Global Hospitals, Apollo, Fortis, Columbia & Max Healthcare in race for India’s Most Valuable Healthcare Chain at ILC 2013

Global Hospitals, Apollo, Fortis, Columbia & Max Healthcare in race for India’s Most Valuable Healthcare Chain at ILC 2013

With Healthcare Expenditure on Rise, top 5 Hospital Giants, Global Hospitals Group,Apollo Hospitals Group,Fortis Hospitals Group,Columbia Asia Hospitals& Max Healthcare compete for Top Recognition

Mumbai, Maharashtra, India, Wednesday, 15th May 2013: Asia’s biggest leadership platform at 4^th Annual India Leadership Conclave & Indian Affairs Business Leadership Awards 2013 is getting bigger & bigger with key players in the healthcare chain are running neck to neck for the top recognition, India’s Most Valuable Healthcare Chain at ILC 2013. In the nomination are country’s top 5 admired & respected Hospital Chain Global Hospitals Group,Apollo Hospitals Group,Fortis Hospitals Group,Columbia Asia Hospitals,Max Healthcare are in public voting. India is one of the world’s most lucrative healthcare markets, and is expanding rapidly. The Indian healthcare industry is seen to be growing at a much rapid pace than it was anticipated before and is expected to become a $238.76 billion industry by 2020. A number of major players in the healthcare sector are actively participating in the growth through expansion plans and putting in huge investments in the sector. According to the Investment Commission of India, the healthcare industry in India has experienced remarkable evolution of an added 12 percent per year during the last 4 years driven by a number of factors such as increase in the average life expectancy and average income levels, and rising awareness for health insurance among consumers.

Global Hospitals Private Ltd. provides specialty care and multi organ transplantation services in India. The company provides its transplantation services for liver, heart, lung, kidney, and bone marrow. It also offers medical and surgical gastroenterology, minimal access surgery, cardiology and cardiothoracic surgery, liver treatment, nephrology and urology, orthopedics and joint replacement, internal medicine and critical care, pediatrics, gynecology, ENT, radiology, imaging, and anesthesia services, as well as laparoscopic training and DNB services. In addition, the company provides laboratory services in the areas of ultrasound, X-ray, bone densitometry, colonoscopy, CT scan, Doppler, echocardiogram, endoscopy, holter monitoring, mammography, MRI scan, sigmoidscopy, and spirometry. Further, it operates a nursing school. The company was incorporated in 1998 and is based in Hyderabad, India. It has additional locations in Hyderabad, Bengaluru, and Chennai, India.

Fortis Healthcare Limited owns, operates, and manages multi-specialty hospitals. Its healthcare facilities offer a range of specialty medical services, such as cardiac care, orthopaedics, neurosciences, metabolic diseases, renal care, oncology, and mother and child care, as well as other services, such as cosmetic surgery, ophthalmology, pulmonology, ear nose throat care, and dermatology. As of April 25, 2013, it operated a network of 76 hospitals, approximately 12,000 beds, approximately 600 primary care centers, 191 day care specialty centers, and approximately 230 diagnostic centers in the Asia Pacific region, including India, Hong Kong, Singapore, Australia, New Zealand, Canada, Dubai, Sri Lanka, Mauritius, Nepal, and Vietnam. Fortis Healthcare Limited was formerly known as Fortis Healthcare (India) Limited and changed its name to Fortis Healthcare Limited in March 2012. The company was incorporated in 1996 and is based in New Delhi, India. Fortis Healthcare Limited is a subsidiary of Fortis Healthcare Holdings Private Limited.

