Indraprastha Medical Corporation Ltd Management Discussions.

Industry Structure & Developments

Good health is central to human happiness and well-being. Irrespective of ones economic strata or geographical location, nothing is more important to a person than his health. Taking care of ones health means much more than medicine and doctors - it starts with being aware of ones body and committing to the pursuit of wellness. It encompasses preventive medicine, health checks and assured equitable access to reliable basic healthcare facilities. People interact with such a healthcare system in various ways and to differing degrees throughout ones life, although those living in poverty, or dealing with the devastating effects of war, are denied this right to healthcare. Developed nations are able to provide their citizens better healthcare infrastructure as compared to developing nations where investment in healthcare infrastructure lags behind. A comparison of the basic health indicators between the two, clearly indicates this gap. Good health makes an important contribution to a countrys economic progress, as healthy populations live longer, are more productive, and save more. The economic growth of any country can be enhanced by healthy citizens and a disease-free society. Studies have shown that health is one of the most important causative factors that affects a countrys aggregate of economic growth. Investment in health is therefore not only desirable, but also an essential priority for societies.

One of the biggest challenges for societies across the world today, is the improvement of access to quality healthcare in terms of both reach and affordability. Coping with modern diseases, public health engineering, disease surveillance and exorbitant costs are some of the other key challenges for the healthcare industry.

The COVID-19 pandemic has caused immense disruption and highlighted the importance of adequate resources for managing such crises without excessive economic disruption. Sustainable and equitable preeminent healthcare for all is imperative. To make this a reality, all stakeholders, including healthcare providers, Governments, investors and consumers, have to come together to understand, analyze and implement necessary changes across the ecosystem. New health technologies such as wearable tech, telemedicine, genomics, virtual reality, robotics and arti_cial intelligence, although still nascent, are expected to soon change the very landscape of the healthcare industry. To meet the demands of the future, these technologies should be capable of adequate scale, compelling healthcare providers to deliver better health outcomes while managing changing consumer demand and behavior.

It is safe to expect that the future of health will focus on digital technology with more importance being given to preventive healthcare. Innovations are already breaking barriers in the way diagnoses and treatments are being provided. Technology will also help to democratize healthcare by lowering costs and breaking geographic hurdles. The increasing pace of technological innovation in healthcare will soon offer a plethora of opportunities for healthcare service providers across the globe. Overall, along with improved healthcare access, there would be a huge focus on the quality of healthcare, use of innovative diagnostics and treatment methods, improved transparency and patient centered models of healthcare delivery.

General Overview on Indias Healthcare Service_Landscape

Historically, people in developing countries have had lower access to health services than those in developed countries. Like most developing countries, India has limited healthcare infrastructure and this is inadequate to meet the demands of a large and diverse population. Even today, there is a signi_cant gap in the supply of healthcare services versus the demand. However, it is important to note that over the years, the Indian healthcare sector has changed from an unorganized sector to an organized one and also moved towards corporatization. It is one of the largest economic sectors in the country today, with regard to both employment and revenue. Various demographic changes like a bulging middle class with increased per capita income and growing awareness about diseases, increasing health consciousness among people, changing lifestyles, and a transition in disease pro_le, have led to an increasing demand for modern healthcare facilities, spurring the growth of the healthcare services sector. The system has therefore grown signi_cantly and through the leverage of medical technology, has garnered many achievements in the treatment and modalities of cure for many diseases.

The country is successfully offering best-in-class healthcare treatment services at a fraction of the cost in other major markets around the globe. The reduced cost of life-saving drugs and medical devices, the evolved pharmaceutical industry, world-class specialty hospitals in Tier 1 and Tier 2 cities coupled with a large pool of well-trained medical professionals, are other factors that have contributed immensely to the growth of the sector. The public healthcare facilities in India have been unable to scale adequately to serve the needs of the large population; reaching the interiors of the country has been another challenge. Additionally, several of these facilities are understaffed, poorly equipped in terms of basic infrastructure and equipment, and in need of enhanced quality standards and protocols. This unmet opportunity combined with strong fundamentals has largely led to the private sector taking center stage in the healthcare landscape. The late 1990s witnessed improvement in the economic conditions and made private healthcare affordable to many Indians. These hospitals turned into Centers of Excellence and over time, became preferred choice for patients and communities. These healthcare institutions provide world class facilities, employ highly skilled and globally recognized professionals, leverage advanced technology in treatments, and maintain high standards of quality. The private sector players have been able to occupy a major share of nearly 80% of the countrys total healthcare market. They also account for almost 74% of the countrys total healthcare expenditure. Their share in hospitals alone is estimated at 74% while its share of hospital beds is estimated at 40%.

Source: A report on ‘Indian Hospital Services Market Outlook by consultancy RNCOS, Grant Thornton, LSI Financial Services, OECD

From the chart below, it is clear that populations in rural as well as urban areas seek private sector treatment for their illness or disease. Of all the levels of care mentioned here, private doctor/clinic is the single most important point of contact for treatment of ailments for rural areas (50.7%) and urban areas (50%). This is followed by treatment at private hospitals, public hospital and HSC, PHC & others. There is great discrepancy in the quality and coverage of medical treatment in India - healthcare in different states, rural and urban areas, can be vastly different.

Source: MoSPI, NSS 71st Round (January-June 2014)

Note: Public sector includes HSC, PHC & others* and public hospitals. Private sector includes private doctor/clinic and hospitals.

* Others include Auxillary Nurse Midwives (ANM), Accredited Social Health Activists (ASHA), Anganwadi Workers (AWW), Dispensaries, Continuing Healthcare (CHC), and Mobile Medical Units (MMU)

Today, the healthcare sector in India offers a potent mix of opportunities and challenges. The signi_cant gap between ‘required and ‘actual healthcare infrastructure has driven considerable investment over the years into assets like hospitals and other facilities. Healthcare in India today provides corporations with a unique opportunity for innovation, differentiation and pro_ts; it has become a preferred sector for strategic and _nancial investments.

Government Initiatives are supporting the growth of the Healthcare industry

Governments all over the world work towards providing good quality healthcare for their people. Creating awareness about health issues, ensuring strong infrastructure, and promoting health insurance are productive activities conducted by the authorities for the peoples welfare. The Indian Government also undertakes such measures from time-to-time. In fact, the Countrys healthcare sector is strongly supported by the Indian Government which has been undertaking commendable work to develop India as a global healthcare hub. Over the years, a multitude of initiatives to drive the growth of the healthcare sector in the country has been yielding positive results. These initiatives have gone a long way in not only improving overall healthcare access for the general population but have also enhanced the quality of healthcare in the country.

