Global Infrastructure: Trend Monitor

Indian Healthcare Edition: Outlook 20092013

ADVISORY

The Global Infrastructure: Trend Monitor is a series of publications allowing infrastructure investments to be compared across geographies. In this third edition, we analyze the medium-term expenditure on healthcare infrastructure across India. Our aim is to help improve the quality of debate in identifying the geographically attractive markets in Indias healthcare infrastructure.

ii Global Infrastructure: Trend Monitor Indian Healthcare Edition

Foreword

India saw rapid economic growth from 2003 to the start of the global economic slowdown in 2008. Among the largest economies in the world, its growth rate was second only to that of China. However, few would disagree that Indias past expenditure on infrastructure has fallen short of demand and, as a result, it may be constraining current and future economic growth. With a population of over a billion, the coordination and strategic choices concerning expenditures on healthcare infrastructures are of vital importance. These are especially challenging given the complex migration patterns typically seen within emerging economies. It remains to be seen how the policies currently in place will shape the Indian healthcare infrastructure market in the future. Private healthcare capacity in India is already significant. Given the anticipated incentives to be offered by the government, including the use of user fee financed provision and the opportunities for Public Private Partnerships (PPP), we believe that the private sector market will attract further foreign investment. This third edition of the Global Infrastructure: Trend Monitor presents forecasts for current and future healthcare infrastructure expenditure across India. By this, we aim to help improve the quality of the debate on the size and geographic location of opportunities in India. We hope you enjoy this publication and find our commentary on this exciting market informative.

Pradip Kanakia
Head of Markets KPMG in India

Kai Rintala
Head of Infrastructure Intelligence KPMG in the UK

2009 KPMG International. KPMG International provides no client services and is a Swiss cooperative with which the independent member firms of the KPMG network are affiliated. All rights reserved. 20866NSS

Global Infrastructure: Trend Monitor Indian Healthcare Edition iii

Contents
1. 2. 3. 4. 5. 6. 7 . Foreword Key findings Important notes Model outputs Insight Method Appendix

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1 Global Infrastructure: Trend Monitor Indian Healthcare Edition

Key Findings
Insights The Indian healthcare industry is estimated to double in value by 2012 and more than quadruple by 20171. The main factors propelling this growth are rising income levels, changing demographics and illness profiles, with a shift from chronic to lifestyle diseases. This is likely to result in considerable infrastructure challenges and opportunities. We believe there is growing appreciation for the role private involvement may have in meeting public demand, and government are looking into the use of PPP models to help improve infrastructure and healthcare provision. The government is also exploring setting up state funded healthcare insurance schemes to support healthcare delivery for the poorer sections of the population. For investment to be effective, the provision of healthcare infrastructure and insurance should be strategically coordinated. Unlike in developed markets, where there is a focus on generating specialized healthcare facilities and innovations to drive improvements in health services, the Indian healthcare delivery model (including use of PPP) has to date only had success in the provision of more healthcare services in relatively small segments. One of the major challenges remains the need to develop scalable and sustainable healthcare delivery models to deal with Indias diversity and changing socioeconomic population profiles. The major innovation in Indian healthcare delivery models should be focused on developing and delivering low cost, affordable, basic healthcare services. Model Outputs Based on the outputs of our econometric model expenditure on healthcare infrastructure across the Indian states is projected to grow by an average of 5.8 percent per annum between 2009 and 2013, taking the total expenditure in 2013 to US$14.2 billion. Of the 32 states considered, the six states of Maharashtra, Rajasthan, West Bengal, Uttar Pradesh, Tamil Nadu and Andra Pradesh are forecast to represent approximately 50 percent of the expenditures for the 2009-2013 period. Of the larger states, expenditure on healthcare infrastructure is expected to grow the fastest in Kerala, Rajasthan, and West Bengal.
1 KPMG/Confederation of Indian Industry (2008) Health Insurance Inc.: The Road Ahead 2009 KPMG International. KPMG International provides no client services and is a Swiss cooperative with which the independent member firms of the KPMG network are affiliated. All rights reserved. 20866NSS

