Healthcare Infrastructure and Services Financing in India Operation and Challenges

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1 15 September 2012 Executive Summary p2 /Introduction p4 /Health profile of India p5 /Financing mechanisms p12 /Recent investments p24 /Challenges for private sector p33 /Emerging PPP models p35 /Conclusion - the way forward p40 /List of Abbreviations p42 /Bibliography p43 Healthcare Infrastructure and Services Financing in India Operation and Challenges

2 Executive Summary India is at the crossroads of an exciting and challenging period in its history. Making healthcare affordable and accessible for all its citizens is one of the key focus areas of the country today. The challenge is immense, as nearly 73% of the country s population lives in rural areas and 26.1% is below poverty level 1. While on one hand, India lacks strong healthcare infrastructure, on the other hand, the country has several inherent weaknesses in its healthcare system. Though the overall level of funding allocated for healthcare nationally is comparatively high (4.1% of GDP 2 ), the government s funding is low (<1% of GDP 3 ) compared to other emerging nations. The health care delivery segment is dominated by the private sector in India, with 70% of the total delivery market in India catered to by the private sector. However most of the organized private infrastructure is confined to the state capitals or Tier I cities. Very few have made inroads in Tier II and Tier III cities. This presents the country with both a challenge and opportunity to not only increase the penetration of quality health services but also be the growth driver in these regions. The central government has given priority to healthcare and is making significant investments to improve the infrastructure and delivery mechanism jointly with the state governments (who will act as the primary implementer) through National Rural Health Mission (NRHM). Before NRHM, the healthcare system in India was marked with significant disparities between urban and rural areas as well as between different states. The 1 Census 2011, Ministry of Home Affairs, Government of India 2 WHO Health Statistics WHO Health Statistics 2012

3 public delivery system did not provide enough incentives for improvement. Under NRHM, a manifold increase in the allocation for the healthcare sector has taken place across all Indian states. The central government has also proposed the National Urban Health Mission (NUHM) scheme to improve the affordability and accessibilty of healthcare services for the urban poor with a focus on slum dwellers and other vulnerable groups. Several central sponsored as well as state sponsored health insurance schemes have also been introduced for the economically backward. In order to complement the skills, expertise and resources of each other as well as alleviate the financing burden for the growth and development of the healthcare sector, the private and public sectors are now working together at a varied pace and working model across the states in India. Some of the successful Public Private Partnerships (PPP) involve laboratory services (pathology, radiology, CT scan, MRI etc.), mobile medical units, PHC management, telemedicine services and hospital maintenance. The models that have been experimented with by the states are: contracting out, contracting in, lease, service agreements (outsourcing), buying of a product/ service, joint venture company, social marketing and franchising. In addition, service delivery through telemedicine, high end tertiary care, innovative models for delivery in rural areas, community insurance schemes are other opportunities where private sector will need to participate. The Government of India has decided to increase healthcare expenditure to 2.5% of the gross domestic product (GDP) by the end of the 12th Five Year Plan ( ). However, the government alone cannot meet the infrastructure, capacity and delivery shortages existing in the current healthcare system. There has to be increased participation of private sector in the PPP schemes for infrastructure, capacity development and delivery. Challenges do exist, some of the PPP initiatives have failed and discontinued due to lack of renewal of the services by the private service provider. The PPP budget allocation under NRHM as well as a number of PPP projects varies considerably across the states. This shows that the state governments are still apprehensive about the success and sustainability of these partnerships and hence not fully committed towards this avenue of development. The priorities for government for healthcare financing must be such it covers the three basic objectives: Affordability, Reach and Quality of services. Some of the way forward measures can be: There needs to be a clearly defined policy and set of guidelines for the successful implementation and sustainability of the healthcare PPP models. This will attract private investments in remote diagnostics, telemedicine services and operations of rural health services in the states. The healthcare sector should be given infrastructure status by the central government and declared as a priority growth area by the state governments. This has to be followed by a consistent policy that is inclusive of incentives and subsidies with respect to land acquisition, tax structure and an approval process. This will help to attract the private sector for investing in manufacturing of medical equipment, setting up training centres for medical professionals (nurses, paramedics etc.) in rural areas, superspecialty and multi-specialty care services, medical colleges as well as medi-cities in the urban and semiurban areas. Increase penetration of private health insurance and community based health insurance schemes in the rural and semi-urban market. At the same time prevent misuse of the existing government funded/ sponsored schemes by considering provision for selective user charges. The central government must intervene in the manufacturing, procurement and distribution of the pharmaceutical drugs industry. This can be done through stricter regulations, and monitoring and supervision, which would help to control the prices of essential drugs. Though the costs involved in the complete upgrade of the healthcare sector are huge, there are enormous pay-offs in long-term investments in this sector. This will not only raise the quality of life for all but can also make the healthcare industry in India, a key enabler for economic growth. Healthcare Infrastructure and Services Financing in India 3