Market Size of Indian Healthcare industry

Today, the Indian healthcare industry is growing at a signi_cant pace owing to its strengthening coverage, services, and increasing expenditure by the public and private sectors. As per a report from the Ministry of Commerce and Industry, the Indian healthcare sector, which stood at a size of USD 140 billion in 2016, is expected to reach a size of over USD 372 billion by 2022, registering a CAGR of 17.69%. India ranks 145 among 195 countries in terms of quality and accessibility of healthcare. For India, the healthcare access and quality (HAQ) index increased from 24.7 in 1990 to 41.2 in 2016. Industry experts believe that there is immense scope for enhancing healthcare services penetration in India, thus presenting ample opportunity for development of the healthcare industry.

The Indian healthcare industry is one of the most knowledgeable and professional industries in the world. Also, the sector is one of the most ef_cient and cost-effective healthcare delivery systems thanks to expert doctors and specialists, well-equipped diagnostics, and nursing services. There is immense scope for enhancing healthcare services penetration in India and ample opportunity for the development of the healthcare industry as a whole.

Source: Frost & Sullivan, LSI Financial Services, Deloitte

In FY19, the Indian healthcare sector stood as the fourth largest employer as the sector employed a total of 3,19,780 people. The Asian Research and Training Institute for Skill Transfer (ARTIST) announced plans to create around one million skilled healthcare providers by 2020.

The Healthcare Service Delivery Landscape in India

The Healthcare sector in India broadly includes Hospitals, Pharmaceutical Companies & Standalone Pharmacies, Diagnostic Services, Medical Equipment and Supplies, Medical Insurance, Telemedicine Companies, Medical Tourism and Retail Healthcare. Government hospitals - It includes healthcare centres, district hospitals and Hospitals general hospitals Private hospitals - It includes nursing homes and mid-tier and top-tier private hospitals It includes manufacturing, extraction, Pharmaceutical processing, puri_cation and packaging of Companies & chemical materials for use as medications Standalone for humans or animals. Standalone Pharmacies pharmacies include both organized and unorganized standalone pharmacies in India. It comprises businesses and laboratories Diagnostics that offer analytical or diagnostic services, Services including body fluid_analysis. It includes establishments primarily Medical manufacturing medical equipment and Equipment & supplies, e.g. surgical, dental, orthopedic, Supplies ophthalmologic, laboratory instruments, etc. It includes health insurance and medical Medical reimbursement facility, covering an Insurance individuals hospitalization expenses incurred due to sickness. Telemedicine has enormous potential in meeting the challenges of healthcare Telemedicine delivery to rural and remote areas besides Industries several other applications in education, training and management in health sector. Indian medical tourism is enhancing the prospects of the Indian healthcare market Medical substantially, bene_ting its healthcare Tourism services players and in increasing the in_ow of foreign exchange into India. Retail in healthcare enables opportunities of clinical service in a marketplace other than regular hospital. The Retail Healthcare Retail business primarily include Primary Care Healthcare Clinics, specialized birthing centers, single specialty clinics, primary health centers and diagnostic chains, apart from Dental, Daycare and Home Healthcare formats.

Source: CRISIL Research

The Healthcare sector is divided into three major categories: primary, secondary and tertiary.

Primary Care Secondary Care Tertiary Care
Services Provides all services as required for the _rst point of contact Provides all services as required, including organized medical research Provides all services as required, including provision for experimental therapeutic modalities and organized research in chosen specialties
Multi- disciplinary Type of service Yes Only medical services and excludes surgical services Yes Overall medical and surgical services Single- or multi- specialty Complex surgical services with sophisticated equipment
Type of patient Only outpatient Inpatient and outpatient Primarily inpatient
No. of beds Dependent on 0 beds Secondary and tertiary care hospitals for further diagnosis and support 50-200 beds Tertiary care hospital for diagnostic and therapeutic support on referral and for patient transfer >200 beds Tertiary care/ secondary hospital for referrals for its workload
Investment Low investment required Medium High

 

Primary Healthcare

Primary care facilities are outpatient units that offer basic, point-of-contact medical and preventive healthcare services, where patients come for routine health screenings and vaccinations. This is the _rst point of contact between the populace and the healthcare service providers. These facilities do not have intensive care units (ICU) or operation theatres. Their infrastructure offers basic medical and health prevention services through a network of Sub Centers and Primary Health Centers in rural areas, whereas in urban areas it is provided through Health Posts and Family Welfare Centers. Primary Care Centers also act as feeders for secondary / tertiary care hospitals, where patients are referred to for treatment of chronic / serious ailments.

 

Secondary Healthcare

Secondary care facilities diagnose and treat ailments that cannot be treated in primary care facilities. These act as the second point of contact in the healthcare system. In India, the health centers for secondary health care include District Hospitals and Community Health Centers at the block level. This infrastructure provides inpatient as well as outpatient medical services which includes simple surgical procedures. Some of medical specialties offered under secondary healthcare include internal medicine, pediatrics and limited coverage of other specialties like urology, cardiology, and other specialties.

 

Tertiary Healthcare

Tertiary care hospitals provide advanced healthcare services, usually on referral from primary or secondary medical care providers. Specialized Intensive Care Units, advanced diagnostic support services and specialized medical personnel are key features of tertiary health care. Single-specialty tertiary care hospitals treat a particular ailment such as cardiac, cancer, etc. On the other hand, there are multi-specialty tertiary hospitals that offer all medical specialties under one roof and treat complex cases such as multi organ failure, high-risk, and trauma cases. In India, under the public health system, tertiary care service is also provided by medical colleges and advanced medical research institutes.

Scope to increase Indias Per Capita Healthcare expenditure

Despite the uptick in Government spending and thrust on increasing insurance coverage, the Government of Indias expenditure on healthcare stood only at 1.4% of GDP in FY18. The continuing disparity of healthcare spends between urban and rural areas have resulted in sharp disparity in healthcare availability across the country. The Government of India is planning to increase public health spending to 2.5% of the Countrys GDP by 2025.

As a percentage of GDP, India current healthcare expenditure falls behind not just developed countries such as the United States (the US) and the United Kingdom (the UK), but also behind various developing countries such as Brazil, Nepal, Vietnam, Singapore, Sri Lanka, Malaysia, and Thailand.