Global Infrastructure: Trend Monitor Indian Healthcare Edition 2

Important Notes
Notes 1) This publication distinguishes between model output-oriented commentary, which is based on the data collated from stated sources, and insight-oriented commentary, which is based on the views among KPMG firms professionals. The limitation of the former is that it does not attempt to capture market developments, new initiatives or shifts in policy. 2) The 2009-2013 data are modeled using the latest figures available at the time of writing. 3) All figures in this publication are in 2006 U.S. dollars based on exchange rates as of June 1 to facilitate direct comparisons and they represent all investment, by both public and private sector, in healthcare infrastructure which may include activities such as medical research, drug production or primary care services. 4) Annual growth rates over the period 2009-2013 are in real terms, i.e. they exclude the impact of inflation. Objective The aim of the Trend Monitor is to help stimulate informed debate of global infrastructure opportunities by providing observations and on-the-ground market insight underpinned by econometric modeling. Existing publications tend to focus on the short-term, identifying opportunities that are about to come to market, or the long-term, estimating the size of the required investment over decades to come. The Trend Monitor is purposefully positioned between the two in order to present a medium-term (2009- 2013) view of market potential. Our analysis builds on what we believe to be the most consistent data sources, and relies on only a small number of explicit assumptions. The publication also leverages the local specialization of professionals in KPMGs Indian member firm to seek to present a better informed view of the future. Definitions and classifications Size and prospects of individual states: Large and growing fast states where 2006 expenditure is above $500m and investment is expected to expand relatively rapidly, with average projected annual growth rates of over 6.5 percent in the period 2009-2013. Large and growing slowly states where 2006 expenditure is above $500m though investment is expected to expand relatively slowly, with average projected annual growth rates below 6.5 percent in the period 2009-2013. Small and growing fast states where 2006 expenditure is below $500m while investment is expected to expand relatively rapidly, with average projected annual growth rates of more than 6.5 percent in the period 2009-2013. Small and growing slowly states where 2006 expenditure is below $500m and investment is expected to expand relatively slowly, with average projected annual growth rates below 6.5 percent in the period 2009-2013. The term state is used throughout this publication as a reference to various areas of the respective federal structures of India. The Trend Monitor is analyzed with all 28 states and four of the seven union territories of India as data for the least populous union territories of Dadra and Nagar Haveli; Daman and Diu; and Lakshadweep were unavailable. Method A detailed overview of the research and analysis method applied can be found in the Method section of this report.

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3 Global Infrastructure: Trend Monitor Indian Healthcare Edition

India: expenditure on healthcare infrastructure in 2006 by state (percentage of total)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. Maharashtra Rajasthan Uttar Pradesh West Bengal Tamil Nadu Andhra Pradesh Kerala Gujarat Karnataka Haryana Delhi Madhya Pradesh Punjab Himachal Pradesh Bihar Orissa Assam Jharkhand Jammu and Kashmir Uttranchal Chattisgarh Manipur Tripura Nagaland Chandigarh Arunachal Pradesh Meghalaya Goa Andaman and Nicobar Islands 30. Mizoram 31. Sikkim 32. Puducherry 12.0% 8.2% 8.1% 7.9% 7.5% 7.0% 6.7% 6.2% 5.2% 4.8% 4.3% 3.5% 2.7% 2.2% 1.8% 1.6% 1.6% 1.6% 1.6% 1.2% 0.9% 0.8% 0.5% 0.4% 0.3% 0.3% 0.3% 0.2% 0.2% 0.2% 0.1% 0.1%

19 14 20 26 11 31 3 15 12 21 16 1 32 18 27 4 23 30 17 24 22

25 13 10 2

6 28 9

29 5 7

Key: Large and growing fast

Large and growing slowly
Small and growing fast
Small and growing slowly

Analysis: KPMG International, refer to Method section of this report

2009 KPMG International. KPMG International provides no client services and is a Swiss cooperative with which the independent member firms of the KPMG network are affiliated. All rights reserved. 20866NSS

