A WIPRO THOUGHT LEADERSHIP INITIATIVE.

An explorative study for deeper insights

Prepared by Dun & Bradstreet India

FORESEEING THE FUTURE OF HEALTHCARE

Future Thought of Business: Healthcare

Preface
The Indian healthcare sector has witnessed unprecedented growth in the last decade. Medical value travel, diagnostics, single speciality hospitals and day care surgical centres are some of the key segments that are expected to witness a major transformation in the years ahead. The healthcare sectors growth is going to be fuelled by changing socio-economic and demographic factors, rising awareness levels and increased adoption of technology. Exciting opportunities in the Indian Healthcare space are luring many investors towards itself. Several private equity, venture capital funds, and multi-national healthcare companies are closely studying the Indian market for a possible foray, supported by the long-term healthy growth prospects of the Indian economy. These increased investments would facilitate improved quality, access and affordability of healthcare services in the country. India has the potential to emerge as one of the most preferred destinations for medical treatment, attracting patients from across the world. However, there exist numerous gaps and bottlenecks which are hindering the sectors overall growth and further expansion. The widening gap between demand and supply for healthcare services is a major cause for concern. Although large hospitals and other leading healthcare chains are on an expansion mode, they represent a small portion of the healthcare landscape, with bulk of the private healthcare being serviced by the unorganised sector. Adding to the woes is the shortage of trained professionals including doctors and support staff like nurses in the country. Nonetheless, the growing Government focus, increased private sector participation and growing penetration of health insurance augurs well for the future prospects. Against this backdrop, Wipro Limited in association with Dun & Bradstreet brings to you The Future Thought of Business: Healthcare. This is an endeavor to highlight the potential that the Indian healthcare sector holds in the coming decade, and to identify the gaps that need to be bridged so as to enable the sector to exploit future opportunities. I hope you enjoy reading this report and look forward to receiving your suggestions. Anand Sankaran Sr Vice President and Business Head - India, Middle East and Africa and Global Business Head - Infrastructure and Services Wipro Limited

Executive Summary
The Indian healthcare sector is one of the most promising sectors of the Indian economy. The strong demand for healthcare services coupled with growing private sector interest sets the stage for the next level of growth. However, numerous challenges need to be addressed in an urgent and effective manner to achieve this. The Future Thought of Business: Healthcare is an attempt to capture the various facets of the Indian healthcare landscape and identify key trends that will define the sectors changing dynamics in the coming decade. The demand potential, the major challenges likely to be faced by the sector and the actions needed to be taken are detailed in the report. With demand for healthcare services expected to be driven by both urban and rural markets in the coming decade, growth prospects for the sector are bright. The increasing penetration of both private and Government health insurance schemes is expected to draw more people under the healthcare net. The sector is witnessing a distinct shift in disease pattern, towards the chronic segment. Rising incidences of lifestyle-related diseases are expected to increase demand for preventive healthcare, and this phenomenon would not be restricted to the urban population.The corporate sector would be a critical factor that will drive expansion of the preventive healthcare market. Low-cost delivery models such as day-care surgical centres, though currently in their infancy in India, are expected to gain prominence in the coming decade. Further, high operating costs in the metro cities and fear of over-supply will drive more healthcare companies to increase their focus on the untapped smaller towns. The coming decade is likely to see more single speciality hospitals coming up in Indias tier II and tier III cities. Rising incomes and awareness levels are driving demand for such speciality centres. More super speciality centres are expected to come up in the areas of heart, cancer, eye, maternal and child care, and cosmetology. Due to the above reasons, the Indian market is likely to attract more foreign players in the coming decade. As a result of the rising competition and the need of healthcare players to enhance scale and geographical reach, the findings predict increased consolidation in future. The sector continues to battle high attrition and faces a manpower crunch, and a resulting increase in the cost of manpower resources. More public-private initiatives are also needed to bridge the demand-supply gap in infrastructure development and medical education. On the plus side, the healthcare sector has been witnessing a reverse brain gain compared to the brain drain in earlier decades. This is expected to improve the overall quality and standard of medical personnel in the country as also the quality of healthcare services. The coming decade is also expected to see increased technology adoption among mostly private sector players, with technology becoming a core function. The need to optimise costs and increase efficiencies will make information technology an integral part of hospital management. Cost-effective cloud-based solutions would drive increased adoption of the hospital management information system (HMIS). India has emerged as one of the fastest growing medical value travel destinations in the world. However, lack of coordinated efforts among the various stakeholders is hindering this segments growth. Nonetheless, the market is growing strongly and in the coming decade, it would particularly benefit from the rising cost burden of the national healthcare system in the developed economies.

Research Framework
Objective of the Study
The Future Thought of Business: Healthcare report aims to identify those trends likely to emerge in the coming decade that could significantly influence the future of business in the Indian healthcare sector. This report is an initiative that thus provides the healthcare sector with a tool to apprehend, strategise and tackle future challenges. Possible recommendations to address the issues so identified have also been detailed in the report.

Research design
The report has been developed based on quantitative and qualitative information. Data and information collection was conducted through secondary research and interviews with industry experts.

Methodology
1. Desk research
A detailed review of relevant literature for the Indian healthcare sector was conducted at this stage.

2. Questionnaire development and industry interactions

Findings of the desk research were used to develop appropriate questionnaires for interviews. Face-to-face and telephonic interviews were conducted with experts in the sector.

3. Collation and analysis of information

All data and information gathered through secondary research and interviews was collated and analysed for the purpose of developing the report.

4. Report writing
Finally, the analysis, results and key findings were written in the form of the current report.

Table of contents
1.................................................................Section I: Indian Healthcare Landscape 2 ................................................................................Low Government Expenditure on Health 2 ................................................................................Government Initiatives 3 ................................................................................Widening Gap between Healthcare Demand and Supply 4 ................................................................................Private Sector Gains Prominence 5 ................................................................................Industry Reaps Benefits of Increased IT Adoption 6 ................................................................................Technological Advancements Redefine Healthcare Delivery 6 ................................................................................Greater Government Involvement is the Need of the Hour 8.................................................................Section II: Future Demand Drivers 8 ................................................................................Changing Patient Profile to Generate Greater Demand for Healthcare Services 10 ..............................................................................Rise in Health Insurance Penetration to Expand Addressable Market 10 ..............................................................................Rise in Awareness and Income Levels to Drive Preventive Healthcare 11 ..............................................................................Rising Incomes and Lifestyle Diseases to Drive Urban and Rural Demand 11 ..............................................................................Governments Changing Role as Facilitator of Healthcare Services 12 ..............................................................Section III: Emerging Trends in the Indian Healthcare Sector 12 ..............................................................................Emergence of Innovative Healthcare Delivery Models 18 ..............................................................................Technology to Become a Core Function 20 ..............................................................................Cohesive Action Needed to Tap Medical Value Travel Market 23 ..............................................................Section IV: Competitive Scenario and Strategic Focus 24 ..............................................................................Consolidation to Gather Momentum 24 ..............................................................................Threat of Over-supply in Metros to Drive Firms to Tier II and Tier III Cities 25 ..............................................................................Accreditation to Become a Necessity 26 ..............................................................................Conclusion 26 ..............................................................................The Way Forward 28 ..............................................................................References and Sources 29 ..............................................................................Acknowledgements

Section I: Indian Healthcare Landscape

In the four decades that followed Indias independence in 1947, its healthcare sector was dominated by the public sector. The opening up of the economy in the 1990s however, steadily led to the increasing involvement of private players. In the last decade, the sector has undergone a radical transformation and it is currently one of the most promising sunrise sectors, in terms of growth, revenues and employment generation. The Indian healthcare sector mainly comprises hospitals and nursing homes, and allied sectors such as diagnostic centres and pathology laboratories, medical equipment, medical tourism and medical insurance. Between April 2000 and August 2011, hospitals and diagnostic centres attracted foreign direct investment (FDI) inflows to the tune of US $ 1.08 billion. Today the Indian healthcare landscape is witnessing the growing dominance of private and corporate hospitals that provide specialised and tertiary medical care facilities. This unprecedented fast-paced growth is based upon several important socio-economic factors including economic liberalisation, changing demographics, increasing disposable incomes, rising urbanisation, changing disease profile of the population, and advent of an information technology (IT)-enabled environment, among others. The Internet has emerged as an important tool for
Source: D&B Research

information dissemination, boosting overall healthcare awareness levels and increasing the demand for healthcare services. This is markedly seen in rural areas, where increased penetration of mobile phones and the Internet, along with mass media such as television, is rapidly increasing awareness about various treatment options and giving rise to demand. Further, increased and effective use of mass media by the Government in areas of health education, HIV/AIDS awareness programmes etc, has also helped in increasing healthcare awareness levels among the people. Healthcare delivery in India

Low Government Expenditure on Health

As per the World Health Organization (WHO), the share of total expenditure on health in Indias gross domestic product (GDP) stands at a low 4.2%. The share of public expenditure in Indias GDP is a negligible 1.1% (2008-09). A salient feature of the Indian healthcare sector is thus the significant and growing role of the private sector in healthcare delivery and total healthcare expenditure. The private healthcare sector accounts for nearly 70% of total healthcare expenditure in the country; while the contribution of governments expenditure in the countrys total expenditure on health is around 30%. Even within the private expenditure, out-of-pocket expenditure constitutes the bulk (nearly 75%). Health Expenditure as % of GDP
Country Bangladesh Brazil China India Indonesia Malaysia Singapore Thailand UK USA Global Health expenditure as % of GDP 3.3 8.4 4.3 4.2 2.3 4.3 3.3 4.1 8.7 15.2 8.5 Government expenditure* 31.4 44.0 47.3 32.4 54.4 44.1 34.1 74.3 82.6 47.8 60.5 Private expenditure* 68.6 56.0 52.7 67.6 45.6 55.9 65.9 25.7 17.4 52.2 38.4

with an aim to provide affordable, accessible and equitable healthcare services. Some of the major initiatives of the Government include the following.

