understanding IT: Information Technology HIS: Hospital Information System EHR: Electronic Health Record EMR: Electronic Medical Record RGI: Registrar General Of India SRS: Sample Registration System RSBY: Rashtriya Swasthya Bima Yojana ASHAs: Accredited Social Health Activists OT: Operation Theatre ICU: Intensive Care Unit US: United States of America UK: United Kingdom UT: Union Territory MIOT: Madras Institute of Orthopaedics and Traumatology GPRS: General Packet Radio Service AYUSH: Department of Ayurveda.

nlm. 43 .businessstandard.businessstandard.eletsonline.html • http://www.timesofindia.html • http://www.gartner.html © Grant Thornton India LLP.photius.com/newsroom/id/234 4215 • http://data.indiatimes.pdf • http://ehealth.com/article/economypolicy/doing-less-with-more-india-s-healthcare-system-113033000209_1.html • Grant Thornton Healthcare Sector Budget report 2013-14 • Research on India – Hospital Market in India (March 2012) • http://www.org/indicator/NY.com/article/companies/indianpharma-market-to-grow-at-15-cagr-by-fy14112060300047_1.G DP.html • http://www.html • http://www.businessstandard.com/rankings/world_h ealth_systems.html • http://data.nih. All rights reserved.CD • http://articles.org/download/Healthcare 50112.com/article/management/improvi ng-the-picture-of-india-s-healthcare112061800066_1.businessinsider.com/rankings/healthra nks.com/insideindias-no-frills-hospitals-where-heartsurgery-costs-just-800-2013-4 • http://www.gov/pmc/articles/ PMC3283025/ • http://www.html • http://www.worldbank.photius.References • Indian Healthcare sector report – MegStrat Consulting • http://www.com/Politics/D0gBg wCn3huK72S06p8K5H/The-darkunderbelly-of-Indias-clinical-trialsbusiness.photius.worldbank.indianmirror.PCAP.PCAP/countries • Health at a Glance 2011: OECD indicators • http://www.org/indicator/SH.com/2013/02/he alth-gets-over-28-hikes-in-budget/ • http://www.livemint.com/indianindustries/2012/health-2012.com/changesho p/primary-healthcare-rural-indianpopulations • http://www.changemakers.ncbi.ibef.com/rankings/world_ health_systems.XP D.com/ 2012-11-01/jaipur/34856928_1_imr-infantmortality-rate-sample-registration-survey • National Health Profile – 2011 and 2010 • http://www.

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