Apollo Hospitals Enterprise Limited provides healthcare services primarily in India, Mauritius, Bangladesh, and Kuwait. The company’s healthcare facilities offer treatment for acute and chronic diseases in primary, secondary, and tertiary care sectors. Its tertiary care hospitals provide care in approximately 50 specialties, including cardiac sciences, oncology, radiology and imaging, gastroenterology, neurosciences, orthopedics, and critical care services, as well as specialize in minimally invasive surgeries and transplantation. In addition, the company offers pre-commissioning consultancy services, such as feasibility studies, infrastructure planning and design advisory services, human resource planning, and recruitment and training services, as well as medical equipment planning, sourcing, and installation services; and post-commissioning consultancy services consisting of management contracts, franchising, and technical consultation. Further, it licenses the Apollo brand name for use by the radiology and laboratory services department of a hospital in Kuwait; and operates stand-alone pharmacies that provide medicines, hospital consumables, surgical and health products, and general over-the-counter products. Additionally, the company provides end-to-end medical outsourcing services, consisting of revenue cycle management of clients-hospitals; and professional services, including medical coding, billing and records maintenance services, and patient claims management services to doctor groups, hospitals, and insurers in the United States. It also offers telemedicine services, education and training programs, and research services. As of January 21, 2013, the company owned 8,500 beds in 50 hospitals, 1,350 pharmacies, 100 primary care and diagnostic clinics, and 100 telemedicine units in 9 countries. Apollo Hospitals Enterprise Limited was founded in 1979 and is based in Chennai, India.

Max Healthcare Institute Limited operates healthcare facilities with indoor and outdoor patient care in India. The company offers healthcare services through its 9 facilities in Delhi and the National Capital Region, and 2 facilities in Mohali and Bathinda. It provides services in the areas of cardiology, orthopedics and joint replacement, cancer, neurosciences, pediatrics, obstetrics and gynecology, aesthetics and reconstructive plastic surgery, internal medicine, eye and dental care, endocrinology, diabetes, obesity, ENT, metal health and behavioral sciences, physiotherapy and rehabilitation, and nuclear medicine, as well as minimal access, metabolic, and bariatric surgery. The company is based in New Delhi, India. Max Healthcare Institute Limited is subsidiary of Max India Limited.

Columbia Asia is an international healthcare group operating a chain of modern hospitals across India, Malaysia, Vietnam and Indonesia. The company’s highly skilled medical experts deliver care in hospitals specifically designed for the needs of patients and built for maximum comfort and efficiency. Columbia Asia Hospitals Pvt. Ltd.is one of the first healthcare companies to enter India through 100% foreign direct investment (FDI) route.Columbia Asia hospitals are clean, efficient, affordable and accessible. The innovative design of the hospitals, from their manageable size to their advanced technology, is focused on creating positive experience for patients.

The first hospital in India commenced operations in 2005 in Hebbal - Bangalore. Currently Columbia Asia operates six multispecialty hospitals, one referral hospital and a clinic. The group has presence in Bangalore, Mysore, Kolkata, Gurgaon, Ghaziabad, Patiala and Pune.The advent of NABH accreditation in 2006 was perceived as an ideal opportunity to further streamline and strengthen the documentation and operating procedures; thus began the journey of association with NABH. All Columbia Asia hospitals have now been mandated to undergo this accreditation.Columbia Asia Hospital - Hebbal, Bangalore obtained NABH accreditation in December 2007 within one and a half years of beginning operation and was the 10th hospital in India to be granted this distinction. The hospital has been re-accredited by NABH in December 2010

Recently Columbia Asia Referral Hospital Yeshwanthpur, Bangalore, Columbia Asia Hospital Palam Vihar, Gurgaon and Columbia Asia Hospital - Mysore have also been NABH accredited and Columbia Asia Hospital - Patiala is in the advanced stages of getting accredited.The laboratory at Columbia Asia Referral Hospital Yeshwanthpur, Bangalore is NABL accredited since September 2010; the labs at Columbia Asia Hospital - Palam Vihar, Gurgaon and Columbia Asia Hospital - Hebbal, Bangalore have also been similarly accredited.

The healthcare sector in India offers a potent mix of opportunities and challenges. On the one hand, the significant gap between ‘required’ and ‘actual’ healthcare infrastructure has driven significant investment into assets like hospitals and other facilities over the years. In turn, the growing availability and affordability of healthcare is spurring demand for other services like diagnostics, pharmacies, equipment etc. The growth story of the healthcare industry is also contributed by many non healthcare corporates and private equity firms infusing the much needed resources (capital and non capital) . Due to the lower cost of procedures, India has become an attractive destination for medical tourism, and a base for clinical trials. The challenges that India Healthcare Inc faces on its way up are optimal utilization of resources, minimizing operational costs, maximizing performance and efficiency, scaling of business, rapidly evolving technology and globalisation of healthcare delivery quality and standards.