National Rural Health Mission (NRHM)

The NRHM was launched throughout the country in April 2005, with special focus on 18 states, including eight Empowered Action Group states (Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, Uttaranchal, Orissa and Rajasthan); eight North-Eastern states (Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura); Jammu & Kashmir and Himachal Pradesh, to provide accessible, affordable and quality healthcare services to the rural population, especially the vulnerable sections. Allocation and release of funds under the NRHM (` billion)

Note: Expenditure figures for 2009-10 & 2010-11 are provisional Source: PIB website

*as % of total expenditure on health; for 2008 Source:World Health Statistics 2011,WHO

Janani Suraksha Yojana (JSY)

This is a safe motherhood intervention under the NRHM being implemented with the objective of reducing maternal and neonatal mortality by promoting institutional delivery among pregnant poor women. It was launched in April 2005 and is being implemented in all states and Union Territories, with a special focus on low-performing states.The launch of this initiative has led to a substantial increase in institutional deliveries: the number of beneficiaries rose from 7.39 lakh in 2005-06 to about one crore in 2009-10.

Government Initiatives
From the supply perspective, making quality healthcare facilities available to the masses remains a big challenge for policy-makers. Moreover, healthcare costs have increased as compared to the past because of the technology involved in delivering healthcare today. Nevertheless, the Government has introduced several measures to expand the reach of healthcare to the masses. The Government has introduced several programmes and schemes in order to bridge the wide gap between optimum and existing healthcare infrastructure,

Rogi Kalyan Samitis (RKS)

Around 599 district hospitals, 4,210 community health centres (CHC), 1,136 other hospitals, and 17,097 primary health centres (PHCs) have their own RKSs with untied funds for improving quality of health services.

of 1:1,000 (doctor-population ratio) the country will require an additional 15.4 lakh doctors. In order to increase the supply of human resources in medical education, the Central Government has revised the teacher-student ratio from 1:1 to 1:2. This has resulted in approximately 4,000 additional post-graduate seats in various disciplines in Government medical colleges from the academic year 2010-11. To increase the number of medical colleges and specialists, the Government has relaxed the norms in respect of land requirement, bed strength, bed occupancy, maximum admission capacity, and age of teaching faculty.

Village Health and Sanitation Committees (VHSCs)

About 4.98 lakh villages have their own VHSCs, each of which has been provided ` 10,000 as an untied grant per year.

Village Health and Nutrition Days

About 35 lakh Village Health and Nutrition Days were observed in 2006-07, to extend the reach of basic health services to rural areas. This increased to 49 lakh in 2007-08, 58 lakh in 2008-09 and 58.7 lakh in 2009-10.

Widening Gap between Demand and Supply

Healthcare

One of the major challenges faced by the sector today is the huge mismatch between demand and supply of resources, both in terms of physical infrastructure and human resources especially when compared to international standards. The density of hospital beds per 10,000 population stands at a dismally low nine, compared to the global average of 29. The number of physicians per 10,000 population at six is also much lower when compared to several other developing countries. The nurse-doctor ratio in India also stands at a low 1.2, compared to developed countries such as the US and UK which have a nurse-physician ratio of 3.0 and 5.0 respectively. Healthcare infrastructure status*
Country Bangladesh Brazil China India Indonesia Malaysia Singapore Thailand UK USA Global Physicians (No.) 43,315 329,041 1,905,436 660,801 65,722 25,102 8,323 18,918 165,317 793,648 9,171,877 Physicians density** 3 17.2 14.2 6 2.9 9.4 18.3 3 27.4 26.7 14 Hospital beds** 4 24 41 9 6 18 31 22 34 31 29

Mobile Medical Units

About 381 Mobile Medical Units are functional under the NRHM so far.

Ayurveda,Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH)

Mainstreaming of AYUSH in national healthcare delivery is an important goal under the NRHM. AYUSH services have been colocated in 14,766 health facilities and 9,578 AYUSH doctors and 3,911 AYUSH paramedics have been added to the system.

Pradhan Mantri Swasthya Suraksha Yojana (PMSSY)

The PMSSY was launched with the twin objectives of (i) correcting regional imbalances in the availability of affordable/reliable tertiary healthcare services and (ii) augmenting facilities for quality medical education in the country. The PMSSY has two components in its first phase: (i) setting up of six AIIMS-like institutions and (ii) upgradation of 13 existing Government medical college institutions. The healthcare sector in India faces severe shortage of availability of human resources. To achieve the WHO recommended norm

*2000-2010; **per 10,000 population Source:World Health Statistics 2011,WHO

duties act as major bottlenecks for healthcare players looking to introduce advanced products/services. The quality of healthcare services rendered in India is second to none in the world. However, the physical infrastructure in the country should also match. opines Dr Sujit Chatterjee, CEO of Dr L H Hiranandani Hospital India has the highest number of medical colleges in the world. There are 229 recognised medical colleges, and 71 colleges have been permitted under Section 10A of the Indian Medical Council Act, 1956 during 2009-10. Approximately 33,528 graduates pass out every year from these colleges. Nevertheless, the healthcare sector continues to face supply constraints due to an inadequate supply of trained manpower and this in turn adversely affects the flow, quality and cost of manpower resources. Attracting and retaining the right talent thus continues to be a major challenge, as the sector battles high attrition rates. This challenge of recruiting and retaining is more acute among nurses, particularly on account of the high demand and attractiveness of employment opportunities in the healthcare field in the Middle East Gulf region, Africa, etc. The brain drain to overseas markets can also be attributed to the limited career growth opportunities available for nurses in India. The market for medical technology in India is currently at a nascent stage, and is characterised by high fragmentation with limited indigenous manufacturing. The country is mostly dependant on imports, with imports meeting nearly three-fourths of the domestic requirement. While domestic firms primarily manufacture low-end technology products, multinational companies mainly import highend medical equipment. As per industry estimates, import duties on medical equipment are as high as 20-30%, while the maximum life of an imported machine is just five to seven years. Given the criticality of technologicallyadvanced equipment in the healthcare sector, the limited manufacturing capacity in the domestic market and the high import Further, the sector has grown rapidly in the last few years, witnessing the emergence of several large private players and attracting huge capital investment.The growing dominance of the private sector and the consequent increase in competitive forces is transforming the Indian healthcare sector from a supply driven market to a demand driven/consumer-centric market. The last decade has seen a fair amount of sophistication as far as patient monitoring systems and minimal access surgeries are concerned. opines Dr Sujit Chatterjee, CEO of Dr L H Hiranandani Hospital. The attrition rate among nurses is quite high. The average tenure of a junior nurse in our hospital is about two years. Nurses in India, on an average, get three promotions in their entire service career. We are trying to create a different environment for nurses, where they become the decision makers, in an effort to retain them. informs Dr Sujit Chatterjee, CEO of Dr L H Hiranandani Hospital

Private Sector Gains Prominence

The private sector plays a dominant role in the delivery of healthcare services in India. It is predominant in medical education, training, diagnostics and technology, manufacture of pharmaceuticals, hospital design, and in construction and management of ancillary services. Over 75% of the human resources and advanced medical technology, 68% of all hospitals and 37% of total hospital beds in India are in the private sector.

Capital raised in the Indian healthcare sector (` crore)

considerably in terms of both availability and quality of the physical infrastructure and human resources. Government expenditure on health is extremely low, and as per D&Bs estimates it is expected to remain low at a meagre 1.5% of GDP in FY20. In such a scenario, private expenditure would have to increase substantially to ensure overall improvement in health infrastructure.

Source: Handbook of Statistics on the Indian Securities Market 2010-SEBI; D&B Research

The Indian healthcare delivery system is highly fragmented, with large number of independent, and small and medium privately-run hospitals and healthcare centres accounting for the bulk, and a few large hospitals accounting for the rest.The past few years have seen the emergence of organised healthcare with several players setting up hospital chains and creating a comprehensive healthcare delivery platform. In India, rural and primary healthcare largely remains in the centre and states domain.The private sector, which continues to strengthen its foothold in the urban areas, is gradually increasing its focus on tier II and tier III cities and small towns. Given the huge demand potential, the private sector is poised to play a greater role in the transformation of the Indian healthcare sector. The long term prospects of the Indian healthcare sector look bright, and much of the growth is expected to come from the private sector. The attractiveness of the growing and under-penetrated healthcare sector is drawing foreign players into this market, through capital investments and technology tie-ups across various segments such as hospitals, diagnostics, medical equipment, etc. As mentioned above, the FDI in this sector between April 2000 and August 2011 stood at US $ 1.08 billion. However, to meet the expected increase in demand for healthcare services, both from domestic population and international patients, the healthcare sector needs to scale up

Very high upfront investment, limited availability of quality manpower including doctors and paramedics and limited access to funding for the Indian population remain three key challenges for the Indian healthcare sector. says Mr Rajiv Sharma, CEO of Sterling Addlife India Limited

Industry Reaps Benefits of Increased IT Adoption

One of the major trends to have emerged in the Indian healthcare sector in the last decade is increased adoption of IT in hospital management. Healthcare providers are increasingly adopting technology to derive various benefits, including improved patient satisfaction (through reduced turnaround time at points of care); enhanced patient safety (through improved decision-making); enhanced productivity and elimination of human error (by way of seamless integration with medical device/equipment); reduction in operational costs (through reduction in staff needed for back-office tasks); improved inventory management (by way of accurate demand estimation and timely procurement and distribution of materials), among others.