Inadequate Healthcare Infrastructure

India which accounts for nearly a _fth of the worlds population, has 12 beds per 10,000 people mainly in urban areas with the number being far lower in rural areas. Indias bed density not only falls far behind the global median of 29 beds, it also lags that of other developing countries such as Brazil (21 beds), Malaysia (19 beds), and Vietnam (26 beds). As per a CRISIL report in 2015, India needs to invest

~ 14 tn (USD 230 bn) in order to meet the global average.

Over the last few decades, India has taken considerable steps to grow its medical educational infrastructure. In November 2020, the number of medical colleges in India increased to >560 from 412 in FY16. The number of doctors possessing recognized medical, quali_cations (under I.M.C Act) registered with state medical councils/medical council of India increased to 1,255,786 in September 2020 from 827,006 in 2010. According to a study, there is one Government doctor in India for every 10,189 people (a de_cit of 6,00,000 doctors) The nurse-to-patient ratio is 1:483. These statistics indicate the alarming gap in healthcare infrastructure in the country and the tremendous growth potential the sector offers.

Key Characteristics

A combination of economic and demographic factors is expected to drive healthcare demand in India. This industry in India is broadly characterized by the following:

 

Rising per capita income and widening of income inequalities

India has witnessed tremendous economic growth over the last 3 decades. The country has been able to register robust GDP growth and has been consistently featured amongst the fastest growing economies. With the country already witnessing a steady economic growth, the per capita income of its population as well as the economic stability of the expanding middle class Indian, is on the rise. This changing scenario and the accompanying demands, has improved affordability and access to better healthcare facilities for millions of upwardly mobile Indians. Indias per-capita income, a broad indicator of living standards, clocked a healthy ~5% CAGR, from Rs. 63,462 in _scal 2012 to Rs. 94,954 in _scal 2020. Growth in per-capita income has been led by better job opportunities, propping up overall GDP growth while the population growth has remained fairly stable at a ~1% CAGR.

FY12 FY13 FY14 FY15 FY16 FY17 FY18 FY19 FY20PE
Per-capita net national income () 63,462 65,538 68,572 72,805 77,805 82,931 87,828 92,085 94,954
On-year growth (%) 2.1 3.3 4.6 6.2 6.7 6.8 5.9 4.8 3.1

Income, 2019-20, CSO, MoSPI, CRISIL Research

Due to increasing affordability, consumers are demanding and willing to pay for superior healthcare services. However, even as India continues to develop, the country is witnessing a widening of income inequalities. Low per capita income, minimal expenditure on healthcare, and a poor number of doctors coupled with muted insurance penetration in rural areas, account for wide disparity in healthcare offerings between urban and rural areas. Also, the inequality is becoming increasingly apparent even within the same city. People from the different socioeconomic groups fall into unique baskets typi_ed by varying healthcare needs. Each of these presents a market in terms of the addressable value proposition.

The enhanced affordability in a segment of the population, due to rising income levels, supports the need for quality medical care at a relatively higher price. Growth in household incomes, and consequently, disposable incomes, is, therefore, critical to the overall growth in the demand for healthcare delivery services in India.

 

Increase in Population and changing demographic trends

According to the ‘World Urbanization Prospects: The 2018 Revision by the United Nations, India and China, the top two countries in terms of population, accounted for nearly 37% of the worlds population in 2015. The report projects that Indias population will increase at 1% CAGR to 1.5 billion by 2030, making it the worlds most populous country, surpassing China with 1.4 billion people. Indias 1.3 billion population base offers a sizable market and pertinent growth opportunities for health care services in the country. As per the National Health Pro_le 2018, 54.6% of Indias population falls in the age group of 20 to 59 years - a productive demographic group with distinct advantages which is likely to propel India towards being ranked among the worlds most developed economy in the next decade. This group expects and is willing to pay for modern and superior quality healthcare services for both treatments and wellness.

P – Projected. Source: World Urbanization Prospects: The 2018 Revision, United Nations, CRISIL Research

While the population of India seems considerably young, there is a parallel elderly population of 60 plus, that is growing. The rise in numbers in this segment combined with rising life expectancy, is another proponent for quality healthcare. Socio-demographic factors in the country, therefore, are expected to boost healthcare services demand in the future.

 

Under–Served, Under–Consumed

Indias healthcare space is under-served due to the absence of credible infrastructure. This scenario is the result of decades of under-investment in the health sector. In addition to this, the domestic healthcare delivery infrastructure is largely skewed by the organized private sector which has presence primarily in state capitals or Tier-1 cities.

The country continues to remain far behind the global curve in providing good quality healthcare access across its population, although making healthcare affordable and accessible to all citizens of the country is one of the Governments key focus areas. In terms of infrastructure, India has 12 hospital beds whereas USA has 29 beds to serve per 10,000 populations. India requires an additional 2 million beds to be at par with the global median. While Indias healthcare service infrastructure is under served, low affordability has also resulted in these services being under-consumed.

 

Transition in disease profile

India has witnessed extensive change in the overall disease pro_le of its population. The share of death for communicable, maternal, neonatal, and nutritional diseases decreased to 27.5% in 2016 from 53.6% in 1990 and that of non-communicable diseases increased to 61.8% in 2016 from 37.9% in 1990. This shift in the disease pro_le has led to an additional need for healthcare services in the country. Non-communicable diseases tend to be of long duration, increasing the need for sustained healthcare services. Due to increased urbanization, the incidence of lifestyle diseases is anticipated to increase faster than any other segment. Within the lifestyle space, cancer is one of the fastest growing ailments.

Transition in disease pro_le 1990 2016
Share of communicable, maternal, neonatal and_nutritional_diseases 53.60% 27.50%
Share of non-communicable diseases 37.90% 61.80%
Share of injuries 8.50% 10.70%

Source: Health of the Nations States 2017: India Council of Medical Research

 

The increasing role of technology in healthcare delivery

The healthcare industry, like other industries, is constantly evolving in terms of technology. Developments in information technology have helped create systems that ensure faster and reliable services. While, on the one hand, these systems help increase reach and quality of healthcare delivery systems across the country, on the other, they enable healthcare delivery providers to improve ef_ciency by helping in resource planning, maintenance of patient records, etc.

In India, leading hospitals have been investing in supportive technology and operative techniques for diagnostics and treatment. The timely adoption of advanced technologies has enabled the availability of and supported advancements in robotic surgeries, radiation surgery and radio therapies with cyber knife options, intensity modulated radiation therapy, image guided radiation therapy, transplant support systems, and advanced neuro and spinal treatments.