The Indian healthcare industry is witnessing growth at a rapid pace and it is expected that the sector will touch $280 billion by 2020. The hospital services market is expected to be worth $81.2 billion by 2015. The major factors driving the growth in the sector are increasing population, growing lifestyle related health issues, easier accessibility to healthcare, thrust in medical tourism, improving health insurance penetration, rise in middle income group population, increased disposable income, government social sector initiatives on penetration of health insurance and focus on public private partnership (PPP) models.

As the Indian healthcare industry has been displaying strong growth prospects and in view of the prevalent optimistic atmosphere, many foreign companies have been displaying eagerness for investment/setting up their base in India and looking to have an access to the untapped market in Tier-II and Tier-III cities. During the period April 2000 to June 2012, the foreign direct investment (FDI) in hospitals and diagnostic centres is $1395.82 million, medical and surgical appliances is $523.54 million and drugs and pharmaceuticals is $9,659.26 million.

India is substantially under-invested in healthcare with 17% of the world's population but only 6% of the beds. Meager public healthcare spending in India presents a big investment opportunity for private players. The Indian healthcare sector is expected to reach US$ 100 billion by 2015 from the current US$ 65 billion, growing at around 20 per cent a year.FDI inflow in hospital and diagnostic centre was US$ 1.4 billion during April 2000 and June 2012, according to the latest Department of Industrial Policy & Promotion (DIPP) data. FDI inflow in medical and surgical appliances stood at US$ 523.5 million during the same period, according to the latest DIPP data.

The year that went by – A quick glimpse

§  India’s gross domestic product (GDP) growth for 2012-13 was projected at around 7.6 per cent; however, the actual GDP growth estimate is only five per cent. At the same time, the expenditure on health has been increased from 1.27 per cent of GDP in 2007-08 to 1.36 per cent of GDP in 2012-13.

§  The demand for hospital beds in India is expected to be around 2.8 million by 2014 to match the global average of three beds per 1000 population from the present 0.7 beds. India needs 100,000 beds each year for the next 20 years.

§  The Government of India (GOI) has launched a large number of programmes and schemes to address the major concerns and bridge the gaps in existing health infrastructure and provide accessible, affordable, equitable healthcare.

§  During the period from April 2000 to November 2012, the share of hospital and diagnostic centres in cumulative FDI equity inflows amounts to 0.82 per cent.

§  The GOI has introduced a new medical visa category for the foreign tourists coming to India for medical treatment. The GOI has also formulated guidelines to address various issues governing wellness centres, covering the entire spectrum of the Indian systems of medicine.

§  Research & Development (R&D) occupies the second position in India’s GDP with consistently high growth at near 20 per cent in the last few years. The GOI has also stressed the need to enunciate a policy for synergising science, technology and innovation and has also established the National Innovation Council. The GOI has announced the Science, Technology and Innovation Policy 2013 and has proposed to increase the gross expenditure on research and development to two per cent of GDP from the current level of less than one per cent.

§  As the Indian healthcare industry has been displaying strong growth prospects, many foreign players are eager to make investments in India. The private equity (PE) firms have made three major investments in the healthcare sector during the calendar year ending December 31, 2012. During the year, the PE investments have made investment of $100 million in the hospitals and clinics sector. The healthcare and life sciences industry attracted $581 million across 14 investments made by the PE investors. The PE investors have quadrupled their investment in India’s primary healthcare, betting the sick and ailing will stop approaching family doctors as the migrants in cities look out for a brand. During the year, the PE investors have invested $520 million into India’s basic healthcare industry and there is a prediction that PE investments will surpass $1 billion in 2013.