Technology is central to healthcare delivery even today, enabling greater efficiency and supporting leaner business models. says Mr. Prabhjit Didyala, Head Strategy, Fortis Healthcare

Technological Advancements Healthcare Delivery

Redefine

period for hospitals in India, there is a need to have a re-look at the existing tax breaks. Further, a fund on the lines of the Technology Upgradation Fund Scheme (TUFS) that is presently in place for the textile industry will encourage greater private participation mainly in the smaller towns. According priority status to the healthcare sector will also go a long way in enabling players to get access to funds at lower rates of interest. A majority (60%) of the health workers reside in urban areas, and a majority (70%) of them are employed in the private sector. The density of health workers per 10,000 population in rural areas stands at a mere 11.8, as compared to 42 in urban areas. Given the staggering gap, another area that needs greater focus is a public private partnership model (PPP) for skill development. A PPP arrangement which would link Government hospitals/health centres with private medical training institutes will help in reducing the demand-supply gap for trained healthcare personnel in Indias rural/ semi-urban areas. The set of challenges in making available quality healthcare services at affordable costs in rural areas is unique. Given the lower paying capacity of the rural populace, there is a need to create lower-cost healthcare delivery models that are suitable for this segment. The Government has undertaken several initiatives to improve the state of healthcare services in the country. However, access to quality and affordable healthcare remains a distant dream, particularly for the poor and vulnerable sections of the society. The Aadhaar, or the Unique Identification number (UID) has the potential to become a powerful tool for the Government, policy makers and healthcare providers to meet some of the healthcare challenges the country faces and deliver healthcare services more effectively, particularly to this section. It can also help to effectively coordinate the services offered by the various stakeholders Government, healthcare providers, insurance companies, among others.

Over the past few decades, healthcare in India has increasingly become technology-driven, whether it is the development of new drugs/vaccines, medical devices/equipment, or even the diagnostic techniques. The last decade witnessed a significant change in the manner in which healthcare services are delivered, with technology having a key role to play. For instance, technological advancements have been made in the field of imaging with an aim to deliver faster and more reliable diagnosis, with reduced doses, procedure time and new interventional application. Considerable advancements have also been made in several other areas, with introduction of advanced technologies such as functional MRI, parallel radio frequency transmission, automated scanning technology, ultrasound systems with 3D/4D capabilities, digital X-ray system, wireless and ambulatory monitoring and micro electromechanical systems, microprocessor-based ECG equipment, home-use devices (glucose monitors, insulin delivery devices, nebulizers and oxygen concentrators) etc. Advances in medical technology have improved the ability of monitoring, preventing, diagnosing, controlling, and curing a number of growing health conditions.

Advances in technology have made it possible to treat a lot more conditions, improve quality of healthcare, give more predictable outcomes and significantly reduce the length of stay. informs Mr. R D Thulasiraj, Executive Director, Lions Aravind Institute of Community Ophthalmology, Aravind Eye Care System

Greater Government Involvement is the Need of the Hour

The existing norms of the Government allow a five year income tax holiday from the start of operations, for setting up hospitals in tier II and III towns. However, considering the large investments needed for setting up the infrastructure and the long break-even

Further, given the staggering gap between demand and the current supply, there is an urgent need to bridge the gap by way of investments in the concerned areas. The need of the hour is to re-evaluate and reform existing policies, especially in public health system, to match the dynamic and changing healthcare needs. Further, there is a dire need to encourage greater partnerships among Government, industry and academia to improve the quality, affordability and accessibility to healthcare services.

Affordability being a major challenge for people to avail quality healthcare services, healthcare service providers should develop different models to serve different segments of population with different needs. says Mr. Prabhjit Didyala, Head Strategy, Fortis Healthcare

Section II: Future Demand Drivers

Today, the healthcare sector in India is on the threshold of a major transformation, largely fuelled by increasing spending power, a rising aspiration for wellness, and a distinct shift in disease pattern towards chronic diseases. The four key factors that would drive growth of the Indian healthcare sector in the coming decade would be: 1. changing patient profile: demographic and socio-economic factors; 2. thrust on health insurance; 3. change in disease profile; and 4. government initiatives. On the supply side, increase in availability of healthcare centres/ hospitals will drive growth of the sector. On the demand side, growing demand for healthcare services is expected to be driven by rising incomes, growing propensity to spend on healthcare, a shift to lifestyle-related diseases, and changing demographics, among others. These are discussed in detail below. (a) increase in population; (b) rise in urbanisation; (c) increase in life expectancy; (d) rise in personal disposable income; and (e) an increase in literacy rate.

Increase in population and rise in urbanisation

Indias population is projected to increase from an estimated 1.1 billion in 2010 to 1.3 billion by 2020. The level of urbanisation is projected to increase from 29.8% in 2010 to 32.1% by 2020. Projected population of India (billion)

Changing Patient Profile to Generate Greater Demand for Healthcare Services

Some of the major demographic and socio-economic factors which are expected to drive growth of the Indian healthcare sector in the coming decade would be:

Source: Census of India 2001, D&B Research

Trend of urbanisation in India

All-India per capita net national product*

Source: Census of India 2001, D&B Research

Units: `; *Per capita net state domestic product at factor cost (At constant prices); Base: 2004-05 Source: Reserve Bank of India website, D&B Research

Rise in life expectancy and per capita income

Increase in life expectancy increases demand for healthcare services. Life expectancy in the country is projected to move upwards in the coming decade along with a rise in personal disposable incomes. Increasing life expectancy coupled with rising disposable income points towards higher demand for healthcare services and increase in the per capita expenditure on healthcare, thereby driving growth of the healthcare sector. Projected values of expectation of life at birth Strong growth in demand for quality healthcare in India and across the globe, corporatisation of private healthcare, and growing access to funding i.e. private health insurance would be the three major factors that will drive industrys growth in the coming decade. says Mr Rajiv Sharma, CEO of Sterling Addlife India Limited

Rise in literacy rates

The literacy rate in the country has increased from 64.8% in 2001 to 74% in 2011. This increase in literacy rates has improved awareness levels, particularly about lifestyle-related diseases, thereby having a bearing on consumption of healthcare services. Literacy rate in India (%)

Units:Years Source: Census of India 2001, D&B Research

Source: Census of India, D&B Research

class, increasing awareness regarding insurance, and increasing Good quality of healthcare professionals, strong processes and creating affordability would be the key factors that would drive growth in the healthcare sector in the coming decade. says Ms Shobana Kamineni, Executive Director-New Initiatives, Apollo Hospitals Group domestic savings and investments would be some of the chief factors that would further drive market penetration of health insurance products in the country in the coming years. Over the last couple of years, health insurance has emerged as one of the most promising segments within the Indian insurance sector. Not only has there been an increase in the number and variety of insurance products introduced, there has also been a rise in the number of insurance companies entering into the health insurance market. In 2009-10, the health insurance industry had underwritten premium worth ` 80 billion, a growth of 20.7% over 2008-09. The contribution of the health segment in total premium stood at 21.2% in 2009-10. The Insurance Regulatory Development Authority (IRDA) expects the health insurance segment to expand manifold in the coming years. With gradual increase in penetration of health insurance, healthcare is likely to become more affordable for a larger proportion of the countrys population. Further, expansion in the health insurance segment would also have a positive rub-off impact on demand for health check-ups/preventive healthcare, which is a mandatory part of health insurance coverage.

Rise in Health Insurance Penetration to Expand Addressable Market

The liberalisation of the insurance industry in 2000 has resulted in the entry of several private and international insurance companies, and proliferation of innovative products as also distribution channels. Some state governments have also launched health insurance schemes targeted at specific sections of the population, which have been successful in improving access to healthcare. Social and community health insurance schemes have also been rolled out in the country. However, the overall level of insurance penetration continues to be low. In India, any form of insurance including the Central Government Health Scheme (CGHS) and the Employees State Insurance Scheme (ESIS), other Government sponsored schemes and private health insurance cumulatively covered only 25% of the countrys population in 2010. And over three-fourths of the coverage is through the Rashtriya Swasthya Bima Yojana and other state-sponsored health insurance schemes. The Indian health insurance landscape has seen a significant transformation in the last three to four years since 2007; from about 75 million people covered in 2007, the estimated number of people covered by health insurance has surged to about 302 million. In the coming decade, driven by rising healthcare costs and the Governments increased thrust on improving access to healthcare, the penetration of health insurance is expected to increase significantly. Further, an increasing section of the domestic workforce is being covered by corporate health plans. Indias growing consumer

Penetration of Government health insurance schemes will increase going forward, and we expect a lot more of our patient inflow to be driven by these Government insurance schemes. says Mr. Prabhjit Didyala, Head Strategy, Fortis Healthcare

Rise in Awareness and Income Levels to Drive Preventive Healthcare

The Indian healthcare sector is gradually moving towards preventive healthcare from curative healthcare. Need for preventive healthcare is expected to become even more crucial in the coming decade due to the rising incidences of lifestyle-related diseases. The incidence of

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lifestyle-related diseases such as diabetes and cardiovascular diseases, and the associated risk factors such as hypertension, high cholesterol and blood pressure, obesity etc is increasing at an alarming rate in India. This in turn can be attributed to urbanisation and changing corporate environment (rising stress levels and sedentary lifestyles), among others. Moreover, this phenomenon is no longer restricted to urban population. Since preventive steps can help prevent the occurrence of such diseases, with rising awareness levels both in the urban and rural areas and increasing disposable incomes, the coming decade is expected to witness increased demand for preventive healthcare. The corporate sector will play a critical role in driving growth in the preventive healthcare market. In a highly competitive corporate environment, both as part of their corporate social responsibility as also to boost their employee efficiencies, the coming decade is expected to witness significant increase in demand for preventive healthcare and wellness programmes.

awareness, higher levels of work-related stress, more sedentary lifestyles, and increased consumption of fast foods, tobacco and alcohol is bringing about a distinct shift in the pattern of diseases. Consequently, these factors have contributed to alarmingly increasing incidences of lifestyle-related diseases such as cardiovascular ailments, obesity, diabetes and cancer.