 

Emerging Technologies in Healthcare Delivery

New health technologies such as wearable tech, telemedicine, genomics, virtual reality (VR), robotics and arti_cial intelligence (AI) are changing the landscape of the Indian healthcare system. Like many other markets, India too is at the cusp of a ‘digital health revolution as a vast number of healthcare companies have started adopting digital technologies which span patient engagement, physician engagement, _eld force effectiveness, R&D ef_ciency and supply chain management. As the pace of digital innovation in healthcare accelerates, so do the opportunities for healthcare service delivery institutions across India who are willing to embrace the digital health space over the coming years. CRISIL Research expects that the advent of 5G, smartphone penetration, and an increasingly health conscious population, will deepen digital healthcare penetration.

 

Scaling up of Medical Value Travel (MVT)

"Affordable and quality treatment makes India a favored destination"

The Indian healthcare industry has been doing exceptionally well in addressing the multi-billion-dollar medical value travel opportunity. Over the years, India has grown to become the preferred destination for medical value travel because it scores high over a range of factors that determine the overall quality of care. From therapy, to the range of procedural and treatment options, infrastructure and skilled manpower, care and compassion, to minimal waiting time for any medical procedure, and availability of generic drugs, the list of bene_ts for medical travelers are many. Healthcare costs in India are extremely competitive compared to those in developed countries and other Asian countries. This is especially for expensive and delicate surgeries like cardiac bypass, solid organ transplants, joint replacements, dental services, cosmetic surgeries and bariatric surgery. The cost of travel and accommodation is also low as compared to developed nations. India also attracts medical tourists from other developing nations due to the lack of advanced medical facilities in many of these countries. Government estimates suggest that the size of the medical tourism market would grow substantially by the next _scal from a size of 3 billion USD in 2015.

 

Cost advantage – India compares favorably with regional peers

Ailments (USD) USA UK Thailand Singapore Korea India
Heart Surgery 1,00,000 40,000 14,000 15,000 28,900 5,000
Bone Marrow
Transplant 2,50,000 2,90,000 62,000 1,50,000 NA 30,000
Liver Transplant 3,00,000 2,00,000 75,000 1,40,000 NA 45,000
Knee
Replacement 48,000 50,000 8,000 25,000 19,800 6,000
Dental Implant 2,800 NA 3,636 1,500 4,200 1,000

Source: CRISIL, FICCI, JCI

The Indian Government has been facilitating easy entry for International patients into the country by providing special medical visas. It has introduced multiple policies such as the introduction of e-Medical visa, multiple entry visas and longer stays as required for treatment. Additionally, the Indian Government has been actively mandating accreditations to wellness centers and Medical Value Travel (MVT) facilitators. These initiatives have gone a long way is enhancing Indias image as a preferred destination for medical tourists.

Source: CY17 CRISIL; Ministry of tourism

 

Rising Investments in the Indian Healthcare space

Infusion of long term capital in the healthcare space goes a long way in strengthening the healthcare infrastructure of the country. Demand growth, cost advantages and policy support are some of the factors that have been playing a very important role in attracting FDI in the healthcare sector. In the past few years, the Indian healthcare industry has attracted a great level of interest for leading global private equity players and venture capitalists. The growth in multi-specialty and single-specialty hospitals in India has largely taken place due to the strong backing of PE funding. Many multinational players have been trying to deepen their presence through partnerships and investments.

The Government of Indias decision to allow 100% FDI in the hospitals sector led to a signi_cant increase in investment from overseas funds. These trends indicate rising investor con_dence in the Indian healthcare space and deepen the perception of India as an attractive healthcare investment destination.

Growing Health Insurance market

Health insurance encourages demand for healthcare services as the insured pays a premium for the policy which is reimbursed by the insurer in case he/she has to undergo treatment on account of illness, sickness or disease. The insurance, to an extent covers the health expenses of an individual and reduces his/her burden of healthcare costs. Therefore, an increase in health insurance market will drive up demand for healthcare services.

Source: Global Health Expenditure Database – World Health Organisation, CRISIL Research

In India, out-of-pocket (OOP) expenditure on health accounted for nearly 63% of total health expenditure as of 2018; the highest among many other countries. Nearly 25% of the rural population and 18% of the urban population is dependent on borrowings for funding their healthcare expenditure. Also, nearly 68% of the rural population and 75% of the urban population use their household savings on healthcare related expenditure. Health expenditure contributes to nearly 3.6% and 2.9% of rural and urban poverty, respectively, annually putting an estimated 60 to 80 million people into poverty due to healthcare-related expenditure. However, Pradhan Mantri Jan Arogya Yojana (PMJAY), is expected to promote healthcare affordability and reduce healthcare expenditure to some degree, especially for the deprived population. Low health-insurance penetration is one of the major impediments to the growth of the healthcare delivery industry in India, as affordability of quality healthcare facilities by the lower-income groups remains an issue. Health insurance coverage has increased from 17% in _scal 2012 to 36% in _scal 2020. As per the Insurance Regulatory and Development Authority (IRDA), nearly 499 million people have health insurance coverage in India (as of _scal 2020), as against 288 million (in _scal 2015), but despite this robust growth, the penetration in _scal 2020 stood at only 36%. The growing incidence of disease coupled with low Government funding has led to an increase in the _nancial burden for healthcare among the general public. Against a backdrop of rising healthcare costs, this underscores glaringly, the crying necessity for larger health coverage for the populace.

Schemes providing health insurance coverage to corporate employees are further helping market penetration of insurance players. Government-funded health insurance options are relatively less attractive as compared to those offered by private players, indicating private insurance coverage will grow at a higher rate. Given that a majority of Indians are not covered under a health insurance scheme, augurs well for the future growth of the health insurance segment in India.

SWOT Analysis

Strengths

Widespread network

High brand salience

Pro_cient medical team with rich medical expertise

Comprehensive offerings

Technological experience

Weaknesses

Capital intensive nature of industry

Scarcity of experienced doctors and skilled medical professionals

Intensive regulatory requirements

Heterogeneous markets

Opportunities

Medical value travel

Changing demographics

Enhanced access and lower cost of delivery through digital solutions

Changing formats and consumer preferences

Preventive health and wellness

Underserved and poorly-served markets

Threats

Heightened competitive intensity

Changes in government regulations

Increasing cost of resources

Shortage of skilled manpower

Strengths

High Brand Salience

Indraprastha Apollo Hospitals has built and maintained a strong leadership position in the Indian healthcare industry. As Indias leading integrated healthcare provider, Indraprastha Apollo Hospitals is respected in the industry. This position is commensurate with its unrelenting focus on consumer needs and safety. It is resolute in maintaining leadership position by embracing innovative cutting-edge technology and clinical protocols. The reputation and trust built over the years is a strong asset, and continue to help the Group attract a large numbers of patients, very talented clinicians, and staff.