§  The Parliamentary Standing Committee on Health and Family Welfare tabled a report in the Parliament on May 8, 2012 on the functioning of the Central Drugs Standard Control Organization (CDSCO). CDSCO is the agency mandated with the regulation of drugs and cosmetics in India. The report covers various aspects of drug regulation including organisational structure and strength of CDSCO, approval of new drugs, and banning of drugs, among others. Subsequent to submission of the report, the Ministry of Health and Family Welfare has constituted a committee to verify the procedure of drug regulation.

elivering health care to a billion-plus population is very complex. And, like eating a Reese’s, there’s no right way to do it. In the past, Indian entrepreneurs have innovated on several business models that range from frugal to world-class luxury care. A testimony to its success is the fact that citizens spent Rs 1,650 billion, or 3.16 percent of the GDP (in 2011-12), on health care, whereas the government spent only 1.04 percent. In other words, a family of four spends nearly Rs 10,000 per year on health care. With the government once again shirking from committing higher budgets to health care, it is tempting to ask: Since there’s money on the table, can entrepreneurs devise privately financed and privately run universal health coverage? Perhaps all it needs is one disruptive idea to show that it’s possible to design comprehensive care outside the government.

NO UNIVERSAL HEALTH CARE SCHEME CAN RUN FOR FREE’
Dr Devi Shetty

Image: Mallikarjun Katakol for Forbes India
Dr Devi Shetty, Founder And Chairman, Narayana Group of Hospitals
Taxpayers’ money cannot pay for health care anymore; it could pay 20 years ago when people retired at 60 and died at 65. Today, people retire at 60 and live on to celebrate their 95th birthday. People are going to live longer not working than they do working, and as you live longer you invariably undergo 5-10 procedures.  Any country dependent on taxpayers’ money for health care is struggling, so we have to relook at how we run health care.

The only concept that will work is that everyone should contribute a tiny amount every month. It’s not an annual premium; if you ask them to pay every year, it’s a lot. A monthly payment should be sufficient to pay for health care. So Yeshasvini, which was the mother of all insurance schemes and which inspired the Andhra Pradesh and Tamil Nadu governments to start Arogyasri and Kalaignar schemes, was designed in a manner to let people pay a tiny amount. They started by paying Rs 5 a month, today they pay Rs 10 a month. It is the only self-funding scheme in the country today. All the other schemes are doled out by the government. When the government gives money, the schemes run well as long as there’s good tax revenue; the moment tax collection goes down, they don’t pay the hospitals, hospitals don’t treat patients and the scheme dies a natural death. It’s not that the government will one day announce that a scheme is not functioning, they just don’t pay. No government has the guts to say the scheme is off because they have no money.

But the government’s strength lies in the credibility it enjoys as an organisation that doesn’t cheat. It is inefficient, but that’s okay. In villages, when we tell people to pay a tiny amount every month to an MNC bank or an insurance company, they are not willing, but when we tell them to pay to the government they are willing because the government is the only organisation they trust. It can also make law, make something mandatory. So, the government should make use of this power. We have 900 million cellphone subscribers who are spending Rs 150 per month to speak on the phone.

 Let’s assume 600 million are active. We could ask them to pay Rs 20 extra. There’s no extra cost to collecting this amount, there already exists a mechanism to collect Rs 150. This way, we could have the largest insurance scheme in the country. I’ve interacted with politicians across many states, including Delhi. The problem lies with them. When a politician launches a scheme, he wants to take the credit of giving it free, he doesn’t know if he’ll be in power after five years, nor does he care if the country runs out of money. As long as this ‘free’ attitude runs, there’ll be no universal health care in this country.

I’ll give an example. In Kerala, a few years ago, the government gave a few 100 crores to insurance companies to cover BPL cardholders, but the latter didn’t know they were covered. So, in the end, barely a few crore claims came and the insurance companies pocketed the whole lot.

If the UK government can’t pay for health care, if the US is struggling, how can the Indian government pay for health care when it’s allocation for health care is just about 1 percent [of the GDP].

Whatever you want to do, first you have to understand where the money is coming from. Today, we have had the mobile revolution; it didn’t happen by charity from the government. People are willing to pay if there is adequate service. People are willing to pay tiny amounts for health care but you have to create a vehicle for them to contribute. You can do simple things. There are a few million maid servants. When they fall sick, who pays for care?

 The employer, in whatever limited manner. If there is a scheme for maid servants where an employer pays Rs 25 every month for the health care, every employer will pay.