4 Introduction Life in India, with a population of 1.21 billion 4 out of which 26.1% is below the poverty line 5, is rife with many challenges - high income disparity, lack of basic infrastructure and the incidence of diseases. As a result delivery of quality affordable healthcare is an enormous challenge. Improvements in the infrastructure and delivery system of health care, provision of manpower, equipments and drugs, improved inter-sector coordination, monitoring and evaluation, and other innovative approaches have been undertaken in order to improve the basic indicators of healthcare. Recognising the need to progressively address the challenges in achieving sustainable reforms, maintaining the required quality of care and accelerating human development, the central government has accorded priority to all three aspects of healthcare - prevention, treatment and discovery. However, this will require financing in different forms by stakeholders involved - as healthcare payer, as funding agency (private equity, long term debt, venture capital), as subsidy, as incentives, and as grants (e.g. Gates-Melinda Foundation, Clinton Foundation). This financing will need to overcome certain challenges: Infrastructure creation and augmentation (hospitals, diagnostics, specialty, telemedicine clinics to provide access to quality healthcare to both rural and urban masses) Enhancing access through insurance (government as a payer) Medical education and training; and Innovation and indigenisation (focus on implants and high-value medical consumables). An analysis of the current healthcare profile of India indicates the gaps and deficiencies in terms of service outreach, available resources, infrastructure and affordability as well as government expenditure, when compared to other developing nations. The emerging PPP models and innovations in healthcare financing outlined here concentrate on key areas affecting important indicators hoping that the success of these initiatives will have far-reaching implications towards better health of the common people. The focus of this report is to improve the synergy between public and private funding in order to overcome existing challenges and clear the way for adoption of a bigger role by the government in developing this social sector at a faster pace. Goals Synergise public and private funding in order to bridge the resource and infrastructure gap. Reduce the burden of healthcare costs on the rural and semiurban population by minimising out-of-pocket expenses and introducing customised and focused health plans. Improve the production and distribution of pharmaceutical drugs to make them more affordable and accessible to citizens Approach and methodology The methodology that has been followed is to first assess the current state of healthcare in India: the socioeconomic and health indicators in India, infrastructure and resource deficiencies, and the central government interventions including health programmes, schemes and funds, partnership with World Bank, DFID, Asian Development Bank and European Commission, and the various PPP initiatives currently undertaken. This is followed by the various modes and areas of financing from the private sector for the growth and development of healthcare in India. A section is also dedicated to the emerging PPP models in healthcare and the trends of various channels to infuse funds in this sector. These formed the basis to identify the most appropriate avenues for healthcare financing. 4 4 Source: Census 2011, Ministry of Home Affairs, Government of India 5 Source: Planning Commission, Government of India

5 Health profile of India With a population of 1.21 billion, India is the second most populous country in the world, next only to China. It comprises 28 states and 7 union territories and covers an area of 32,87,2631 sq km 6. Provision of health care to such a vast population needs sound planning and implementation of health policies by the government with the support of the private sector, local and regional bodies, NGOs and self-help groups. Nearly 72% of the country s population lives in rural areas. While substantial progress has been made in the provision of healthcare services in the urban areas, there is a need to improve the availability of services and enhance the quality of care in many rural areas. Demographic and socioeconomic indicators The demographic indicators of the country help in identifying areas requiring policy and programmed intervention, deciding priorities and setting short-term and long-term goals. The National Health Profile, 2010, compiled by the Central Bureau of Health Intelligence, reveals the following key demographic data: The sex ratio (females per 1,000 males) has shown a slight improvement in the last two decades, it was 926, 933 and 940 during the 1991, 2001 and 2011 census respectively. The birth rate declined from 26.1 in 1999 to 22.5 in 2009, while the death rate declined from 8.7 to 7.3 per 1,000 persons over the same period. Life expectancy at birth has increased from 59.7 years in to 62.6 years in for males and from 60.9 years in to 64.2 years in for females. The increase in life expectancy is leading to an increase in the number of elderly persons in the population creating a demand for specific health facilities. The IMR has declined considerably from 70 in 1999 to 50 per 1,000 live births in 2009 though the difference between rural (55) and urban (34) IMR is still high. The TFR has shown no deviation over the last two surveys conducted in India, being at 2.6 both in SRS 2008 and SRS It is 2.9 among the rural population and 2.0 in urban areas. Population trends in India ( ) Year Male (in lakh) Female (in lakh) Total (in lakh) Sex ratio Population density/sq.km % of Urban population , , , N.A , , , , , , , , , , , , , , , , , , Source: Registrar General of India The MMR has declined considerably from 301 in SRS to 254 in SRS and finally to 212 as per SRS This is an indication of better health awareness and medical provision in the rural areas. There are 593 districts, 5,470 sub-districts, 5,161 towns and 6,38,588 villages (including uninhabited villages) in India. Decennial change (%) 6 Census 2011, Ministry of Home Affairs, Government of India Healthcare Infrastructure and Services Financing in India 5

6 The increase in the percentage of urban population can be attributed to the movement of rural population to towns and cities for better livelihood and opportunities with respect to education, health and modern amenities. The information obtained from the Central Bureau of Health Intelligence and the Ministry of Health and Family Welfare reveals the following: The literacy rate in India has increased by 13.9% during the decade and by 9.56% during the decade Currently it is 74.04%, 82.14% for males and 65.46% for females (Census 2011). According to Planning Commission estimated for the year , 28.3% of the population in rural areas and 25.7% of the population in urban areas lived below the poverty line. The gross national income (GNI) for the year , at factor cost was 60,95,230 crore INR at current price and 44,64,854 crore INR at constant price (base year ); the net national income was 52,21,199 crore INR and 39,54,861 crore INR at current price and constant price respectively. The per capita net national product is 46,492 INR at current price and 33, 731 INR at constant price ( ) for the year The increase in per capita net national product during shows a steeper trend for current price than constant price. The poverty line at India level is obtained from the distribution of persons according to their expenditure class and the poverty ratio of the country, which is the weighted average of the state-wise poverty ratio. Estimated birth rate, death rate and IMR in India ( ) Year Birth rate Death rate Infant mortality rate Rural Urban Combined Rural Urban Combined Rural Urban Combined Source: SRS Bulletin January 2011, Registrar General of India, New Delhi 6 ICC - PwC