Health awareness and information on the kind of treatment options available is increasing in rural areas. This is one of the key factors driving demand for healthcare services in these markets. To tap this demand, there is a need to develop lower-cost models. says Mr. Prabhjit Didyala, Head Strategy, Fortis Healthcare

Governments Changing Role as Facilitator of Healthcare Services

The role of the Government should evolve as a facilitator for providing healthcare services in the country. Increasing focus of the Government on enhancing the reach of healthcare services at affordable costs across the country could also be achieved if some of the current norms are relaxed. Tariff-related policy measures which could benefit healthcare providing companies include reduction of customs duty on medical equipment/spares; reduction of excise duties on indigenously manufactured medical equipment, drugs, consumables, etc, allowance of higher rate of depreciation in order to counter the high rate of obsolescence of technology and enable the companies to generate funds for replacement, etc.

Based on published reports, it is expected that incidence of lifestyle-related diseases is expected to grow at a rate faster than infectious diseases, which would result in increase in cost per treatment. informs Dr Naveen Nagar, Associate Vice President - Operations & Strategy, HealthCare Global Enterprises

Rising Incomes and Lifestyle Diseases to Drive Urban and Rural Demand
India has the worlds largest population of diabetics, with an estimated 50.8 million people living with diabetes. According to estimates of the International Diabetes Federation (IDF) for 2010, the national prevalence of diabetes in India stands at 7.1% of the population (2079 years). By 2030, this figure is estimated to increase to 8.6% of the countrys population (20-79 years), with an estimated 87.0 million people having diabetes. Increase in life expectancy coupled with rising income, increased

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Section III: Emerging Trends in the Indian Healthcare Sector

In the coming decade, the Indian healthcare sector will witness the emergence of several innovative healthcare delivery models.The four key models identified are: (i) PPP-based models (ii) day care surgical centres (iii) single speciality hospitals and (iv) telemedicine. Further, the role of technology will evolve to become the core of functions. The medical value travel market is poised to register strong growth. There trends are discussed in detail below.

Improved PPP Models to Bridge Demand-Supply Gap

The PPP model is important for improving the healthcare scenario in India. However, the success of this model will depend on reaching a mutually agreed arrangement where objectives of both the parties involved are met. While the private sector is driven largely by the profit motive, the Governments objective is to provide healthcare services at affordable costs to the masses. As far as provision of primary health is concerned, the country faces certain key challenges in terms of coverage, accessibility, management, and quality and availability of healthcare professionals. Internationally, PPP models have been successful in meeting some of these challenges. This reflects the possibility of adopting such models in the Indian context. Currently, Government hospitals suffer from lack of advanced technology, inadequately skilled paramedical staff, poor/underutilisation of infrastructure and other resources, ineffective/ inefficient utilisation of funds, and low levels of customer satisfaction. At the same time, the Government is striving to provide access to affordable healthcare services to the masses through the PPP route.

Emergence of Innovative Healthcare Delivery Models

The coming decade is expected to witness the emergence of several innovative healthcare delivery models that are aimed at enhancing the reach of quality healthcare services at affordable rates. There exists vast untapped demand in semi-urban/rural areas. However, the existing models of healthcare delivery are unable to meet this demand at a price which this segment of the population can afford. Even for the non-rural segment, considering the fact that a large proportion of private expenditure on health is out-of-pocket, the key objective of the emerging delivery models would be to provide quality healthcare facilities at affordable costs. The four prominent delivery models that are likely to emerge would be based on public-private partnerships; single speciality hospitals; day care surgical centres and telemedicine. These are discussed in detail in the following section.

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Data on PPP projects in India reveals that currently sectors such as PPP model has an important role to play in facilitating better delivery of healthcare at a lower cost. says Ms Shobana Kamineni, Executive Director-New Initiatives, Apollo Hospitals Group healthcare, education, railways etc account for a negligible share in the total value of the PPP projects. Healthcare remains highly untapped, with a share of a meagre 0.5% in the total value of existing projects. Moreover, as can be seen from the following table, only a handful of states have taken the initiative in building a PPP framework. PPP projects in healthcare in India*
State Andhra Pradesh Andhra Pradesh Andhra Pradesh Andhra Pradesh Andhra Pradesh Andhra Pradesh Assam Project name Urban Slum Health Care Project Status Not available (N.A.) Cost (` crore) Project type

Potential thrust areas for PPPs in the healthcare sector

26.72 N.A.

III Haemodialysis Machines under Operational Arogyasri Second Phase in Govt. Hospitals Arogya Raksha Scheme Arogya Raksha Scheme Emergency Response Services (ERS) Rajiv Aarogyasri Community Health Insurance Scheme Regional Diagnostic Centre Indra Gandhi Government Medical College (IGGMC) Complex Dispensary,Vartak Nagar (RCC, G+7) 660 Sqm, by MC Thane Operational Operational Operational Operational Bidding

0 BOOT**

1.5 PPP 50 PPP 99 PPP 900 PPP 20 Lease

Source: D&B Research

The current state of PPP mechanism suffers from several restrictions and conditions imposed on the private player (e.g. free treatment to be provided to certain percentage of patients; decisions involving recruitment of doctors etc). Nevertheless, several initiatives are being undertaken by the Government to enable a better PPP framework and to remove the existing bottlenecks. The PPP arrangements are being explored in areas of running of operations, management and maintenance of Government hospitals; operation and maintenance of mobile health vans; setting up of diagnostic centres and super speciality hospitals; and setting up of speciality centres (e.g. cardiac centre, nephrology centre, etc) within the Government hospitals. Status of PPP projects in healthcare in India*
Project category Up to ` 100 crore ` 100-250 crore ` 251-500 crore More than ` 500 crore Total value of contracts (` crore) Total investments (` crore) 315 343 275 900 1,833
Maharashtra Maharashtra Maharashtra Maharashtra Maharashtra Maharashtra

Bidding

275 BOOT

Construction

0.53 BOT***

Primary Health Centre, Kopari, (RCC, G+3), Construction 357.78 Sqm, by MC Thane Setting up and Running Trauma Center and Hospital, at Bopodi Pune Setting up and Running Trauma Centre and Hospital at Yerwada, Pune Setting up and Running Trauma Centre and Hospital at Yerwada, Pune Development of Hospital Building at Indrayani Nagar Pradhikaran Sector No. 1 by MC Pimpri Chinchwad Greenfield Super Specialty Hospital at Mohali Construction

0.8 BOT

1 BOT

Construction

1.5 BOT

Construction

2.5 BOT

Punjab

Construction

99 DBFOT****

*As of July 2011 Source: PPP India Database, Department of Economic Affairs, D&B Research

Punjab

Construction

118 DBFOT

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Punjab Uttar Pradesh

Punjab Institute of Medical Sciences

Construction N.A.

225

Concession BOT N.A.

day care surgical centres is currently at its infancy, but is poised to slowly but steadily catch up. For a healthcare provider, the two chief advantages of setting up day care surgical centres lie in the lower cost of initial investments and lower break-even period, as compared to a hospital. For instance, while a typical 100-bed hospital with five operation theatres would require an initial set-up cost of about ` 120-130 crore with a break-even period of five to seven years, a day care surgical centre could be set up at one-tenth of the cost and have a much lower break-even time of as little as ten months. Day care surgical centres also have much lower overhead costs as manpower needs at day care surgical centres are about one-fourth of a traditional 150-bed hospital, thereby keeping the operations costs also lower. For the healthcare provider, these surgical centres can be instrumental in increasing the availability of hospital beds for higher margin inpatient surgeries. Further, the lower break-even period also makes re-investment for expansion easier, as compared to a traditional hospital. These factors are attracting the investor community, particularly venture capitalists, into seriously looking at investing in day care surgical centres in the country. For the patient, such centres offer not only convenience, but also cost-effectiveness as it eliminates stay and the associated expenses. Further, advancements in medical technology have made performing minimally invasive surgical procedures and faster post-operative recovery possible. Considering the fact that today 75% of private expenditure on health is out-of-pocket and there is also growing patient preference for shorter hospital stays, this phenomenon is likely to gain popularity. With the cost of treatment and surgeries at day care surgical centres being much lower than in the corporate and established hospitals, this concept has become popular in advanced nations such as USA, where over 70% of the surgeries are conducted at day care surgical centres. The first ambulatory surgery centre was opened in the US

Para medical colleges at Bidding Jhansi, Saifai

State Medical colleges Uttar Kannauj, Azamgarh, Bidding N.A. N.A. Pradesh Jalaun, Banda Saharanpur *As on January 31, 2011; **Build, own, operate, transfer; ***Build, own, transfer; ****Design, build, finance, operate, transfer. Source: PPP India Database, Department of Economic Affairs, D&B Research

Given the wide demand-supply gap in healthcare services, the coming decade will see increased healthcare sector PPP, where the initiatives create synergies between the strengths of the Government and the private sector. However, the two key factors necessary to ensure that the PPP model is profitable and is a success would be clearly laid down growth and expansion strategies, and project objectives and risks associated; and clear and regular communication among the stakeholders with an aim to ensure transparency of operations. Going forward, demand for healthcare delivery systems based on the PPP model is likely to gain further momentum in the case of super speciality hospitals also.This is considering the fact that setting up such specialised centres involves high capital investment (land etc) that can be catered to by the Government, and requires highlevel of quality care that can be provided by the private sector.