 

Proficient Medical Team with Rich Medical Expertise

Indraprastha Apollo Hospitals strong brand image and best in class working environment continue to attract and retain top clinical and professional talent from India and abroad. The doctors and supporting medical personnel at Indraprastha Apollo Hospitals are not only well quali_ed but possess rich experience in their respective _elds. The ef_cient clinical and non-clinical staff at Indraprastha Apollo Hospitals is well trained to deliver the best possible clinical outcomes to patients. Indraprastha Apollo Hospitals senior management team has established a strong ecosystem which enables and motivates the staff in delivering a superior level of care.

The doctors at Indraprastha Apollo Hospital have an enviable track record whether it is in terms of performing critical surgeries or medical procedures. Their domain expertise is revered and has gained acknowledgement from patients across the globe. Many specialists across Indraprastha Apollo Hospital continue to receive multiple accolades and awards at different healthcare forums due to their expertise in the _eld of medicine.

 

Comprehensive Offerings

Indraprastha Apollo Hospital has taken considerable steps to ensure that access to quality care is not restricted to the hospital setting, but is also available outside of it or in a post hospitalization scenario. Today, Indraprastha Apollo Hospitals breadth of service offerings successfully spans the entire value chain of healthcare services.

 

Widespread Network

Indraprastha Apollo Hospital has established various touch points which facilitate smoother access to services for its patients. By providing premium and affordable medical services over the years, Indraprastha Apollo Hospital enjoys many competitive advantages like enhanced customer experience, economies of scale, cost ef_ciencies, wider reach, access to a larger patient base and the leverage of synergies.

 

Technological experience

Since its inception, Indraprastha Apollo Hospitals has given utmost importance to continually enhancing and adopting newer technologies. The Company has remained at the forefront in outlaying necessary capital for embracing best available advanced medical technology. This approach has gone a long way in enabling Indraprastha Apollo Hospitals to provide seamless treatment to its patients. Additionally, in order to provide patients smooth access to Indraprastha Apollo Hospitals services, the Company has built an integrated online platform called ‘Ask Apollo, using which, patients enjoy several bene_ts like booking doctor appointments and scheduling online consultation for basic medical needs. Most recently, Apollo Hospitals has launched its advanced App, Apollo 24/7, which provides a platform for virtual consults with doctors, on-line access to integrated medical records and prescriptions, and the ability to _ll prescriptions through Apollo Pharmacy.

Weaknesses

Capital Intensive Nature of Industry

The Healthcare industry is highly capital intensive. The basic requirements for operating a medical facility such as land, construction costs for specialized interiors, medical equipment and manpower, need high investments. These intensive capital requirements become barriers to entry into the industry and to expand operations. In addition, maintenance and upgradation of medical treatment technologies also requires considerable recurring expenditure. It is observed that once an enterprise is able to manage the initial capex requirement to set up a facility, the subsequent task of balancing day-to-day expenditure with competitive prices for healthcare services is challenging. Therefore, the basic cost of setting up and running a hospital is considerably high and escalates break-even levels while stretching viability.

 

Scarcity of experienced doctors and skilled medical professionals

The healthcare services industry is workforce intensive. The quality of doctors and supporting healthcare professionals is critical to the eminence and ef_ciency of the business. India is a country with abundant workforce given the sheer size of its population. However, there is a huge gap in the provision of relevant education for a majority of this population and a dearth of competent training institutes for appropriate workforce skilling. Therefore, skilled workforce - doctors, nurses and paramedical staff comprising lab-technicians, radiographers and therapists - are in short supply. Skilled professionals in the healthcare industry enjoy attractive opportunities both in India and overseas. Intense competitiveness amongst healthcare providers in urban areas has led to unsustainable increases in remuneration for quali_ed personnel. The availability of skilled professionals is therefore a challenge for setting up and running a healthcare institution pro_tably in India.

 

Intensive Regulatory requirements

Multiple licenses and approvals required to set up a hospital is another barrier for private players to expand their operations. Today, apart from licensing and approvals, the Government is also regulating the prices of drugs and consumables. It has to be understood that the value of output delivered by the sector is not just the sum of the value of inputs. There is an intrinsic value in the sum total of services that needs to be considered.

From a regulatory point of view, there are many requirements, which can prove to be onerous when compared to global norms like single window clearance. Better understanding between the various regulatory authorities and healthcare service providers is necessary. It is important to understand that private healthcare service providers cannot be equated with other businesses. Healthcare service providers have to be viewed from the perspective of the important contribution that they are making in ensuring the general wellbeing of the community.

 

Heterogeneous Markets

With a diverse and growing population, the need for quality healthcare services is very pressing in India. The requirements are different even in markets, which are reasonably proximate. Every micro-market has a unique set of circumstances with variance in demographics, disease pro_les, customer attitudes, seasonal variations, price sensitivity and so on. Hospitals in two different cities in the same state and even two facilities within the same city have different operating circumstances with varying parameters. This necessitates a higher degree of customization and monitoring.

Signi_cant management oversight is required in the face of these complexities for sustaining clinical standards, balancing case mix, ensuring adequate volumes and upgrading technology regularly.

Opportunities

Medical Value Travel

Medical Value Travel (MVT) is a growing multi-billion-dollar industry and is likely to grow further due to the many bene_ts that it offers to patients. World-class hospitals, equipped with best-in-class technology, skilled medical professionals and low treatment costs have strengthened Indias position as a preferred destination for medical tourism. Indian hospitals are able to offer superior services at comparatively lower costs. The assurance of quality healthcare facilities and cost- effectiveness are the two main factors that have been attracting millions of patients from across the globe for medical treatment in India. Proactive steps taken by the Union Government like approving issuance of e-medical visas, have also contributed to the growth of medical value travel in the country.

 

Changing Demographics

While India is blessed with a favorable demographic quotient given the relatively young population, it also has a very large number of ageing citizens in absolute terms. Therefore, Indian healthcare service providers have an opportunity to meet the healthcare expectations of the young and attend to the increasing healthcare requirements of the elderly. Alongside, the country is witnessing a sharp increase in disposable income among several groups, including a burgeoning middle class, who can afford to pay for quality healthcare. These evolving demographics present an exciting opportunity to service providers.