7 Population living below poverty line in India Year Poverty line (Per capita income in INR/month) No. of persons (lakh) Percentage of persons Rural Urban Rural Urban Combined Rural Urban Combined , , % 25.5% 37.2% , , % 20.9% 29.8% Source: Planning Commission of India Gross national income, net national income and per capita income in India ( ) Year GNI at factor cost (crore INR) Current prices Constant prices GDP at factor cost (crore INR) Current prices Constant prices NNI at factor cost (crore INR) Current prices Constant prices Per capita net national product Current prices Constant prices ,45,224 29,45,224 29,67,599 29,67,599 26,23,995 26,23,995 24,095 24, ,76,200 32,24,186 34,02,316 32,49,130 30,06,469 28,72,212 27,183 25, ,12,087 35,37,679 39,41,865 35,64,627 34,87,175 31,49,912 31,080 28, ,21,099 38,76,386 45,40,987 38,93,457 40,31,881 34,49,970 35,430 30, ,07,534 41,38,174 52,28,650 41,54,973 46,32,304 36,72,192 40,141 31, ,95,230 44,64,854 61,33,230 44,93,743 52,21,199 39,54,861 46,492 33,731 Healthcare Infrastructure and Services Financing in India 7

8 Disease burden indicators As India continues its economic development, the proportion of the elderly in India s population will rise and is expected to increase to nearly 11.8% by the year This will have several implications as the elderly population needs greater healthcare facilities, which will require higher health care expenditures than other population groups. In 2005, the National Commission on Macroeconomics and Health identified the major classes of health conditions that contributed more than 80% of the overall disease burden in India and require priority policy attention. The following table presents the disease-burden estimations for the identified health conditions: See Table above. The Reproductive and Child Health programme, part of the National Health Profile 2010, reveals the following: 52% mothers had at least three antenatal care visits for their last birth. 46.6% of child births were assisted by a doctor, nurse, ANM or other health personnel. 38.7% of institutional births were reported. 43.5% of children between the age of 12 and 23 months age were fully immunized with BCG, measles, and three doses each of polio/dpt. 5.1% of children between the age of 12 and 23 months did not receive any immunisation Disease burden estimations Disease/health condition Communicable Diseases Estimates in 2005 (lakh) Projected estimate for 2015 (lakh) Pulmonary Tuberculosis 85 NA HIV/AIDS Acute Respiratory Infection NA Diarrheal diseases (episodes/year) Malaria and other vector borne conditions NA Enteric Fever 6.95 NA Pneumonia 7.74 NA 7.32 Leprosy 3.67 Expected to be eliminated Otitis Media Non-communicable conditions Cancer Diabetes Mental health Blindness Cardiovascular diseases COPD and Asthma Other non-communicable conditions Injuries-deaths No. of hospitalisations Cases reported in 2010 (lakh) Source: Report of the National Commission on Macroeconomics and Health, National Health Profile Central Bureau of Health Intelligence Report of the National Commission on Macroeconomics and Health, 2005

9 Healthcare finance indicators The healthcare finance indicators provide an understanding of patterns of investments, expenditure, sources of funding and proportion of allocation against the total allocation. They also help us understand the health outcomes in relation to the expenditure. The below table shows the pattern of central allocation on a five-year plan outlay: The below data shows that the percentage of allocation for the health sector against the total planned investment in the country by the central government has increased to some extent in the Eleventh Plan when the Health Research Department was created and the NRHM schemes were started. Health expenditures in India on the basis of a selected list of the National Health Account indicators for the period is outlined below: Infrastructure indicators The healthcare infrastructure indicator(s) help us understand the healthcare delivery provisions and mechanisms in India and signify the investments and priority accorded to creating the infrastructure in public and private sectors. In the past few years India has made good progress with respect to both the service infrastructure as well as the educational infrastructure, which is evident from the facts revealed in the National Health Profile 2010, conducted by the Central Bureau of Health Intelligence: Pattern of central allocation (total vs. health sector) (crore INR) Period Total planned investment Health allocation Family welfare allocation AYUSH allocation Total for health sector Eighth Plan ( ) 4,34, ,494.2 (1.7%) 6,500.0 (1.5%) (0.02%) 14,102.2 (3.2%) Ninth Plan ( ) 8,59, ,818.4 (2.31%) 15,120.2 (1.76%) (0.03%) 35, (4.09%) Tenth Plan ( ) 14,84, ,020.3 (2.09%) 27,125.0 (1.83%) (0.05%) 58,920.3 (3.97%) Eleventh Plan ( ) 21,56, ,36, (6.31%) 3,988.0 (0.18%) 1,40,135.0 (6.49%) Source: Planning Commission of India Measured levels of expenditure on health in India ( ) Selected National Health Accounts indicators Total expenditure on health as a % of GDP General government expenditure on health as a % total expenditure on health Private expenditure on health as a % of total expenditure on health General government expenditure on health as a % of total government expenditure External resources for health as a % of total expenditure on health Social Security expenditure on health as a % of general government expenditure on health Out-of-Pocket expenditure as a % of private expenditure on health Private prepaid plans as a % of private expenditure on health Source: World Health Statistics 2010 There are 12,760 hospitals having 5,76,793 beds in the country. Under the department of AYUSH there are 24,465 dispensaries and 3,408 hospitals in April There were 148,124 sub-centers, 23,887 PHCs and 4,809 CHCs as per Ministry of Health and Family Welfare, Government of India, 2011 There were 2,445 licensed blood banks in the country in January The country currently has 314 medical colleges, 289 colleges for BDS courses and 140 colleges for MDS courses with total admission of 29263, and 2783 students respectively during There were 2,028 institutions for GNM with admission capacity of 80,332 and 608 colleges for pharmacy (diploma) with admission capacity of 36,115, in March Dept. of Health & Family Welfare merged in 2005 and the allocation includes Rs.4, crores for Health Research Department, newly created in Healthcare Infrastructure and Services Financing in India 9