PPP is a way forward by which healthcare providers can quickly scale up by leveraging existing public infrastructure, while bringing their own managerial expertise to the table. However, there need to be clearly defined roles for the parties involved. opines Mr. Prabhjit Didyala, Head Strategy, Fortis Healthcare

Day Care Surgical Centres to Gain Popularity

The concept of day care surgical centres (also known as ambulatory surgery or outpatient surgery centres) is popular in developed economies such as the United States of America (USA), the United Kingdom (UK), France, etc. In India, the concept of stand-alone

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in 1970. Presently, about 20 million surgeries are performed every year in more than 5,000 ambulatory surgery centres across the US. The common procedures performed in these centres include ophthalmology, gastroenterology, orthopedic, ENT (ear, nose & throat), gynaecology, and plastic surgery. Apart from cost containment, decompression of busy hospital beds and lesser incidence of hospital-acquired infections (because of recovery at home) are some of the other benefits of such outpatient surgery centres. Given the high healthcare costs in India and restricted affordability of a large proportion of the population, coupled with mounting pressure on healthcare companies to contain costs and improve operational efficiencies, this low-cost delivery model is emerging as a win-win situation not just for the healthcare providers and consumers, but also for insurance companies and business organisations providing insurance facilities to their employees. In the coming years, day care surgical centres would play a critical role in addressing issues of accessibility and affordability.

huge untapped opportunities to offer these services in Indias tier II and III cities and smaller towns. On the one hand, there is demand for quality and specialised healthcare services in smaller towns, since it saves time and money spent in travelling to bigger cities for treatment. On the other hand, lower rentals and manpower costs associated with smaller towns enable healthcare companies to offer services at lower rates compared to those offered by them in the big cities. Healthcare players who have set up speciality centres in tier II and tier III cities also attract patients from neighbouring small towns, thereby enabling them to effectively play the volume game and offer services at affordable costs. In the coming decade, this trend of hospitals offering treatments in one therapeutic segment is likely to gather pace, indicating a maturing healthcare sector in the country. Single speciality hospitals focus on one segment, providing endto-end services and personalised care in one core area. Such hospitals require less manpower, equipment and infrastructure, and are easier to operate and manage. Furthermore, in an increasingly competitive market environment, the higher margins enjoyed by unispeciality hospitals vis--vis multi-speciality hospitals, on account of better economies of scale and cost optimisation, is increasing the attractiveness of this segment. However, given the increasing number of super speciality centres mushrooming across the country, the shortage of experienced personnel, medical professionals and other paramedical staff could become acute. The expected increase in the number of single speciality hospitals in the country would have a positive impact on the medical technology/ medical equipment market. Several global companies are already closely watching the Indian market to set up operations here, which in turn is expected to fuel competition in this segment.

Rising Incomes and Awareness Levels to Drive Demand for Single Speciality Hospitals
Single speciality hospitals are a comparatively new but rapidly growing segment in India. HealthCare Global Enterprises (oncology), Care Hospitals (cardiology), Vasan Eye Care and Aravind Eye Care (ophthalmology) are some of the leading super speciality hospital chains in India.The success of single speciality centres is encouraging more healthcare players to venture into this segment and the existing companies to expand operations. Among the segments, the coming decade is expected to see more super speciality centres being set up in the areas of heart, cancer, eye, maternal and child care, and cosmetology. Rising incomes and increasing health awareness is driving demand for such speciality centres. Currently, speciality hospitals are largely present in metros and tier I cities. Going forward, these centres are expected to spread their wings into the

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Single speciality hospitals enjoy higher profit margins than multi-speciality hospitals by optimising resources and leveraging economies of scale. says Mr. R D Thulasiraj, Executive Director, Lions Aravind Institute of Community Ophthalmology, Aravind Eye Care System

Challenges of healthcare delivery in rural areas are different from those in big cities. While accessibility is a major issue in rural areas, in big cities huge variations in quality of healthcare delivery is a major issue. says Mr. Prabhjit Didyala, Head Strategy, Fortis Healthcare

Telemedicine - Taking Healthcare to Rural India

About 70% of Indias population is in rural India and a vast majority of the rural areas lack basic healthcare amenities such as hospitals, trained medical personnel,diagnostic laboratories,medical equipment, etc. A person living in a remote area has to travel 100 kilometres on an average to avail the nearest healthcare facility. Further, only one-fourth of Indias specialist physicians reside in semi-urban areas, and less than 5% live in rural areas. Moreover, the inadequate health infrastructure, including shortage of doctors and paramedical professionals is severely restricting delivery of healthcare services in the rural areas.

Over the years, bottlenecks in the growth of telemedicine in India have not been many in terms of connectivity, but are greater in terms of availability of trained manpower to run operations in the rural areas. Further, lack of common standards that govern medical information and legal issues related to medical advice provided via tele-conferencing, etc are also major impediments to the growth of telemedicine in India. Integrating tele-health into the healthcare delivery system will go a long way in furthering the Governments aim of increasing access to healthcare facilities among the rural population.
Case Study - The ISROs Telemedicine Programme

Given the demand-supply mismatch, particularly when medical experts are usually unwilling to practice in rural areas, telemedicine has the potential to improve access to medical experts, specialised medical information, diagnostic tools and consultations. With the rapid penetration of wireless technology, in the coming decade, initiatives such as telemedicine, mobile healthcare etc are expected to revolutionise the manner in which healthcare is delivered. Tele-health initiatives were introduced in India about a decade ago and their growth has been slow but steady. The coming decade is expected to witness a major transformation in healthcare delivery in rural areas, driven by technology, particularly telemedicine. Convergence of healthcare with emerging technologies will lay the stepping stone in improving the quality of healthcare at affordable costs to the rural populace.

The Initiative The Indian Space Research Organisations (ISRO) telemedicine pilot project was started in 2001 to make telemedicine accessible to the population at the grassroots.This initiative was launched under the GRAMSAT (rural satellite) programme, in co-ordination with various system providers such as Infinium, Apollo, OTRI, BEL-VEPRO, TeleVital, etc. The telemedicine facility connects remote district hospitals/health centres with super speciality hospitals in cities, through the INSAT satellites for providing expert consultation to the needy and underserved population. The valuable experience gained during the initial pilot projects encouraged ISRO to undertake further endeavours to enable speciality healthcare delivery to the rural populace. The focus has been to introduce satellite communications-based telemedicine technology in various parts of the country through pilot projects.

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The Technology The telemedicine system consists of customised hardware and software at both the patient and specialist doctors end, with some of the diagnostic equipment such as ECG, X-Ray, and pathology microscope/camera provided at the patient end. They are connected through a Very Small Aperture Terminal (VSAT) system and controlled by the Network Hub Station of the ISRO. Through a telemedicine system consisting of simple computer with communication systems, the medical images and other information pertaining to the patients can be sent to the specialist doctors, either in advance or on a real time basis through the satellite link in the form of digital data packets. These packets are received at the specialist centre, the images and other information reconstructed so that the specialist doctor can study the data, diagnose, interact with the patient and suggest the appropriate treatment during a video conference with the patient end. The Telemedicine Network Presently, the ISROs telemedicine network has enabled 382 hospitals with telemedicine facility. As of now 306 remote/rural/district hospital/ health centres and 16 mobile telemedicine units are connected to 60 super speciality hospitals located in major cities. About 1.5 lakh patients are getting the benefits of telemedicine every year.

Thrust Areas The ISROs telemedicine initiatives are aimed at providing telemedicine technology and connectivity in the following areas: remote/rural hospital and super speciality hospital for teleconsultation, treatment and training of doctors and paramedics; continuing medical education (CME) between medical colleges and post graduate medical institutions/hospitals; mobile telemedicine units (MTU) for rural health camps, especially in the areas of ophthalmology and community health; disaster management support and relief; and integrating with village resource centres/information kiosks. Achievements The ISRO has successfully linked hospitals and healthcare centres in remote rural areas with speciality hospitals in cities through INSAT satellites. Thus, connectivity between patients at remote end and the specialist doctors at urban centres has been effectively established. Remote areas such as Kargil and Leh in North India, offshore islands of Andaman and Nicobar and Lakshwadeep, and some of the interior parts of Orissa, Karnataka, Kerala, Chattisgarh, Jammu & Kashmir, the North-Eastern states of India and some tribal districts in certain other states now have access to speciality healthcare from some of the major speciality hospitals in the country. The ISROs CME efforts provide doctors at rural healthcare centres with an opportunity to upgrade their medical knowledge and skills through interactions with experts at the speciality hospitals through satellite-based tele-link. The CME programme has been integrated with the tele-education programme by linking some of the medical institutions with the speciality hospitals and research centres. The MTUs consist of medical equipment along with telemedicine hardware, software and VSAT system mounted in a bus/van establishing a mobile telemedicine centre at any place. The key areas of mobile telemedicine applications are in the field of tele-ophthalmology and community health. Under mobile tele-ophthalmology, rural eye camps are conducted and the rural population undergoes eye screening for cataract, glaucoma and diabetic retinopathy. Under the community health programme, MTUs are useful not only for disease prevention but also for health promotion in terms of running awareness camps and teaching hygienic practices.

The ISROs Telemedicine Network Growth Story

Note: Remote refers to remote hospitals and speciality refers to speciality hospitals Source:Website of Asia-Pacific Regional Space Agency Forum, D&B Research

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 The ISROs telemedicine facilities at three hospitals GB Pant Hospital, Indian Naval Hospital Ship (INHS) Dhanvantari at Port Blair, Andaman Island and Bishop Richardson Hospital at Car Nicobar along with an ISRO Gramasat Network at eight islands was effectively used during post tsunami disaster relief work for the benefit of the remote population of the Andaman and Nicobar islands. More such telemedicine centres are being planned at the primary health centres of various islands of Andaman and Nicobar.