Global Infrastructure: Trend Monitor Indian Healthcare Edition 4

India: expenditure on healthcare infrastructure in 2006 (US$ million)

India: expenditure on healthcare infrastructure in 2006 (US$ million)

1,400 1,200 1,000 800
US$m

600 400 200 0

Jammu and Kashmir Bihar Himachal Pradesh Andaman and Nicobar Islands Madhya Pradesh Andhra Pradesh Arunachal Pradesh Uttar Pradesh
Uttar Pradesh

Analysis: KPMG International, refer to Method section of this report

India: expenditure on healthcare infrastructure in 2006 per person (US$ )

India: annual expenditure on healthcare infrastructure in 2006 per person (US$)

40 35 30 25
US$

20 15 10 5 0

Andaman and Nicobar Islands

Haryana

Karnataka

Maharashtra

Meghalaya

Puducherry

Sikkim

Orissa

Goa

Kerala

Andhra Pradesh

Arunachal Pradesh

Chandigarh

Chattisgarh

Himachal Pradesh

Jharkhand

Madhya Pradesh

Nagaland

Rajasthan

Jammu and Kashmir

Tamil Nadu

Gujarat

Manipur

Mizoram

Tripura

Punjab

Bihar

Delhi

Uttranchal

Analysis: KPMG International, refer to Method section of this report

2009 KPMG International. KPMG International provides no client services and is a Swiss cooperative with which the independent member firms of the KPMG network are affiliated. All rights reserved. 20866NSS

West Bengal

Assam

West Bengal

Mizoram

Assam

Sikkim

Tamil Nadu

Jharkhand

Chattisgarh

Maharashtra

Chandigarh

Meghalaya

Puducherry

Uttranchal

Manipur

Gujarat

Delhi

Rajasthan

Nagaland

Punjab

Orissa

Kerala

Karnataka

Haryana

Tripura

Goa

5 Global Infrastructure: Trend Monitor Indian Healthcare Edition

India: forecast average annual growth rate in healthcare infrastructure expenditure 2009-2013 (percent)

India: forecast average annual growth rate in healthcare infrastructure expenditure 2009- 2013 (percent)
9% 8% 7% 6% 5% 4% 3% 2% 1% 0%
Jammu and Kashmir Bihar Andaman and Nicobar Islands Himachal Pradesh Andhra Pradesh Arunachal Pradesh Madhya Pradesh Uttar Pradesh West Bengal Assam Mizoram Sikkim Tamil Nadu Gujarat Manipur Delhi Chattisgarh Chandigarh Jharkhand Maharashtra Meghalaya Puducherry Uttranchal Rajasthan Nagaland Haryana Karnataka Punjab Goa Kerala Orissa Tripura

Analysis: KPMG International, refer to Method section of this report

India: forecast cumulative expenditure on healthcare infrastructure in 20092013 (US$ billion) India: forecast cumulative expenditure on healthcare infrastructure

in 20092013 (US$ billion)

8 7 6 5 US$bn 4 3 2 1 0

Jammu and Kashmir

Bihar

Andaman and Nicobar Islands

Himachal Pradesh

Andhra Pradesh

Arunachal Pradesh

Madhya Pradesh

Analysis: KPMG International, refer to Method section of this report

2009 KPMG International. KPMG International provides no client services and is a Swiss cooperative with which the independent member firms of the KPMG network are affiliated. All rights reserved. 20866NSS

Uttar Pradesh

West Bengal

Assam

Mizoram

Sikkim

Tamil Nadu

Gujarat

Manipur

Delhi

Chattisgarh

Chandigarh

Jharkhand

Maharashtra

Meghalaya

Puducherry

Uttranchal

Punjab

Rajasthan

Nagaland

Orissa

Kerala

Karnataka

Haryana

Tripura

Goa

Global Infrastructure: Trend Monitor Indian Healthcare Edition 6

India: forecast cumulative expenditure on healthcare infrastructure in 20092013in person (US$) India: forecast cumulative expenditure on healthcare infrastructure per 20092013 per person (US$)
300