On the other hand, the government always complains health care is expensive. Has anyone asked why private sector is so expensive? When it comes to paying taxes, we are treated on a par with the entertainment industry. Then, look at the salary costs and the acute shortage of medical professionals. We have a shortage of more than 1 million doctors. But we make such stringent rules in running a medical college that no one can start medical colleges in this country; even if one starts, it costs over Rs 200-300 crore, whereas anywhere in the world one can start a medical college with any building. They don’t need 25 acres of land and teachers retiring at 60.

All over the world, higher education happens at big hospitals, you don’t need to have medical schools. But here, you have a shortage of post-graduate opportunities because if you open it up, capitation fee will collapse and then the [medical education] industry will collapse.

To universalise health care, there has to be one health insurance scheme, one open source software for the whole country. With UID coming, ID will not be a problem. One concept, one body, but every state should monitor it itself because health is a state subject and the Centre can’t manage these schemes.

We also have a piecemeal approach to health care. We should be integrating primary, secondary and tertiary care with a lot of emphasis on preventive care. We [at the Narayana Group] have been thinking of [entering primary care] but you can’t deliver primary care with MBBS doctors.

Today, a nurse who has worked in hospitals for 20 years cannot give a paracetamol tablet. Are you aware of it? Legally, she is not covered. Unless the government comes up with a regulation that alternative medical specialists and nurses can look at primary care, there is no future. For the last 12 years, I’ve been speaking about it, everyone thinks it’s a great idea, but nothing happens in reality, because medical lobbies are very powerful. 

Buoyed by a congenial economic environment and demographic changes, the Indian healthcare industry has experienced exceptional growth over the past few years. In 2010, the industry was valued at USD 50 billion and was projected to grow at a healthy CAGR of 15 percent for the next five years. This momentum is expected to continue and place the sector at the top of the service sector players in India.Globally, the industry is amongst fastest growing sectors, with approximate revenues of USD 5.5 trillion in 2010. Within this context, India is viewed as one of the most promising markets among the developing countries and is projected to reach USD 140 billion by 2017. This report gives a comprehensive insight into the soaring Indian healthcare industry. It analyses the wide and diverse spectrum of Indian healthcare, with emphasis on opportunities in the areas of hospital infrastructure, pharmaceuticals, medical equipment, diagnostic labs and emerging fields like healthcare tourism, clinical trials & research and telemedicine.

The overall industry scenario is upbeat, propelled by a growing economy, shifting demographics, rising disposable incomes, high incidence of lifestyle-induced diseases, new investment avenues and a large pool of talented and cost-effective human resource. The segments that are reaping the most benefits are hospitals, pharmaceuticals, medical equipment companies, pathological labs and other service providers,

The Indian government, on its part, is promoting this sector through positive regulations like the introduction of the Health Bill, which proposes to bring all independent bodies like the Medical Council of India (MCI), the Dental Council of India (DCI), the Pharmacy Council of India (PCI) and the Nursing Council of India (NCI) under a centralized authority. The government is also increasing public expenditure on healthcare to 2.5 percent of GDP from 1 percent, encouraging public-private partnerships (PPP) in hospital infrastructure, and boosting medical tourism. Taking advantage of the prevalent optimistic atmosphere, many foreign players are looking to enter the country, especially in Tier-II and Tier-III cities, which have huge untapped markets.

Meanwhile, the generic drugs market is set to expand, since most patents are going to expire in the next 5 years. Simultaneously, health cities and single specialty clinics are gaining prominence in promoting quality healthcare services at affordable prices. Health insurance portability is expected to increase the penetration of insurance by not only improving the quality of service levels, but also by raising competition among insurers to retain customers.

The 17-storeyed Global Hospital, Mumbai is finally close to being fully operational. Dr R V Karanjekar, Executive Director, Medical Services & CEO shares some learnings and future plans withViveka Roychowdhury

Global Hospital's Mumbai facility opened its doors to its first patients in October last year and will be fully operational this October. But its impressive 17-storeyed glass facade is a testimony to the fact that the best laid plans can go off track. And how perseverance and experience finally pays off.