Nonetheless, the overall Indian healthcare delivery mechanism is taking baby steps towards automation and deploying various hospital informatics and management solutions. The healthcare sector is poised to embrace cloud computing in a big way in the coming decade. Cost-effective cloud-based solutions are expected to drive increased adoption of HMIS and EMRs. The various benefits that can be derived, such as easy accessibility irrespective of geographical location, fewer errors, fast response in times of emergencies, patient convenience, among others, would drive increased adoption. To drive improved efficiencies, more hospitals are likely to seek automation for their workforce management, administration, finance, billing, patient records and pharmacies. On the back of growing popularity of digitisation in hospitals, market penetration of picture archiving and communication systems (PACS) is likely to increase further in the coming years. With India expected to experience a major shortage of radiologists over the next five to ten years, the need and utilisation of teleradiology is expected to increase rapidly. Though PPPs have yet to take off, they are expected to gather steam in the coming decade which will also see an increased demand for transparency and accountability among the stakeholders.This in turn, will increase the demand for IT-enabled systems such as HIS and related IT infrastructure, EMRs etc. Even in the case of public health, maintaining and consolidating important data from Government and rural hospitals and integrating several systems will drive demand for greater automation in healthcare services in the coming years.

Technology to Become a Core Function

Considering the limited availability and access to proper healthcare facilities in rural areas and increasing customer expectation of better facilities and improved services in urban markets, in the coming decade, technology will be a game changer in the manner in which healthcare services will be delivered. While Government hospitals are showing some interest in adopting IT solutions, the private sector would be the major driving force behind technology adoption in the Indian healthcare segment. To optimise costs and effectively manage operations, IT solutions will become an integral part of process management, patient care and the management information system (MIS) in hospitals.With the health insurance sector poised for major growth in the coming decade, increasing demand from this sector for more efficient systems for storage and retrieval of information will put pressure on hospitals and other healthcare providers to imbibe technology to modernise existing infrastructure. The convergence of healthcare with upcoming technologies such as cloud computing and wireless technologies will play a key role in improving accessibility and meeting the challenge of manpower shortage. The coming years are expected to witness greater deployment of tools such as telemedicine, teleradiology, hospital information systems (HIS)/hospital management information systems (HMIS), online or electronic medical records (EMR), etc. Electronic record keeping is the first step towards automation. The majority of Government hospitals are rooted in manual processes.

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The exhibit below indicates the factors that will drive demand for increased technology adoption going forward. Drivers for technology adoption

Project Panchdeep Wipros initiative for the ESIC

IT -enablement

The Employees State Insurance Corporation (ESIC) partnered with Wipro Limited to establish an IT eco-system in line with its complex requirement of developing an infrastructure network for delivering medical care services. The initiative, Project Panchdeep, is Indias largest e-governance project to transform the manner in which 15 million industrial and service labourers receive healthcare and social security protection. The task at hand was to turnaround an ailing manual system into a state-of-the-art automated and integrated medical environment powered by information technology, covering 2,220 sites across India and roll out of over 20 million bio-metric identity cards and a database of over 50 million fingerprints. ESICs nationwide citizen health record created for over 50 million

Source: D&B Research

citizens, enables better healthcare services anytime anywhere for them across 144 hospitals and 1,400 dispensaries.This initiative exemplifies how technology will enable healthcare and social security services to reach and benefit society in the future. says Mr Prasenjit Lahiri, General Manager, ESIC Account- Wipro Infotech. The Wipro solution runs on an integrated fabric that seamlessly orchestrates the real-time IT delivery needed by one of the worlds largest e-governance projects.The transformation has enabled the ESIC to reduce turnaround time and operational costs; shorten claim processing time; improve employee productivity and operation co-ordination across functional departments; and also made it possible for the insured person to avail medical services at any ESIC facility across India. Digitalisation of beneficiary data and the issue of bio-metric identity cards is a critical element of ESICs strategy going forward. I am sure that it will be a great step to serving the beneficiaries in a better way. says Mr Mallikarjun Kharge, Union Minister of Labour & Employment. Major benefits derived a) Identification, authentication and verification of insured persons and issue of 20 million biometric cards.This provided the users with a digital identity and a convenient access to healthcare facility anywhere in India b) A unified information system automated all ESIC processes (internal and external).This system provides a single view of all data to improve efficiency, transparency and accountability across ESIC and the eco system

Healthcare companies will also increasingly invest on adopting technology in a bigger way to attract the huge foreign patient pool, which is looking for best options of high-quality healthcare services at affordable costs. The role of technology would evolve from that of a support function to become the core function; for example in the areas of minimally invasive surgery, laparoscopic and robotic surgeries, etc. However, the road to greater technology adoption is not going to be without its share of challenges. Currently, the IT budget for Indian hospitals does not exceed 10% of their revenues, substantially lower than allocation on IT in hospitals in the West. Moreover, despite the long-term gains in efficiencies and costs that can be achieved, the initial high capital investments may act as impediments for organisations looking to invest in advanced technology products/services. Further, lack of in-house IT expertise, lack of standards, reluctance/resistance of staff, inadequate support from the IT vendors, etc are some of the bottlenecks that will have to be effectively dealt with in this direction.

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c) A web-based medical information system enabled a seamless online registration of employers including online filing of documents. The system is also enabled with online payment mechanism between banks, financial institutions and ESIC d) ESIC offices are now powered with state-of-the-art voice and videoconferencing equipment, making it a future-ready workplace e) Establishment of a Central Data Centre and Disaster Recovery Centre and instalment of centralised hardware is ensuring an integrated and a secured information retrieval system.

for medical procedure, among others. Apart from modern medical procedures, India also offers varied holistic and wellness medicinal services such as Yoga, Ayurveda, Meditation, Naturopathy etc.

Project Panchdeep:Thrust areas

There is a reverse brain gain taking place, which is very positive for Indian medical tourism. Every new hospital coming up in the country today has half the doctors who have worked abroad for many years. says Mr. Pradeep Thukral, Executive Director, Indian Medical Travel Association

India attracts about 50-60% of its foreign patients from the neighbouring countries such as Bangladesh, Pakistan, Nepal and Sri Lanka, with the remaining significant share of patients coming from Africa and the Middle East. In the Asian medical tourism market, India faces competition from Thailand, Singapore, Malaysia and Philippines. While Thailand is more popular for cosmetic surgeries and dental treatments, India and Singapore specialise in complex medical procedures.
Source:Wipro Limited; D&B Research

Procedure-wise composition of foreign patients (%)

Cohesive Action Needed to Tap Medical Value Travel Market

As per the International Trade Commission in Geneva, the global medical tourism market could grow into a US $ 188 billion business by 2013. Although currently India has a marginal share in the world medical tourism (or medical value travel) business, it has emerged as one of the fastest growing medical travel destinations in Asia. According to industry estimates, every year 400,000 to 500,000 foreign patients come to India, with the nations medical value travel market growing at a rate of 20-30% annually. Currently India receives patients from over 50 countries across the world. The growing significance of this segment is largely driven by Indias low-cost advantage; emergence of several large private players; perceived quality of clinical component (competence of doctors and paramedical staff, procedure and infrastructure); and less waiting time The Government is taking some initiatives to boost medical tourism in India by way of a market development assistance scheme, and other marketing activities (overseas road shows, etc). However, for India to cash in on the high demand for out-patient procedures
Source: A Study of Problems and Challenges Faced by Medical Tourists Visiting India, Ministry of Tourism, Govt. of India; D&B Research

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such as cosmetic surgeries and dental treatments, concerted efforts by all the concerned stakeholders are needed to be taken to offer tourist-friendly experience to the international patient. At a policy level, there is a need to have more tourist-friendly initiatives (e.g. a simpler visa regime), while on the other hand, there is an urgent need to build up infrastructure. An image building exercise to improve the perception about India among foreign patients could also be facilitated by the Government. Notwithstanding the high value proposition of foreign patients, many Indian hospitals are not motivated enough to tap international patients.This is not because they do not meet the required standards, but because they already enjoy high demand from domestic patients and are running at full capacities. Further, there is also an urgent need to set up large number of hotels and provide accommodation facilities at lower rates. Countries such as Thailand enjoy an edge due to a large hospital base and their competitive tourism industry, where food and lodging during recuperation would be less expensive, as compared to India.