10 Details of the medical and dental colleges between 2006 and 2011 are provided in the two tables below: Medical colleges and capacities in India ( to ) Year No. of medical colleges Male admissions Female admissions Total admissions ,449 10,609 28, ,208 12,082 30, ,486 14,329 32, ,224 15,860 34, ,299 14,964 29,263 Source: Medical Council of India As is shown below, there is large disparity in the healthcare infrastructure indicators across the Indian states when compared to the national average. The table shows the comparison of different infrastructure indicators between India, with respect to its best performing state and a poorly performing state. Beds per thousand Population Dental colleges and capacities in India ( to ) Year No. of dental colleges No. of admissions (BDS) ,120 1, ,910 2, ,650 2, ,520 2, ,547 2,783 Source: Dental Council of India No. of admissions (MDS) Source: National Health Profile, 2008 Moreover the doctor patient ratio in rural areas of India is 1:20,000, while the urban ratio is 1:2,000 against the statutory 1:250 ratio from WHO for which India requires 6,00,000 doctors Data was not received from 58 out of the 314 medical colleges

11 HR indicators The human resource indicator provide an overview of the availability of trained and specialized medical, nursing and paramedical personnel in India along with an understanding of the regional distribution and disparities. They provide the details of allopathic doctors, dental surgeons, AYUSH doctors, nursing staff and various paramedical healthcare workers in India. The key facts on human resources include the following: The number of allopathic doctors who possess recognized medical qualifications (under the MCI Act) and are registered with state medical councils for the years 2009 and 2010 were 7,93,305 and 8,16, respectively. The number of dental surgeons registered with central/state dental councils as on December 31, 2009 were 1,04, The total number of registered AYUSH doctors in India in January 2010 was 7,52, Ratio of government doctors to population served in 2010 States Govt doctors Govt dental surgeons Avg population served/govt doctor India 85,254 3,421 13,531 33,722 Andhra Pradesh 4, ,988 6,16,122 Bihar 3, ,174 35,46,461 West Bengal 9, ,407 2,27,356 Odisha 4, ,485 25,24,312 Karnataka 4, ,933 16,849 Maharashtra 4, ,540 20,57,741 Source: Directorate of State Health Services Registered Nurses and Pharmacists in India States Registered ANM Registered GNM Registered LHV Avg population served/ govt dental surgeon Pharmacists India 5,76,542 10,73,638 52,375 6,56,101 Andhra Pradesh 1,12,269 1,36,477 2,480 43,958 Bihar 7,501 NA 511 4,163 West Bengal 56,302 48,470 11,938 89,630 Odisha 49,170 63, ,312 Karnataka 48,509 1,36,421 6,839 79,508 Maharashtra 33,158 93, ,06,220 Source: Indian Nursing Council, Pharmacy Council of India 10 Source: Medical Council of India 11 Source: Dental Council of India 12 Source: Department of AYUSH, MoHFW, GOI Healthcare Infrastructure and Services Financing in India 11

12 Financing mechanisms The present inefficiencies and inequities in the public healthcare system in India have pushed forward the need for creative thinking and innovative solutions. Crippling health problems have raised a need for change in the existing structure of health service provision and risk pooling, both in public and private sectors. On a national level, there have been several efforts to reform the health system to improve the access to quality services for the poor. However all the central govt. efforts at influencing public health have focused on the five-year plans. On the other hand, the reforms brought on by the economic policies of the 1990 s, helped India attract a lot of interest and investment from foreign sources. Private equity, venture capital, external commercial borrowings, etc brought in new funding options besides long-term debt which was used as the primary mechanism to finance hospitals in India. Given the flurry of activity in the health care sector which includes the setting up green field projects, expanding existing hospitals and acquiring brown field facilities, there is a dire need for innovative funding mechanisms. Considering the huge need gap, rapid rate of growth and capital-intensive nature of hospitals, many players are looking for funding mechanisms beyond the conventional borrowing route. Currently the investment landscape in health care is predominantly characterized by debt financing. In addition, many private sector banks have developed a separate health care portfolio. 12 ICC - PwC Avenues for healthcare funding in India Private Public Others Debt financing - long term bank loan Annual govt budget for rural health Foreign donations Foreign direct investment Annual govt budget for urban health PPP project funding External commercial borrowing Govt. funding for community programmes Private equity funds Incentives and subsidies Individual investors Govt. sponsored schemes Foreign institutional investors Community based schemes Venture capital funds