Dr RV Karanjekar ED-Medical Services & CEO, Global Hospital, Mumbai was (and remains) the man in the hot seat. In a career spanning more than three decades, he has been on the clinical side as well as hospital administration, in both private hospital like Fortis, Lilavati Hospital, as well as civic hospitals like Tata Memorial Hospital-Mumbai, before he joined the Global Hospitals Group around three and half years back.

In line with the positioning of the Group, the Mumbai facility too is a high end super speciality tertiary care facility. The Group's special focus is multi-organ transplant surgeries which is the expertise area of Dr K Ravindranath, Chairman & MD, Global Hospitals Group.

As Dr Karanjekar points out, Mumbai clearly lacked such a facility in 2007, when the Group did a feasibility study and first broke ground at the site in Lower Parel. This was underlined when Maharashtra's former Chief Minister and Union Minister, Vilas Rao Deshmukh had to be flown to Global Hospital, Chennai for his liver transplant last year. Since its inception in 1998, the Group has positioned itself as a leader in performing liver, heart, lung, kidney and heart-lung transplantation, as well as bone marrow transplantation. The Mumbai centre aims to continue this tradition, as a high end super-speciality centre of excellence in digestive, liver, kidney, urological diseases, organ transplants, cardiology and orthopaedics as well as related oncology offering comprehensive, end-to-end therapeutic, surgical and diagnostic services, all under one roof.

"By October this year, all 17 floors of Global Hospital's Mumbai facility should be fully operational." Dr R V Karanjekar Executive Director, Medical Services & CEO Global Hospitals - Mumbai

Dr Karanjekar points out that while there may be many other high end tertiary care facilities in Mumbai, they aim to differentiate themselves by being “super specialists in sub speciality areas”. This is based on their gap analysis of Mumbai as a healthcare destination where they zeroed in on certain treatment lacunae in the city. This is the path to growth, says Dr Karanjekar, as without these sub specialities, diseases may go undiagnosed and under-treated.

For instance, the Baldota Institute of Digestive Sciences inaugurated at the Mumbai facility last October offers advanced gastroenterology and GI endoscopy under Dr Amit Maydeo. Similarly, Mumbai also got its first adrenal disorders clinic on January 31 this year, with a multidisciplinary team of endocrinologists, cardiologists, radiologists, pathologists, nephrologists and urologists – all under one roof at Global Hospitals. A vascular clinic and diabetic foot clinic are also on the cards, according to Dr Karanjekar.

Global Hospital, Mumbai has already conducted some of the most complex cases like India’s first incision-free surgery, called Per Oral Endoscopic Myotomy (POEM), performed by Dr Maydeo. This procedure treats achalasia, a distressing disorder which causes severe difficulty in swallowing, reflux, chest pain and eventually oesophageal cancer. This innovative surgery was performed through the mouth with no external cuts.

So also Dr Prashant Rao, Director of Gastro Intestinal & Minimal Access Surgery, Global Hospital performed the State’s first Whipple’s procedure also known as Whipple’s Surgery, which is a very complex abdominal operation done with an extensive resection followed by extensive reconstruction involving four to five organs and three to four anastomoses. A Whipple’s procedure is also called pancreaticoduodenectomy and is done for duodenal/ampullary/lower end bile duct (jointly called periampullary) and head pancreas malignancy. Dr Rao performed this complex surgery laparascopically through five small incisions instead of a single large incision. Compared to classic procedures, laparoscopic procedures may result in less blood loss, a shorter hospital stay, a quicker recovery, and fewer complications.

At the other end of the spectrum, the Group will also promote prevention. Dr Karanjekar says the Group's philosophy is to promote a culture for health management rather than disease management. The Mumbai facility has already started implementing this by signing up some corporates in their locality and educating the staff on healthy lifestyle choices, organising free general health screening camps, etc.