India attracts foreign patients for high Lack of coordinated efforts at value medical procedures such as Government level to promote heart surgeries, nephrology, oncology, medical tourism orthopaedics, joint replacement, etc Highly skilled and competent doctors Skilled paramedical staff Government regulations issuance of medical visas on

Lack of proper regulatory system for hospitals Poor coordination among various stakeholders (healthcare players, insurance companies, Government, tourism and hospitality companies) Threats Competition from tourismfriendly neighbouring countries (Thailand, Singapore, Malaysia etc)

English-speaking medical personnel

Opportunities Rising cost burden of national healthcare system in developed countries; rising ageing population in countries such as US, UK etc

Inadequate medical care facilities in Increasing demand from medical other South Asian countries; and in the tourists from non-English African continent and the Middle East speaking countries (Iran, Iraq, Oman, etc.) Increase in brain gain of medical personnel to India
Source: D&B Research

The number of foreign patients coming to India every year is expected to more than double in the next 10 years. says Ms Shobana Kamineni, Executive Director-New Initiatives, Apollo Hospitals Group

Traditionally India has been attracting patients from neighbouring countries, and presently there is a boom in demand from Africa and the Middle East. Going forward, rise in ageing population and increasing healthcare costs would bring more patients from the developed economies of Europe and Americas. informs Mr. Pradeep Thukral, Executive Director, Indian Medical Travel Association In the coming decade, the trend of foreign patients from developed economies travelling to India for medical treatment is expected to gather momentum. The demand would be driven by changing demographics of the population in these countries. An ageing population and increase in life expectancy would increase demand for healthcare. At the same time, inability of the national healthcare systems in these nations to meet the expected rise in demand for healthcare and their worsening economic condition would result in long waiting lists and high costs. Economic slowdown in the developed

SWOT Analysis: Medical Tourism in India

Strengths Weaknesses World class healthcare services at Low healthcare manpower-toa fraction of the cost incurred in population ratio as compared to western countries global norms Little or no waiting for treatment General infrastructure in the country is not impressive; shortage of hotel rooms

Equipped with latest medical Lesser number of hospitals are technology & equipment, and quality accredited clinical infrastructure

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economies coupled with loss of jobs and medical insurance is also expected to give a boost to Indian medical tourism market going forward. With a large majority of the foreign patients coming for medical treatment to India being self-financed/not covered by social security/health insurance, the low-cost advantage enjoyed by India could augur well for further growth of medical tourism. In such a scenario, the number of foreign patients seeking healthcare facilities in countries such as India,Thailand, Singapore, etc, which offer treatment at costs which are much lower compared to advanced economies, are equipped with latest medical technology, and offer services that match international quality standards, is set to see a significant increase. Within the Asian sub-continent, there exists tremendous potential for India to cash in on its low-cost advantage vis--vis its Asian counterparts such as Singapore and Thailand, where treatment costs are higher by as much as two to three times and 50-80%, respectively.

Improvement in the overall quality of treatment and care offered in India at competitive rates, coupled with overall increase in awareness levels, is resulting in several foreign patients who earlier went to Thailand or Singapore, coming to India (e.g. African patients). Another encouraging trend witnessed in the Indian context is the brain gain. A large number of non-resident Indian (NRI) doctors and other medical personnel are returning to India in view of the huge growth opportunities in the Indian healthcare sector. In the coming years, this trend will help in further raising the overall quality of medical care services in India. Accreditation, compliance with quality expectations along with reduced medical costs and access to latest medical technology will be the key demand drivers for medical value travel in the coming decade. The Indian medical tourism market is still at a nascent stage. The

Although currently foreign patients comprise only a small proportion (10-20%) of their total patient base (with domestic patients accounting for the rest), several private healthcare players are aggressively focusing on attracting foreign patients. This is on account of the vast differential in the average per patient revenue (in-patient) between a domestic patient (US$ 3,000) and a foreign patient (US$ 7,000-8,000) for high-end treatments such as heart surgery/knee replacement/cancer treatment, which acts as icing on the cake for these companies. Most private healthcare players catering to international patients have a separate department to cater to this category of patients. Medical tourism facilitators in the country offer attractive healthcare packages to foreign tourists visiting India for medical treatments/wellness. Catering to foreign patients helps healthcare companies in improving their financial viability, as foreign patients usually seek high-value medical treatment in India. This explains the increasing focus of companies to cater to this higher-margin segment.

huge potential from the Indian medical tourism business is reiterated by the fact that while a foreign tourist coming to India spends an average US $ 3,000, a foreign patient coming to India spends on an average at least US $ 6,000-7,000. Further, currently medical tourism in India is confined to just 10-12 big cities. India can leverage the huge opportunity in medical tourism provided concerted and coordinated efforts are taken by all the concerned stakeholders. There is also greater need for accreditation of hospitals to build up the perception of quality among foreign tourists.

Manpower crunch is a constant battle for healthcare companies. Nonetheless, the reverse brain gain is benefitting the sector, with overall competency levels going up. informs Mr. R D Thulasiraj, Executive Director, Lions Aravind Institute of Community Ophthalmology, Aravind Eye Care System

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Section IV: Competitive Scenario and Strategic Focus

The most dominant feature of the Indian healthcare sector is the wide demand-supply gap in healthcare services. While the prime concern of the Government is to increase access and affordability of healthcare services, the private healthcare sector accounts for bulk of the total healthcare expenditure in the country. Private healthcare delivery is highly fragmented, with the bulk of private healthcare being serviced by the unorganised sector. However, this market is witnessing increasing corporatisation in healthcare delivery. The overall healthcare delivery market in the country is at a nascent stage, characterised by high demand and growth potential. However, competitive intensity seems to be increasing, particularly in the metros and big cities. The capital-intensive nature of the healthcare industry, with long gestation period and constant need to invest in new/upcoming technologies puts pressure on profit margins of healthcare players. The larger established players enjoy the first mover advantage with accumulation of sizeable hospital assets on land acquired at historical prices, and have internal cash flows to take care of expansion plans. For the new entrants, the rising real estate prices have created high entry barriers. This is leading to several healthcare companies increasing their attention to the tier II and III cities and small towns to enhance their presence. However, successful entry into these In the coming decade, the strategies to be adopted by the healthcare players would be aimed at enhancing market presence and entering untapped markets; reducing costs and improving productivity; achieving improved economies of scale; providing better customer service; capital investment, including investment in infrastructure and IT; The entry of more number of players, increasing corporatisation and foreign funding is expected to have several positive implications for the healthcare sector, such as improvement in overall physical infrastructure, technology, delivery systems and processes, and overall quality of healthcare, thereby boosting further growth and development of the sector. Growing demand for healthcare services and emergence of large established private players is encouraging several foreign players as also non-resident Indians to enter the Indian healthcare sector. This rapidly growing sector is also attracting growing interest from several private equity funds and venture capitalists, banks, and domestic and international financial institutions to explore investment opportunities across the healthcare value chain. smaller markets characterised by comparatively lower affordability would necessitate development of new and innovative healthcare delivery models.

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introduction of new products/services, and mergers and acquisitions. The three core areas of strategic actions likely to be undertaken by healthcare players in the coming decade are discussed below.

Consolidation to Gather Momentum

Given the cruciality of economies of scale for the success of hospitals, several private hospitals are likely to adopt the consolidation route in the coming years.The need for consolidation/mergers and acquisitions (M&As) would also be driven by the fact that demand exceeds supply and entry of more players has increased competition and need to widen geographical reach and healthcare delivery capabilities. Further, considering the high costs involved in setting up hospitals and the long gestation period, M&As would be a faster way of expanding operations. Consolidation activities in the overall healthcare sector in the coming years would also be driven by the objective of large healthcare companies to become integrated healthcare service providers. Within the healthcare sector, the diagnostics and pathology laboratory segment is witnessing increasing competition since the last few years with the advent of large pathology laboratory chains and entry of foreign health insurance companies. Emergence of these large chains with pan-India presence is posing a threat to and eating into the market shares of the large number of small pathology labs that have mushroomed across the country in recent years. In the coming decade, rising awareness levels among consumers, particularly towards preventive healthcare, and increasing income levels of the middle class consumers is likely to increase demand for pathology labs with emphasis on quality, standards and accuracy of test results; thereby posing threat of existence to the small unorganised players. Further, given the huge untapped potential in the health insurance market, these organised players are optimistic on the long-term future prospects of the diagnostics market and are hence likely to adopt the consolidation route to enhance scale and penetration.

The market is likely to see increasing competition which will lead to some level of consolidation.We may see entry of major international healthcare players in the Indian market and also more focus on quality healthcare and efficient deployment of capital. says Mr Rajiv Sharma, CEO of Sterling Addlife India Limited

Threat of Over-supply in Metros to Drive Firms to Tier II and Tier III Cities
With competition in the healthcare sector becoming fiercer in the metro cities, healthcare players have started to pay attention to the demand for healthcare services in Indias tier II and tier III cities. The entry of several new players in the Indian healthcare sector and the likely entry of foreign players in the coming years are likely to create a situation of over-supply in the metro cities. Further, high costs of land in the larger cities is restricting expansion plans of healthcare players, including diagnostics companies, which are now looking at tapping the large untapped demand from the smaller towns. The lower upfront costs and break-even period as compared to setting up healthcare facilities in a metro city is expected to increase penetration of healthcare services in the tier II and tier III cities in the coming years. However, given the profile of the customers in these smaller markets, healthcare players would adopt a differential business model, which could be in terms of smaller hospitals (i.e. less number of beds); investing in less expensive medical equipment (without compromising on quality), etc. Considering the lower affordability of consumers from smaller towns, healthcare companies would thereby adopt a low-cost model in which the patients would be required to travel to the nearest big city only for the high-end services. In fact, by establishing a presence in the smaller towns, healthcare players can ensure flow of referral patients from these areas to their main hospitals in the big city.

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Healthcare players are interested in tapping the tier II and tier III cities due to the growing opportunities in these markets and indirectly reducing the cost of care to the patient by taking it to their doorstep. says Dr Naveen Nagar, Associate Vice President - Operations & Strategy, HealthCare Global Enterprises

Accreditation to Become a Necessity

Rise in income levels and awareness would increase demand for quality healthcare services. With the healthcare market increasingly becoming customer centric, high quality standards would ensure greater consumer satisfaction. Further, to cash in on the rising demand for healthcare services from foreign patients, more healthcare players in India are likely to get accreditation from national as well as international accreditation agencies. Moreover, entry of new and foreign players would further push up need for ensuring quality healthcare services among existing players. In such a scenario, healthcare players would use accreditation as an important differentiating tool amidst increase in competition levels. Accreditation also has a critical role to play in regulating the healthcare industry, upgrading the quality environment of the healthcare organisations and for ensuring reach of quality healthcare to the rural masses. Although currently there is no mandatory requirement for an accreditation, in the coming decade, in a dynamically changing healthcare landscape, accreditation is expected to become a necessity.