13 Private sources Debt financing Debt financing from banks and financial institutions is the preferred route for raising capital for smaller health care providers. However large private players also routinely access funds through this route. With the growth in services sector and health care in particular, the role of banks and other lending institutions acquires a special significance. The healthcare business in India over a last couple of years has witnessed growth in terms of new facilities as well as acquisitions and expansion of operations. Banks, at present, do not focus on funding health care projects in Tier II and Tier III Indian cities but the growing presence of corporate players in these areas will encourage the lending institutions. Risk evaluation for healthcare projects seems to be a major concern for most banks making forays in health care delivery funding in these regions. Over 50% of long-term financing for hospitals is obtained through bank loans from nationalized banks. At present most banks have a healthcare portfolio. However they do not have a specific focus on healthcare delivery organizations. Their portfolios are mostly concentrated in pharma, biotech and clinical research sectors. Some of the key observations are presented below: The current environment is favorable for investments in healthcare delivery projects. The past experience in healthcare delivery has been good with negligible defaults. Banks have research teams for health care but no specific domain expertise in health care delivery. They mainly rely on public domain information and specific reports. Banks are actively thinking of developing portfolios in health care delivery. Foreign direct investment The growing Indian health care market and lucrative opportunities in the sector are attracting foreign investors. The foreign players are seeking to enter the Indian healthcare delivery market through various channels including capital investment, technology tie ups or some form of collaborative ventures with Indian counterparts in the area of medical technology, diagnostics, health care education and training. FDI inflows in healthcare sector (April 2000 to June 2012) Sector Amount (crore INR) Amount (million USD) %age with Total FDI (+) Hospital and diagnostic centers 6, , Medical and surgical appliances 2, Drugs and pharmaceuticals 45, , Source: FDI Statistics June 2012, DIPP, Ministry of Commerce & Industry, GOI The role of foreign financing in the various formats of health care is primarily governed by FDI policy which permits 100% foreign investments under automatic route. FDI under the automatic route does not require prior approval either by the government of India or the Reserve Bank of India. Investors are only required to notify the concerned Regional office of RBI within 30 days of receipt of inward remittances and file the required documents with that office within 30 days of issue of shares to foreign investors. Some of the issues that inhibit FDI are listed below: Lack of quality assets. Lack of size. Lack of adequate transparency. No public listing of most of the hospitals. Healthcare Infrastructure and Services Financing in India 13

14 External commercial borrowings The external commercial borrowings (ECB) mode of financing has been used only in a limited number of projects. Due to the complexity in the process of getting approvals from the Reserve Bank of India (RBI), the healthcare sector has not witnessed many ECBs. However, with the relaxation of rules relating to ECB s more hospitals will be willing to access this route. At present, entities in the services sector, which include hotels, hospitals and software sector, are allowed to avail ECB up to 100 million USD per financial year for import of capital goods, under the approval route. Further the government has now decided to permit entities in the hotels, hospitals and software sectors to avail ECB up to 100 million USD per financial year, under the automatic route, for foreign currency and/or rupee capital expenditure for permissible end use. One of the main reasons for popularity of ECBs is the lower interest rates in the US & European markets compared to India. Some of the benefits of ECBs over other sources of funds are: Cost of raising ECBs is much lower than that of domestic borrowings. Global financial market is a much bigger source of credit. Foreign lenders provide far more flexibility in terms of providing security for ECBs. The top deals in ECBs for the healthcare sector of India during 2012 are: Healthcare ECBs in India (Jan Jul 2012) Borrower Amount in million USD Purpose Maturity Period Shasun Pharmaceuticals Ltd 10.0 Modernization 5 years Medley Pharmaceuticals Ltd 5.6 New project 6 years 1 month Emcure Pharmaceuticals Ltd 10.0 Other 5 years Claris Lifesciences Ltd 10.0 Modernization 6 years 10 months Volunteers for Village Development 0.25 Micro finance 7 years 1 month Ranbaxy Laboratories Ltd 50.0 Rupee expenditure Loc. CG 5 years Apollo Hospitals Ltd Import of capital goods 9 years 10 months Ajanta Pharma Ltd Modernization 5 years Alexis Multi-Specialty Hospital Pvt Ltd 5.0 New project 7 years 2 months Amneal Pharmaceutical Co Pvt. Ltd 1.2 Modernization 6 years 7 months Elder Pharmaceuticals Ltd 15.0 Modernization 5 years Torrent Pharmaceuticals Ltd 5.0 Rupee expenditure Loc. CG 5 years Apollo Hospitals Ltd New project 7 years 1 month Claris Lifesciences Ltd 10.0 Modernization 5 years Cadila Healthcare Limited 6.67 Refinancing of old loans 1 year 10 months Degania Medical Devices Pvt. Ltd 2.0 Modernization 9 years 11 months Raichem Life Sciences Pvt. Ltd 6.0 New project 5 years Source: Database for ECB, Reserve Bank of India 14 ICC - PwC