OPD	Lobby

The core team

The Mumbai facility seemed to have everything going for it when construction started in mid 2007. The promoter-doctor team, besides the Chairman of the Group, comprises globally trained and reputed super specialists like Dr Amit Maydeo (a specialist in gastroenterology – medical with many first-in-India procedures to his name), Dr Prashant Rao (Chief of the Centre of Excellence for Minimal Access and Bariatric Surgery), Dr Bharat Shah (a nephrologist who heads Global Hospital's Institute of Renal Sciences and Transplant), and Dr Pradeep Rao who heads the Department of Urology. Dr Sushil Shah and Ameera Shah (of the Metropolis Group) as well as Harsh Mariwala, Founder of the Marico Group are also co-promoters of the Mumbai facility.

The core team came as board as full-timers and collectively own 30 per cent equity stakes in the facility with Dr Ravindranath, on behalf of the Global Hospital Group, holding the rest. The trend of promoter-doctors investing in and having stakes in such facilities is catching on in India and serves to assure patients of a continuum of care at the same facility. For the hospital management, this arrangement provides a certain amount of stability as these key super specialists cannot be poached away by rival hospitals. This allows the hospital to standardise treatment protocols which results in better health outcomes as well. From a footfall point of view, these super specialists moved their practices and patients to Global Hospital,Mumbai. And thus, patient footfalls were assured from day one.

Mumbai's medical Mecca

Location wise too, the hospital is at a prime location. Centrally located in Lower Parel, Global Hospital-Mumbai is less than a kilometre away from older medical facilities like Mumbai's pioneer municipal hospital, the almost century old KEM Hospital, Tata Memorial Hospital that specialises in treatment of cancer, Wadia Hospitals, (one each for children and women), and MGM (an ESI hospital).

With Mumbai's long defunct cotton mills of Lower Parel making way for luxury hotels like ITC Hotel-The Grand Central as well as high end malls like High Street Phoenix, the area is considered prime real estate. Global Hospital, Mumbai, with a planned built-up area of over 2,67,000 sq ft spread over 17 floors, is tucked away down the tree-shaded Dr E Borges Road, within walking distance from the ITC Grand Maratha. Thus it is conveniently located for the premium medical traveller segment as well.

The prime site is on a 99-year lease from Ajai Verma, a philanthropist who set up a trust to allocate prime real estate for the construction of a hospital. This is in line with his vision to provide Mumbai's citizens with better healthcare facilities. Verma is carrying forward the vision of his father, the late Mangaldas Verma who founded the Maharshi Dayanand College, also in Parel, with a similar objective with education as well as other similar projects.

The facility was planned to accommodate around 425 beds. 150 wards plus 50 ICU beds were to be commissioned by end-2010, in the first phase, at an initial budget of Rs 175 crores. But a delay of 25-30 months, meant that Phase one was finally completed in April this year, with 210 beds (of which 85 are ICU beds) and 10 floors commissioned. Initially the cost of the first phase was estimated to be Rs 175 crores but this ballooned to Rs 240 crores due to the delays and design changes.

However, the bulk of the capital expenditure seems to be behind the Mumbai facility, as this represents almost 85 per cent of the facility. Dr Karanjekar says most of the heavy capex facilities like the radiology and pathology labs, operation theatres and all ICU beds are already in place.

According to Dr Karanjekar, work is on in full swing to get the remaining floors functional, at an estimated Rs 2.5 crores per floor and Rs 60-70 lakhs per bed. By October this year, all 17 floors of Global Hospital's Mumbai facility should be fully operational. He estimates a total investment of Rs 260-265 crores and predicts that they will reach cash break even within six-eight months, and financial break-even in a minimum of two years.

Single room	Twin sharing room

In hindsight

Dr Karanjekar breaks down the 25-30 month delay into phases. The initial delay of four-five months was due to the sudden and temporary non-availability of sand, a vital ingredient in the construction process. This in turn led to the management and architects re-thinking the hospital's blueprints. In an attempt to reduce the amount of wall space to be constructed, the revised blueprint incorporated a fair amount of glass, but this meant a complete re-calibration of measurements and further slowed down the construction process.

As the management was eager to start treating patients in the first 10 floors, they applied for a partial Occupation Certificate (OC) with the usual labyrinth of paper work adding a further two-three months time lag to the process.