 

Enhanced access and lower cost of delivery through Digital Solutions

Digital Technology will play a crucial role in enabling access to healthcare for Indias masses. Ongoing digitization and the introduction of new technologies like telehealth, are already breaking down boundaries and creating patient-centric healthcare systems. Technology is enabling patients to book their appointments and opt for basic medical needs seamlessly from their homes. Doctors are able to access patient records at their _ngertips and effortlessly provide consultations using digital technologies and telemedicine. Technological development in recent decades has opened up ways to reduce distribution costs and increase healthcare penetration. Such solutions will be most successful in extending connectivity to rural and remote areas and offering _rst-class care thus obviating the need to undertake lengthy travels to urban health centers.

 

Changing formats and consumer preferences

The general perception is that some hospitals tend to be intimidating to patients who respond better in a more relaxed atmosphere. Today, patients largely prefer accessing single specialty centers and other healthcare delivery formats for non-critical ailments. In order to cater to this trend, healthcare service providers have been providing a variety of options such as short stay centers, single specialty centers, neighbourhood clinics, and home services. These alternate healthcare delivery formats are economically attractive, as they require lower capital investment, are able to achieve faster breakeven and deliver a better return pro_le. Some of these new formats have demonstrated greater specialization and the ability to create signi_cant value as compared to larger multi-specialty hospitals.

 

Preventive Health and Wellness

There is considerable rise in health awareness across the population of this country. People are increasingly realizing the importance of healthy living and are taking considerable efforts to adopt a healthy lifestyle. They are recognizing the importance of diagnosing a disease at an early stage and preventing critical progression. This awareness has led to a promising opportunity in the areas of preventive health and wellness, encompassing preventive health checks, diet and nutrition, exercise and well-being.

 

Underserved and Poorly-Served Markets

Signi_cant inequalities exist in the quality of healthcare services available in metro cities and large urban areas as compared to that in the rural areas of the country. Indias rural population continues to experience access barriers to quality healthcare services. Even persons with better resources and _nancial means have to commute to metro / urban areas to gain access to medical treatment or related health care services. Healthcare service providers who are willing to penetrate into semi urban and rural areas will bene_t from a ready marketplace for their services.

Threats

Heightened Competitive Intensity

The competitive intensity among unorganized as well as organized players continues to remain high. Given the growing demand for healthcare services, many entrepreneurs and business houses have been entering the healthcare business. The sector has been witnessing rising interest from private and foreign players. They intend to invest and venture in the various segments available in the healthcare industry. Most of these newer players are often offering services at lower costs as compared to established players and creating further competitive intensity. There are even pockets of overcapacity in certain metros and rising competition could lead to competitors adapting unfair practices in order to survive, hampering the growth and pro_tability of other players. Every market player, whether from the organized or the unorganized sector, is striving for market leadership.

 

Changes in Government regulations

In the last few years, the Government of India has taken a number of positive initiatives, such as National Health Protection Scheme (NHPS) and Pradhan Mantri Jan Arogya Yojana (PMJAY), which have bene_ted the Indian healthcare sector. However, GST implementation had an adverse impact on health care service delivery costs and operating margins since hospitals are unable to utilize input GST credit on output services, as hospital services are under the exempt category.

The possibility of further regulatory interventions by Government agencies in the future is an existing challenge for Indian healthcare service providers.

 

Increasing cost of resources

Healthcare service providers are required to deliver a reasonable return on invested capital growth to their shareholders. Controlling costs and _nding ways to improve realizations seem to be the golden mean. However, input costs in healthcare have become signi_cant and are expected to rise in the coming times due to increasing competition.

There is a substantial demand for certain _nite resources such as land, quality medical professionals and equipment. Healthcare players also have to constantly enhance and adopt newer technologies which increases overall healthcare costs. Additionally, with the Governments thrust towards price reduction through regulation, there is a real threat of hospital _nances being rendered unviable. The constraint of incurring higher costs leads to long gestation periods and relatively low returns on investment.

 

Shortage of Skilled Manpower

There is an acute shortage of skilled healthcare resources in India. At 8 physicians and 21 nursing personnel per 10,000 populations, India stands well behind other countries including other developing nations like Brazil on these parameters. Unless immediate steps are taken to increase the number of doctors, nurses and paramedics, the shortage of manpower will lead to prohibitive costs and derail the delivery of healthcare services.

Company Overview

Excellence in Operations

Indraprastha Apollo Hospital offers international standard medical care in New Delhi, delivering multi specialties under one roof. The hospital offers world class treatment at an affordable cost, focusing on speci_c areas where it can optimize efforts and values. Transplants, cardiology, oncology, neurology and orthopedic with higher revenue prospects are some of the key specialties.

Apart from these specialties, the hospital has been able to deliver outstanding clinical outcomes in some critical cases and emergencies.

Medical Value Travel

Medical Value Travel has been gaining strategic importance given its ability to create employment, encourage cultural exchanges, improve positioning of the country by projecting its ‘soft power and earning foreign exchange. Patients across the globe seek better quality and affordable health care options, availability of the latest medical technologies and accreditations, facilitation around hospitality services and minimal waiting time. India has been able to successfully emerge as one of the most affordable and best providers of healthcare among all medical tourism destinations. The country has been ranked in the top three destinations in Asia along with Thailand and Singapore. Indraprastha Apollo Hospital is the _agbearer in the medical value travel space as it has been catering to patients from across the globe. Indraprastha Apollo Hospital provides state-of-the-art medical facilities and cutting-edge technologies, and has been attracting International patients in large numbers. The hospital has a stellar track record of providing better clinical outcomes when compared to the best institutions in the world, at a fraction of the International costs. Indraprastha Apollo Hospitals has been providing a wide range of high-quality services to patients from various countries, including Preventive Health Checks, Organ Transplantations (kidney, liver, and cornea transplants), Robotic Surgeries, Cancer Treatments, Joint Replacement Surgeries, Cosmetic Procedures, Eye Procedures, Brain and Spine Surgeries, and so on. The hospital has successfully attracted large number of patients from countries like Paci_c Islands, Afghanistan, Bangladesh, Iraq, Kenya, Nigeria, Ethiopia, Oman, Yemen, Sri Lanka, Uzbekistan, Myanmar and Nepal. The Company has entered into various agreements with the Ministries of Health of several other countries to treat patients referred by them.