15 Private equity Private Equity (PE) is now emerging as one of the most preferred form of funding. PE funds invest in the companies with a proven track record of profitability and sustainable growth. The fund brings in not only the capital but also the adequate strategic planning and management skill sets for growth. Most PE funds are keen on investing in the health care sector given the high growth and recession proof nature of the industry. However, the soaring real estate costs, issues relating to scalability, management bandwidth, workforce, lack of entrepreneurship etc are the major deterrents. According to Venture Intelligence, a research firm that tracks PE and venture capital (VC) activity, over 42% of the PE and VC investors recently surveyed sensed strong opportunity to tap the market for healthcare services in semi-urban and rural areas. Its report also stated that around 20% of new PE or VC fund corpuses are expected to be invested into the healthcare services. Currently the Indian healthcare market, particularly on the provider side, offers the following opportunities to PE funds: High need gap. Limited presence of network hospital system. Skewed bed: population ratio. Mostly privatized healthcare delivery leading to higher spend in the private sector; Recession-proof sector. Viable formats (secondary and tertiary care). Mix of brownfield and greenfield projects. Good operating margins. Good rate of return as compared to other industries. However, there are some existing challenges faced by PEs in terms of the following: Real estate cost. Scalability. Management bandwidth. Clinical, nursing and paramedical workforce. Lack of entrepreneurship. PE investments in the healthcare sector amounts to 749 million USD across 25 deals in the first half of 2012, as against 421 million USD and 498 million USD during the same period in 2010 and 2009 respectively. The top deals in healthcare in 2012 includes the following: Company Amount (million USD) Investors Date Care Hospitals 110 Advent International 12-March-2012 DM Healthcare 100 Olympus Capital 12-January-2012 Vasan Eye Care 100 GIC 12-March-2012 Specialty Hospital 77 Halcyon Group 12-February-2012 Super Religare Lab 66 IFC, NYLIM India 12-June-2012 Nova Medical Centers Source: Economic Times, 23 August, Goldman Sachs and New Enterprise Associates Individual investors Individual investors have set up healthcare facilities in the rural and semi-urban markets across several states in India in the form of nursing homes or medical centers or diagnostic facilities. These are mainly family owned business establishments, being started as an entrepreneurial activity by the individual doctors and healthcare specialists. 12-August-2012 Healthcare Infrastructure and Services Financing in India 15

16 Foreign institutional investors Foreign institutional investors (FII) are investment funds registered in a country outside India and include hedge funds, insurance companies, pension funds and mutual funds. They must register with SEBI to participate in the Indian market and are subject to regulatory compliance that places limits on FII ownership in Indian companies. There are quite a few foreign insurance companies like AIG, BUPA, and Allianz which have entered into a JV with Indian companies to invest in the private health insurance market in the country, catering to the urban population. Net investments through FII in India during 2012 Sector January February March April May Healthcare services Healthcare equipment and supplies Drugs and pharma Cr. INR Mn. USD Cr. INR Mn. USD Cr. INR Mn. USD Cr. INR Mn. USD Cr. INR Mn. USD Source: FII Sector-Wise Fortnightly Statistics, Securities & Exchange Board of India Venture capital funds These are companies that specialize in financing new ventures like bringing a new product to the market when the venture may need to attract financial funding. There are several categories of financing avenues. While smaller ventures sometimes rely on family funding, loans from friends or personal bank loans, more ambitious projects that need more substantial funding may turn to private investors who use their own capital to finance a venture s need. Public sources Annual government budget for rural health The central government has launched the National Rural Health Mission (NRHM) in 2005 to carry out necessary architectural correction in the basic health care delivery system so that the quality of life is improved. This initiative is intended to provide healthcare services to the rural population of the country with a special focus on 18 states. This mission is believed to be a reflection of the government s commitment to raise public spending on healthcare from 0.9% of GDP to 2-3% of GDP. Apart from strengthening sub-centers, PHCs, CHCs and disease control programmes and promoting publicprivate partnerships (PPPs) for public health goals, the NRHM also seeks to set up a task group to focus on new health financing mechanisms. This group will examine the introduction and rollout of the new financing mechanisms, including risk pooling for hospital care. The key elements of this mechanism are as follows: Payment of hospitals for services as reimbursement by the district health missions, on the principle of money follows the patient. Standardization of outpatient, in-patient and laboratory services and associated costs by a committee of experts in each state on a periodic basis. Monitoring of standards by a National Expert Group to give suitable guidance on protocols and cost comparisons. Payment of wage component for all existing CHCs on a monthly basis and reimbursement of other recurring costs for services from district health fund. 16 ICC - PwC