The fourth cause of delay was the lack of construction manpower. Dr Karanjekar narrates the frustration of putting in place all the equipment and material, only to realise that all migrant labour disappear from cities for six months, from May to the end of the monsoons, when they moonlight as farm labour in India's hinterland.

Tips to peers

Reception

None of these obstacles are permanent hindrances; in fact, in the long run, they will most likely go down as merely a small bump on the facility's march towards many more medical milestones. But they hold some vital learnings and Dr Karanjekar shared a few tips for hospital managements planning greenfield facilities.

Firstly, he strongly advises them to have on board all the heads of the key speciality areas from the blueprint stage. The specialists should be encouraged to participate in the planning and design of the hospital and specifically their domain areas as they know best the congestion points, etc. Breaking down and reconstructing after the hospital is commissioned adds to the cost and is not desirable from the quality and patient safety perspective as well, he points out.

Secondly, his maxim is to choose utility rather than aesthetics. “Don't go fancy unless you have the money in place or delays are guaranteed,” he says harking back to the decision to add the glass facade. A smaller hospital chain would have had the additional burden of financing the increased costs as well, which thankfully was not a constraint for the Global Hospitals Group.

Thirdly, he advises that managements should commission the hospital in stages, as each phase is completed after getting partial OCs from the civic authorities. This is crucial especially for smaller groups as having a revenue stream open up will ease the pressure and reassure financiers that they've made a good investment.

And his fourth suggestion is about putting in place the 'soft' infrastructure. He advices that hospital managements should hire directly rather than go to recruitment agencies. Discovering the right medical manpower will not be a problem in metros, but will be a constraint in smaller locations. Smaller hospital groups may also be hampered by the lack of personal contacts with reputed senior medical talent or the fact that their brands may not be strong enough to attract and retain key medical staff.

His final piece of advice is to plan ahead, harking back to an oft repeated yet very apt phrase: If you fail to plan, you are planning to fail.

Fast forward

Work on the remaining floors at Global Hospital's Mumbai site seems to be in fast forward mode, even as the lobby sees a steady stream of patients and their families. No doubt the management will meet its deadline to be fully functional by October this year.

Today when Dr Karanjekar and his colleagues view the imposing glass facade already accepted as a part of the Lower Parel skyline, they have clearly put aside the frustration of the past months. Instead, there is a quiet pride that they will be part of a legacy that will serve Mumbai, nay the world, well in the decades to come.

International Finance Corporation (IFC) is investing $25 million (Rs 134 crore) in Chennai-headquartered Ravindranath GE Medical Associates Pvt Ltd (RGE), which operates a chain of hospitals in Chennai, Hyderabad, Bangalore and Mumbai under the Global Hospitals brand.

IFC’s investment includes a mix of debt and equity as a portion of the money will be infused as equity.

Global Hospitals will use the funds for capital expenditure for its existing facilities and also to part-finance its $60 million project. It seeks to increase the number of beds from the current 1,000 to 1,800 in FY16 in its existing hospitals besides rationalising capital structure by refinancing existing borrowings.

Founded in 1998, RGE operates a chain of five hub hospitals and three spoke hospitals, with around 1,000 operational beds. It also operates telemedicine centres at seven locations in India, including three in low-income states in the east and the north-east where local tertiary care access is limited.

Dr K Ravindranath, promoter of the company, is a specialist in gastroenterology and laparoscopic surgery. He has more than three decades of experience in the healthcare sector.

The firm is backed by a fund managed by Everstone Capital Management and Samsara Capital, which together invested $73.8 million in Global Hospitals in July 2007. In April that year, the firm acquired Chennai-based Sri Kanchi Kamakoti Sankara Hospital for $59.76 million.

For IFC, the private sector investment arm of the World Bank Group, this is the second investment in the healthcare space this year. Last month, it invested $100 million in Fortis Healthcare Ltd and previously invested in Fortis’ diagnostics chain subsidiary SRL besides the flagship holding company for the financial services business Religare Enterprises.

Other large size investments in the sector include Manipal Health Enterprises raising $180 million from India Value Fund and Quality Care India raising $110 million from Advent International, among others. PE deals in the healthcare space hit an all-time high in CY2012, bucking the overall trend in the Indian private equity funding landscape.