The Government of India has launched a number of initiatives to promote medical tourism, which is helping improve Indias image as a preferred destination for medical tourists. Initiatives such as facilitating visa on arrival and e-medical visa have made the modalities of admitting foreign patients a lot easier. The Niti Aayog Yojna has identi_ed Medical Value Travel as one of the major growth drivers and a major source of forex earning. Indraprastha Apollo Hospital has been leading advocacy in this area and has been working closely with the Indian Government, to ensure seamless implementation of new policy initiatives. The Apollo Hospitals Group has also collaborated with the Ministry of External Affairs of the Government of India to train doctors and paramedics from Africa. On the whole, today, Indraprastha Apollo Hospital considers itself well placed to capitalize on the opportunity created by the countrys growing Medical Value Travel segment.

Apollo 24/7

Apollo 24/7 is Indraprastha Apollo Hospitals new direct-to-patient M-Health platform which follows and guides the entire patient engagement cycle – from scheduling a doctors appointment, virtual consultations, health checks, diagnostic services, anytime-anywhere access to electronic health records, as well as chat-bot based assistance. The App also provides the facility to order medicines online and get them delivered at home. Apollo 24/7 is a fully integrated offering to track a persons entire medical health and wellness journey. It starts with a virtual consultation with an Apollo certi_ed doctor, from the safety of ones own home. 2,500+ doctors are on the Apollo 24/7 Tele-consultation platform covering 60 specialties for round the clock service. The program offers a quick path to Apollos Emergency Services should one need it and top quality diagnostic services round the clock, even at ones doorstep. The technicians are well trained, clinically ef_cient, courteous, and friendly to the consumer.

Apollo 24/7 is an omni channel solution and is health safe for PHR. It is the only comprehensive condition management solution in India which blends wellness and clinical advisory services. It is also the only platform that can leverage on-line and off-line records to provide AI based predictions.

ProHealth

At Indraprastha Apollo Hospitals, we give ‘Care the same importance as ‘Cure. Preventive Health has been a key focus area for us when we _rst introduced Master Health Checks. Drawing on this experience and learning, we have launched Apollo ProHealth, a proactive Health Management program. A _rst of its kind, this holistic, comprehensive health program, is powered by pHRA (personalised Health Risk Assessment), enabled by Arti_cial Intelligence. ProHealth empowers individuals and businesses with actionable health analytics, to know and eradicate health risks through appropriate clinical and lifestyle interventions. Driven by technology, the program also offers a personal Health Mentor as guide. We plan to create awareness regarding these preventive health initiatives amongst a wide section of people in the urban areas using mobile clinics. Well equipped with high-end technology for advanced screening of NCDs, the Samsung-Apollo Mobile Clinic will drive awareness on NCDs and facilitate early detection and preventive screening.

Non Communicable Diseases, including cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, which account for about 60% of all deaths in India, can be prevented or managed by making appropriate lifestyle changes, if diagnosed early. It is critical to undergo regular health check- ups to detect NCDs at an early stage to avoid future health related complications.

COVID-19 has brought the importance of good health to the fore. While over 80% of those affected have only mild symptoms and show good recovery, the prognosis is poor in patients with obesity, diabetes, hypertension, cardiac diseases and respiratory diseases - Studies have shown that 90% of hospitalized COVID-19 patients have one of these underlying conditions. These _ndings underscore the importance of good health in promoting a strong immune system to help _ght off disease. These predictive and precautionary healthcare tools will help Predict, Prevent, and Overcome the ill effects of NCDs and mitigate potential health issues at an early stage.

Infection Control and Environment

The Infection Prevention and Control Program has been an integral part of our organization since its inception. Reducing the preventable part of health care associated infections (HCAI) is central to our program. Our healthcare indices currently are 0.62 for CLABSI (central-line associated bloodstream infections), 1.41 for VAP (ventilator associated pneumonia) and 1.01 for CAUTI (catheter associated urinary tract infections) per 1000 device days respectively through implementation of ‘bundles with other preventive measures and are comparable to international healthcare centers.

Antimicrobial Stewardship Program forms a major focus for the Program and aims at judicious use of antimicrobials. Periodic review of antimicrobial guidelines is carried out along with strict vigilance of highly restricted antimicrobials which are issued by Pharmacy upon clearance from Infection Control after necessary interaction with the treating team. Newer antimicrobials are allowed to form a part of our in-house hospital formulary only after evaluation of scienti_c evidence. Syndromic molecular array panels that are being carried out, aid in identifying infections early and initiating appropriate antimicrobials in a timely manner. Emphasizing the need for antimicrobial stewardship during the COVID era, these aspects have been reinforced for rational use of antimicrobials including antifungals.

Efforts continue towards increasing hand-hygiene through innovative tools so as to spread the message not only hospital-wide but also other medical institutions and the community also, in this most important hygiene aspect. Strict infection control practices have become all the more imperative in the COVID era, whether it is to do with direct patient-care or with diagnostics. We were amongst the _rst corporate healthcare institutions who were given permission for diagnostics (RT-PCR) as we already had a structured infrastructure for Molecular Microbiology. Moving forward, we had to address newer challenges in terms of preventive engineering adjustments with appropriate pressure gradients in segregated work-areas and biomedical waste management. With the cases on the surge, the increased sample load was managed in real-time by upgrading resources in the form of equipment as well as training and diverting our existing non-COVID staff towards the COVID areas. The real-time data is being shared with Government authorities.

The creation and implementation of standard operating procedures for the staff involved in direct patient activities was taken up on priority so as to ensure safety for them and the patients. The challenges posed have been overcome with the timely response of recreating process _ows into existing facilities as well as creating new facilities with speci_c environmental changes. Repeated training activities and competency checks along with counselling have helped overcome the psychological barriers and and helped motivate our re-deployed or newly recruited staff. The training activities encompass retraining on hand-hygiene, safe PPE use, respiratory and mask etiquette and orientation to staff and patient _ow in different areas. The evolution of our Infection Control Program continues to strive for infection prevention in healthcare facilities, and focus upon the safety of staff, patients and attendants. It also disseminates awareness in the community, catering to the needs of the state and the nation during COVID pandemic.

Awards and Accolades

The Hospital received a number of awards and accolades during the year. Some of them are as under: -

Award Category/Project Awarded
Hospital Management Asia Talent development– We care for our warriors
Apollo Innovation Best HR practices– We care for our warriors
AHPI Healthcare Excellence Award 2021 COVID Management

Risks and Concerns

At Indraprastha Apollo Hospitals, we identify business sustainability risks and opportunities on an ongoing basis and integrate these into our existing risk management framework. We have adopted certain processes which continuously enhance risk awareness and promote a culture of risk management.