17 Monitoring of any credible community based health insurance schemes and providing subsidies to cover a part of the premiums for the poor by the central government. Create a district health accounting system to monitor the district health fund management and take corrective action. The funding arrangements that were envisaged for successful implementation of NRHM initiative are: The NRHM is conceived as an umbrella programme covering the existing programmes of the Department of Health and Family Welfare department of the central government; The budget head for NRHM is created at central and state levels with the vertical health and family welfare programmes retaining their sub-budget head under the NRHM; The outlay of NRHM for was around 6,700 crore INR. The NRHM anticipates an additional 30% over existing annual budgetary outlays, every year, to fulfill the mandate of the National Common Minimum Programme to raise the outlays for public health from 0.9% of GDP to 2-3% of GDP. The states are expected to raise their contributions to public health budget by minimum 10% every year to support the Mission s activities. Some key improvements and outcomes that took place at the national level over the last few years due to the NRHM initiative can be summarized as follows: Infrastructure As on March 2011, there were 148,124 sub-centers, 23,887 PHCs and 4,809 CHCs 13 functioning in the country with the CHCs upgraded to IPHS norms. Other infrastructural improvements and findings are presented below: Name Improvements/Findings No. of sub-centers (SC) Increased from 146,026 in 2005 to 148,124 in 2011 SCs in government buildings Increased from 50% in 2005 to 62.7% in 2011 No. of PHCs Increase of 651 PHCs between 2005 and 2011 PHCs in government buildings Increased from 78% in 2005 to 86.7% in 2011 No. of CHCs Increase of 1,463 CHCs between 2005 and 2011 CHCs in government buildings Increased from 90% in 2005 to 95.3% in 2011 Rogi Kalyan Samitis (RKS) 24x7 health facilities Mobile medical units (MMU) AYUSH 570 DHs, 4210 CHCs, 1125 other than CHC hospitals (above CHC but below DH), PHCs and 6795 other health facilities above SCs have their own RKS with untied funds for improving health service quality Total of 15,873 APHCs, PHCs, CHCs and other Sub District facilities 1,031 MMUs functional under NRHM to provide diagnostic and outpatient services 12,134 health facilities have co-located AYUSH services Rural population coverage by SCs Average 5,624 against the norm of 3,000-5,000 Rural population coverage by PHCs Average 34,876 against the norm of 20,000-30,000 Rural population coverage by CHCs Average 173,235 against the norm of 80, ,000 Source: Ministry of Health & Family Welfare, Government of India 13 Ministry of Health and Family Welfare, Government of India Healthcare Infrastructure and Services Financing in India 17

18 Human resources The key improvements and/or findings are shown below: Name ASHAs Medical staff AYUSH Programme management units Female health workers [HW(F)] / ANM in SCs and PHCs Overall shortfall of 3.8% of the total requirement Allopathic doctors at PHCs Overall shortfall of 12.0% of the total requirement General duty medical officer (GDMO) Staff shortfall at CHCs Improvements/Findings 8.09 lakhs ASHAs selected, 2.55 lakhs trained up to 5th module and 5.53 lakhs with drug kits in their villages Added 1589 specialists, 8648 MBBS doctors, staff nurses, ANMs Added 7,993 AYUSH doctors and 3,232 AYUSH paramedics on contract basis Added 584 DPMs, 568 DAMs, 533 DDMs, 633 DPMUs, 34 SPMUs, 3434 block managers, 3150 accountants and 3434 Block PMUs on contract basis Increased from 133,194 in 2005 to 207,868 in 2011, an increase of 56% Increased from 20,308 in 2005 to 26, 329 in 2011, an increase of 29% 11,798 GDMOs are available at CHCs as on March 2011 Overall shortfall of 63.9% specialists; shortfall of 75% of surgeons, 65.9% of obstetricians and gynecologists, 80.1% of physicians and 74.4% of pediatricians Source: Ministry of Health & Family Welfare, Government of India Annual government budget for urban healthcare The total urban population in the country as per Census 2011 is more than 377 million constituting 31.16% of the total population. There are a total of 468 urban agglomerations (UA)/Towns (increase of 18.8% from Census 2001), having 70% of the total urban population. About 15% of the urban population and 23% of the population living in UAs lives in the slums 14. In order to meet the health challenges of the urban population with a special focus on urban poor living in listed and unlisted slums, the Ministry of Health and Family Welfare had proposed to launch the National Urban Health Mission (NUHM), to Poor environmental conditions in the slums along with high population density make slum dwellers vulnerable to lung diseases like Asthma, Tuberculosis etc. They also have a high incidence of vector borne diseases with twice as many cases of malaria and dengue among the urban poor than the other city dwellers. The scheme would cover all the state capitals and 430 identified cities with a population of more than one lakh. The NUHM is aimed at strengthening the primary public health systems, filling the gaps in service delivery through private partnerships using a regulatory framework and also a community based risk pooling insurance mechanism, and making special provision for inclusion of the most vulnerable among the poor. The financial sharing ratio for NUHM between the central government and state will be 85:15 during the Eleventh Five-Year Plan and 75:25 during the Twelfth Five-Year Plan, with the 25% state contribution in the Twelfth Plan being shared between the states and urban local bodies (ULB) NUHM, Urban Health Division, Ministry of Health & Family Welfare, Government of India 15 Revised NUHM, Urban Health Division, Department of Health & Family Welfare, Government of India