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Conclusion
The Indian healthcare sector is on the threshold of a major transformation. In the coming decade, the changing dynamics of the sector would be characterised by rise in demand for healthcare services at affordable costs; increased investments, both in terms of infrastructure and technology; and expansion of market, particularly in the tier II and tier III cities and towns. Apart from the traditional demand drivers such as rising incomes and urbanisation, factors like increase in penetration of health insurance schemes, Government initiatives, increased awareness levels and changing disease pattern would play a critical role in driving demand. However, widening gap between demand and supply of healthcare services would remain a major challenge for all stakeholders. Concerted efforts are needed to be taken by all the stakeholders to ensure availability of quality and affordable healthcare services to the Indian population. Providing concessions on land would help the healthcare companies in substantially reducing their costs, as they continue to grapple with rising costs. Reducing the customs duty on imported medical equipment would also them in saving cost. At the same time, encouraging domestic production of medical equipment would bring down acquisition costs for healthcare players and reduce the sectors high dependence on imports. Indigenised local production would also help in bringing down overall costs of healthcare delivery. to develop sustainable low-cost delivery models. To increase accessibility of healthcare services in the far flung areas, more PPP initiatives would help in addressing this challenge. Telemedicine has a critical role to play in improving access to medical experts, specialised medical information, diagnostic tools and consultations for the rural populace.

The Way Forward

There is a need for the Governments role to evolve from a provider to that of a facilitator in extending healthcare services. Presently healthcare accounts for a negligible share in the existing PPP projects in the country. Given the low public health expenditure in the country, greater efforts need to be taken to foster more PPP-based initiatives for building healthcare infrastructure, particularly in the rural areas. PPP framework in the area of medical education would help in addressing the severe manpower shortage in the sector.

Technology is poised to be a game changer in the manner in which healthcare services will be delivered in the coming decade. Greater deployment of technology will address the challenge of rising costs of healthcare companies by automating routine administrative functions and improve overall productivity levels. More importantly, increased IT adoption will enable improved diagnosis, and more accurate clinical decisions and treatment, thereby improving the overall quality of services delivered. To exploit the immense potential of the medical value travel

Providing incentives and subsidies would attract greater private sector participation. A fund on the lines of the TUFS for the textiles industry will encourage greater private participation in the healthcare sector, particularly in the smaller towns. Affordability being a major bottleneck among the vulnerable section of the society, the public and private sector should come together

business, there is a need for the Government to facilitate greater brand building initiatives (through overseas road shows, seminars, conferences etc) in conjunction with healthcare providers, third party administrators and other concerned stakeholders. Cohesive action is also needed to offer tourist-friendly experience to the international patient looking for high-value out-patient procedures (e.g. dental treatment, cosmetic surgery). Relaxing the existing visa

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norms and making it easier to access all the relevant information (regarding hospitals, treatment options, charges, accommodation etc) using different medium (Internet, published reports, magazines, etc) would also go a long way in attracting more foreign patients into the country. While awareness levels have improved, increased use of information and communication technology will go a long way in bringing more people under the healthcare net, thereby increasing demand for healthcare services. Insurance is the way forward towards expanding reach of healthcare services across the nation. Demand for healthcare is expected to remain strong in the coming years. However, there is a need for healthcare providers to increase thrust on developing innovative healthcare delivery models to increase access/reach and affordability. To achieve this, there needs to be greater partnerships between healthcare companies, medical equipment providers and insurance companies, with the Government playing an enabling role. To achieve sustainable and long term growth of the Indian healthcare sector, collaborative action among all concerned stakeholders, with clear and common objectives of increasing accessibility and affordability is the way forward.

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References & Sources

Working Paper Policy for Indias Services Sector, Department of Economic Affairs Improving Health and Education Service Delivery in India through Public-Private Partnerships, Govt. of India Medical Council of India documents Reserve Bank of India documents Planning Commission documents Industry interactions Ministry of Tourism Confederation of Indian Industries Economic Survey, 2010-11 The National Medical Journal of India Report of Task Force on Medical Education for the National Rural Health Mission, Ministry of Health and Family Welfare Handbook of Statistics on the Indian Securities Market 2010-SEBI Census of India Reports Annual Reports of Healthcare Companies National Health Profile of India, 2010 World Health Statistics 2011,WHO Annual Report of Ministry of Health & Family Welfare, 2010 Annual Report of Medical Council of India, 2009-10

Websites:
www.pib.nic.in www.irda.gov.in www.finmin.nic.in www.dipp.nic.in www.medicalbuyer.co.in www.modernmedicare.co.in www.novamedicalcenters.com www.aprsaf.org www.ibef.org www.indianhealthcare.in www.pppindiadatabase.com www.expresshealthcare.in www.expresscomputeronline.com www.worlddiabetesfoundation.org www.indiabudget.nic.in www.nlm.nic.in www.medind.nic.in www.openmed.nic.in www.ehealthonline.org www.whoindia.org www.upppc.org www.decu.gov.in www.idf.org www.isro.org

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Acknowledgements
We would like to thank the following experts for sharing their insights during the preparation of this report:
Dr Naveen Nagar Associate Vice President - Operations & Strategy, HealthCare Global Enterprises Dr Naveen Nagar is an ENT Surgeon and a management professional in the healthcare sector with over 15 years of experience. He is currently Associate Vice President - Operations & Strategy at HealthCare Global Enterprises (HCG) - South Asias largest network of cancer hospitals.

Mr Prabhjit Singh Didyala Head Strategy, Fortis Healthcare Mr Prabhjit Didyala is focused on Corporate Strategy, Medium Term Planning for Hospital Medical Programs, Incubation of ideas around various focus areas for the Company, and Program managing complex change management projects. Prior to joining Fortis, Mr. Didyala has worked for The Boston Consulting Group in India, E.I. DuPont in Shanghai, for Accenture (then Andersen Consulting) in India and at Tata Cummins. He is a Mechanical Engineer (from BIT Mesra) and an MBA (from IIM Lucknow), and a gold medalist at both places. Mr Pradeep Thukral Executive Director Indian Medical Travel Association (IMTA) Mr Pradeep Thukral is Executive Director of the IMTA - a non-profit organisation that brings together leading players in the Indian Medical Tourism industry like JCI, NABH accredited hospitals, healthcare & wellness service providers, facilitators and specialised travel companies and aims to make India the leading global healthcare destination. Prior to joining the IMTA, he was Group Head - International Marketing, Apollo Hospitals and before that he was with Wockhardt Hospitals Group in India, where he successfully set up its International Marketing function from the scratch. He is presently working closely with Indias Ministry of Tourism and in the past has served on the task force constituted by the CII and the Indian Ministry of Tourism to suggest a strategy for promoting medical tourism to India.

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Mr Rajiv Sharma CEO - Sterling Addlife India Limited Mr Rajiv Sharma is a B.E. (Mechanical) from PEC Chandigarh and a postgraduate in management from IIM, Ahmedabad. He has a career spanning 16 years across various functions ranging from sales & marketing to consulting and M&A. Under his leadership, from a single hospital in Ahmedabad, Sterling Hospitals has emerged to be the largest and dominant chain of corporate hospitals in Gujarat with 5 operational hospitals in all major cities in Gujarat, with close to 1,000 beds under management. Rajiv Sharma is an eminent speaker on various healthcare issues and is a member of healthcare committee of FICCI Gujarat. Ms Shobana Kamineni Executive Director New Initiatives, Apollo Hospitals Group Ms Shobana Kamineni has a degree in Economics and 20 years of experience in the healthcare industry. She is part of the founding family of the Apollo Hospitals Group, which is Asias largest healthcare provider and the worlds 4th largest For Profit hospital with 8,500 tertiary & secondary care beds, Health BPO, 75 Clinics, Pharmacies, Educational Institutions, Research, Insurance,Wellness spas, and Health Media.As Executive Director of New Initiatives, Ms Kamineni is currently involved with the pharmaceutical retailing 1,200 pharmacies, supply chain management, Clinical Trials, Research and the Apollo Groups foray into Health Insurance.

Dr Sujit Chatterjee CEO - Dr L H Hiranandani Hospital Dr Sujit Chatterjee, M.D. (Obs. & Gyn.) is the CEO of Dr L H Hiranandani Hospital since inception. The hospital is a 240 bedded super-speciality hospital located in Mumbai. Dr Sujit Chatterjees areas of specialisation are Obstetrics and Gynaecology & Gynac Oncology. He has published papers in various scientific journals and has won awards for the best scientific presentation. He led the Hiranandani Group to arguably the first Public Private Partnership in healthcare with Navi Mumbai Municipal Corporation. Dr Chatterjee is involved in Corporate Health Strategy planning and also interacting with other healthcare companies to help forge joint ventures.

Mr R D Thulasiraj Executive Director - Lions Aravind Institute of Community Ophthalmology (LAICO), Aravind Eye Care System Mr R D Thulasiraj, an IIM Calcutta graduate, has been working in the field of eye care for over 25 years. He is part of the leadership team that built Aravind into the worlds largest provider of eye care. In 1992, he shifted his focus to capacity building, training and consultancy by setting up the LAICO which by 2010, had worked with over 260 hospitals across the globe. He has served as an Advisor on several national and international bodies, and has been actively involved in several research activities, both clinical and operations research. He has been a Technical Advisor to Indias National Programme for the Control of Blindness and to the WHO. For the past five years, Mr Thulasiraj has been representing eye care at the World Economic Forum as Davos.

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About Wipro Infotech

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