The Board of Directors had constituted a Risk Management Committee to identify elements of risk in different areas of operations and to develop a policy for actions associated to mitigate the risks. The Committee on a timely basis informed the members of the Board about risk assessment and minimization procedures and in the opinion of the Committee there was no risk that may threaten the existence of the Company.

The risks that may adversely impact the functioning of the Company include, but are not limited to: -

Competitive intensity and new entrants to the market

Pace of obsolescence of technology and treatment methods utilized by us

In_ationary pressures & other factors affecting demand

Increasing costs of wages, materials, transport &_storage

Labor shortages and attrition of key staff including medical professionals

On a Public Interest Litigation (PIL) regarding free treatment in the hospital, the Honble Delhi High Court vide its order dated 22nd September, 2009 has held that free treatment provided by the hospital shall be inclusive of medicines and consumables. The company has _led a Special Leave Petition before the Honble Supreme Court challenging the order of the Honble Delhi High Court. The Honble Supreme Court of India has admitted the Special Leave Petition and has passed an interim order on 30th November, 2009. In pursuance of the interim order, the Company has been providing free treatment to the patients referred by the Govt. of NCT of Delhi and has been charging only for medicines & medical consumables.

The Company has moved an Interlocutary Application before the Honble Supreme Court seeking a direction that the conditions relating to provision of free treatment facilities for patients belonging to indigent category to the extent of 10% IPD and 25% OPD be made applicable to the Company as have been made applicable in case of other hospitals. Additionally, the Company has also made representations before the Govt. of NCT of Delhi to allow the Company to extend free treatment including medicines and consumables up to 10% IPD and 25% OPD as applicable to other hospitals.

Increasing pricing pressure from insurance companies, e.g., requests for discounts on rack rates, medication etc., will have an adverse impact on margins and revenues.

The unprecedented COVID-19 pandemic has resulted in major revenue impact for the hospital. This is due to various factors such as sharp drop in OPD revenues, elective surgeries, consultations and international patients.

Internal Control Systems and their Adequacy

Indraprastha Apollo Hospital is committed to maintaining high standards of internal controls throughout its operations. An adequate and synchronized internal control framework deploys a well-designed robust system which allows optimal use and protection of assets, facilitates accurate and timely compilation of _nancial statements and management reports. Additionally, it also ensures compliance with statutory laws, regulations and company policies.

At Indraprastha Apollo Hospital, the management is responsible for assessing business risks in all aspects of its operations and for implementing effective and ef_cient processes and controls whilst ensuring compliance with internal and external rules and regulations. While reviewing our internal controls, suf_cient regard is given to the risks to which the business is exposed, the likelihood of such risks occurring, and the costs of protecting against them.

Financials

Discussion on Financial Performance and Results of Operations

Due to the COVID Pandemic, the _nancial performance of the Company has declined in the _nancial year 2020-21. The total revenue declined from 8314.55 million in the _nancial year 2019-20 to 6140.60 million in the _nancial year 2020-21.

The Pro_t Before Tax for the _nancial year 2020-21 stood at 42.89 million as compared to pro_t of 481.92 in the previous year. The Pro_t After Tax for the _nancial year 2020-21 stood at 23.29 million as compared to pro_t of

436.24 in the previous year.

The following table shows the key drivers of our revenues for the periods presented:

Year Ended March 31, 2021

Particulars 31.03.2021 31.03.2020 increase (decrease) % increase (decrease)
Discharges 39,452 56,969 (17,517) -31%
Revenues per patient () 1,55,475 1,45,828 9,647 7%
Average length of stay (days) 3.59 3.29
Out-patients 2,15,858 4,90,042 (2,74,184) -56%
Revenue per bed day () 43,312 44,333 (1,021) -2%

Key Financial Ratios

There are signi_cant changes (i.e. change of 25% or more as compared to the previous _nancial year) in the key _nancial ratios viz., Return on Net Worth, Operating Pro_t and Net Pro_t Margins attributed mainly due to reduction in pro_tability due to COVID-19 pandemic.

Key Ratios FY 2020-21 FY 2019-20
Return on Net worth (%) 1% 16%
Operating Pro_t Margin (%) 1% 6%
Net Pro_t Margin (%) 0% 5%

Human Resources

Values de_nes a company. Indraprastha Apollo has always been a family, working together, crossing hurdles together, and notching up victories together. The Companys core values hold and unite the people for a common purpose. They exemplify what is fundamentally the Apollo culture which is what makes Apollo one of the leading healthcare providers in the world.

Indraprastha Apollo Hospital which has always given utmost importance to excellence and innovation in the _eld of healthcare continues to place its focus on its most valued resource, its employees. The institution has always understood the importance of having a highly skilled workforce, which is pro_ciently trained to provide the highest standard of care.

In addition to the high level of skills, commitment and professionalism of its people, Indraprastha Apollo Hospital strongly believes that proper management of human resources is extremely critical in providing high quality healthcare. The Company has therefore built an effective Human Resources department which supports the business in achieving sustainable and responsible growth. Indraprastha Apollo Hospitals has always strived hard in developing its workforce and building the right capabilities in the organization. It continues to focus on progressive employee relations policies, creating an inclusive work culture and building a strong talent pipeline. The Human Resources function contributes to the success of Indraprastha Apollo Hospital and its employees through leadership, service and excellence in human resource management. The Human Resources department at Indraprastha Apollo Hospitals has been playing an important role in creating a conducive work environment for its employees and supports them throughout their employment life cycle.

The total number of employees in the Company as on 31st March, 2021 was 2783 as against 3215 employees in previous year. The Company has also engaged contractors for various support services in the Hospital and they have deployed 923 workers as against 1052 workers in the previous year. Besides the above, there are Consultant Doctors who work on a ‘Fee for Service basis.

Rewards and Recognition

Rewards and Recognition is an integral part of the Organizations culture which believes that a satis_ed individual contributes more. Consistent efforts are taken by the Company to recognize and reward its employees for their contributions.

Cautionary Statement

Some of the statements in this Management Discussion and Analysis that describe the Companys objectives, projections, estimates, expectations and predictions may contain certain ‘forward looking statements which are within the meaning of applicable laws and regulations. These statements and forecasts involve risks and uncertainty because they relate to events and depend upon circumstances that may occur in the future. There are a variety of factors that may cause real events or trends to vary signi_cantly from those re_ected or implied by these forward-looking statements and predictions. Important developments that could impact Companys performance include increased material costs, technology developments, signi_cant changes in the political and economic environment, tax laws and labor relations.

For and on behalf of the Board

Jasmine Shah

Chairman

(DIN 08621290)

Place: New Delhi

Date : 9th August, 2021