19 It is assumed that the states would contribute 15% and ULBs would contribute 10%. Based on this financing pattern, the estimated contribution for the proposed NUHM are approximately 25,000 crore INR for the central government, 5,000 crore INR for the state governments and 3,000 crore INR for the ULBs, totalling up to the Mission grant of 33,000 crore INR. Government funding for community programmes In order to address the current disease burden for the Indian population, the key community health programmes initiated, sponsored and monitored by the central government are: Vector Borne Disease Control - Vector-borne diseases (VBD) are a group of communicable diseases transmitted by mosquitoes and other vectors, e.g. malaria, dengue, filaria, kala-azar, chikungunya. This programme is for prevention and control of these VBDs and aims to make the investments sustainable by developing robust systems and supporting the local capacity. Reproductive and Child Health Programme (RCH) - This programme aims to reduce the infant, child and maternal mortality by improving the quality, coverage and effectiveness of existing the family welfare services. This is a component of NRHM and works nationwide. TB Control Programme - Tuberculosis (TB) is an infectious disease caused by a bacterium and a single patient can infect 10 or more people in a year. The goal of this programme is to decrease mortality and morbidity due to TB and cut transmission of infection. This programme aims to achieve and maintain cure rate of 85% and detection rate of at least 70% of such cases. Blindness Control Programme - This programme was launched as a 100% centrally sponsored scheme to reduce the prevalence of blindness from 1.4% to 0.3%. The programme objectives are developing eye care facilities in every district, securing participation of voluntary organizations in eye care and developing human resources for providing eye care services. Leprosy Eradication Programme - Leprosy is a chronic infectious disease caused by mycobacterium leprae and is a leading cause of permanent disability. This programme is centrally sponsored but implemented by the states and supported as partners by the World Health Organization, and the International Federation for Anti-leprosy Associations. As of March 2011, leprosy has been eliminated in 32 out of 35 states/union territories. Iodine Deficiency Disorders Control Programme - This is a 100% centrally supported programme. The expected impact of the above programmes on health indicators are formulated according to the targets of the NRHM for the focus states, e.g. reduced IMR, MMR, TFR, and incidence of Tuberculosis, Leprosy and Malaria. Decreased malnutrition levels, with special attention to child malnutrition, reduced financial burden for the poor with regard to healthcare and positive impact on the present levels of poverty, are all among the expected outcomes of the implemented programmes. Incentives and subsidies Apart from the funding and/or sponsoring schemes from the central government for development of urban and semi-urban health, mostly in the Tier II and Tier III cities, there are some incentives provided by the Government to promote the private service providers in the healthcare sector: 100% FDI permitted under the Automatic Route. Five-year tax holiday for setting up hospitals in Tier II and Tier III cities from 2009 to Some of the incentives provided by the different state governments to promote private participation in the healthcare sector are listed below: Land (Odisha) Earmarking lands for hospitals in town planning. Providing land at concessional prices to private hospitals. Large Special Economic Zones (Karnataka and Tamil Nadu) Larger SEZs are required to have land allocated for healthcare purposes. For example, for an SEZ of 35 acres the developer is required to set up a healthcare facility on at least half an acre (larger healthcare facility for bigger SEZ). Therefore allocation of SEZs will ensure that developers bring some quality hospital infrastructure in the state. Karnataka has given approval for two SEZs for the development and growth of the pharmaceuticals industry, viz. KIADB Pharmaceutical Special Economic Zone at Hassan and Ozone SEZ Developers Pvt. Ltd. at Chikkaballapura. Healthcare Infrastructure and Services Financing in India 19

20 Tamil Nadu has given approval for two healthcare SEZs, Frontier Mediville at Elavoor near Chennai spread over 360 acres of land with a total investment of 1,000 crore INR and BioPure Integrated Health SEZ at Hosur taluk in Krishnagiri district spread over 900 acres. Government facilitations and removal of red tape (Andhra Pradesh, Tamil Nadu and Karnataka) In general it is difficult getting all the licenses and approvals required to establish a hospital. However states like Andhra Pradesh and Tamil Nadu have developed a single window system making it easier for private players to get approvals. For opening nursing, paramedical or any medical colleges, NOC clearance from state is needed while applying to MCI. States like Kerala and Karnataka have made the process of obtaining NOC easy and transparent and do it on priority basis. This has helped a large number of private players in opening healthcare-specific training centres and colleges in these states. Government sponsored insurance schemes Less than 10% of India s population today has any form of health insurance cover. A very small proportion has opted for voluntary health insurance, but most of the others are part of the employees state insurance scheme (ESIS) and central government health scheme (CGHS). Tier III cities and rural areas are marked by a negligible insurance coverage except for a few government administered schemes. The major initiative from the central government came with the launch of Rashtriya Swasthya Bima Yojana in 2008, which provided access to quality health care to the vast population living below the poverty line. Under this scheme a maximum of 30,000 INR will be reimbursed annually for medical treatments, where the central government will bear 75% of the annual premium expenses (subject to a maximum of 565 INR per family per annum) and the respective state governments have to take care of the remaining 25%. Two smart cards are being provided to each BPL family - one for the head of the family and another for rest of the family members. The beneficiary would pay 30 INR per annum as registration or renewal fee. Till date a total of 3,23,10,732 active smart cards have been given that were used for a total of 40,55,289 hospitalization cases (as of 24 August, 2012). States No. of districts In districts with enrolment Hospitals Selected Complete In progress Total BPL families BPL families enrolled Private Public Total Bihar ,50,11,570 73,98, Odisha ,91,971 32,78, West Bengal ,49,343 45,43, Mizoram ,299 43, Gujarat ,39,634 18,10,326 1, ,683 Maharashtra ,38,792 20,81,821 1, ,222 Karnataka ,71,204 16,80, Kerala ,11,319 17,48, Source: Rashtriya Swasthya Bima Yojna, Government of India Enrolment of beneficiaries and empanelment of providers for RSBY across eight states In addition to the RSBY scheme of the central government, the West Bengal state government, which has a large percentage of workers in the unorganized sector across 44 identified industries, has introduced a Samajik Mukti card to be given out to 30 lakh workers. This card would help those workers to get benefits on hospitalization in addition to accidental death cover, pension and children s education. Allowances up to 10,000 INR is provided to the workers for treating serious illnesses like cancer, cardiac problems, kidney problems, AIDS etc. and there is an allowance of 5,000 INR per year for medical expenses if the hospitalization for the worker lasts for more than five days. 20 ICC - PwC

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