250

200

US$

150

100

50

0 Andaman and Nicobar Islands Jammu and Kashmir Andhra Pradesh Arunachal Pradesh Himachal Pradesh Madhya Pradesh Uttar Pradesh West Bengal Meghalaya Delhi Maharashtra Puducherry Chandigarh Chattisgarh Jharkhand Tamil Nadu Uttranchal Assam Mizoram Haryana Karnataka Sikkim Goa Kerala Orissa Gujarat Manipur Nagaland Rajasthan Tripura Bihar Punjab

India: ratio forecast cumulative expenditure on healthcare 2009 2013 India: ratio ofof forecast cumulative expenditure on healthcare to the forecast average for all state 2009 2013 to the forecast average for all states
3.66 2.66

4.0 3.5 3.0 2.5

2.62

2.39

2.32

2.31

2.20

Ratio

1.69

1.59

2.0 1.5 1.0 0.5 0.0 Maharashtra Rajasthan

1.91

1.33

1.10

0.85

0.78

0.57

0.54

0.48

0.48

0.48

0.41

0.35

0.33

0.20

0.14

0.13

0.10

0.08

0.07

0.06

0.05

0.05

West Bengal

Mizoram

Manipur

Assam

Uttranchal

Sikkim

Delhi

Orissa

Uttar Pradesh

Jammu and Kashmir

Madhya Pradesh

Andhra Pradesh

Himachal Pradesh

Chandigarh

Arunachal Pradesh

Analysis: KPMG International, refer to Method section of this report

2009 KPMG International. KPMG International provides no client services and is a Swiss cooperative with which the independent member firms of the KPMG network are affiliated. All rights reserved. 20866NSS

Andaman and Nicobar Islands

Puducherry

Chattisgarh

Tamil Nadu

Meghalaya

Bihar

Tripura

Punjab

Jharkhand

Gujarat

Kerala

Haryana

Karnataka

Nagaland

Goa

0.03

7 Global Infrastructure: Trend Monitor Indian Healthcare Edition

Model Output
Total healthcare infrastructure expenditure for 2013 is predicted to reach $14.2 billion, a near 50 percent increase on the 2006 total. Of the 32 states, the six states of Maharashtra, Rajasthan, West Bengal, Uttar Pradesh, Tamil Nadu and Andra Pradesh represent just over 50 percent of the total expenditure in 2006. Maharashtra alone spent around 12 percent of the total expenditure at approximately US$1.1 billion, yet the state accommodates fewer than 10 percent of the overall population. Twelve states spent less than US$100million each in 2006, together representing less than 4.5 percent of total national expenditure and 3.6 percent of the population. Among these the smallest expenditure states were Goa, Andaman and Nicobar Islands, Mizoram, Sikkim, and Puducherry. The state of Uttar Pradesh was only the third largest in terms of absolute expenditure in 2006 but hosts over 16 percent of the population. The states of Himachal Pradesh, Manipur and Andaman and Nicobar Islands were the only states to spend over US$30 per capita on healthcare infrastructure in 2006, with about two thirds of the remaining states spending less than US$15, including the 6 largest absolute expenditure states. The state with the highest per capita healthcare expenditure for 2006 is the Andaman and Nicobar Islands at $36, while the state with lowest is Bihar at just $1.90, revealing uneven spending on healthcare infrastructure. The states of Manipur and Nagaland are expected to grow the fastest through the medium term, each projected to have average annual growth rates over 8 percent against an overall national rate of 5.8 percent. Of the larger states, expenditure on healthcare infrastructure is expected to grow the fastest in Rajasthan and West Bengal. Maharashtra maintains its dominance as the state with the highest cumulative healthcare infrastructure expenditure over the forecast period, with a projected spend at over US$7 .3 billion. Only the two other states of Rajasthan and West Bengal are projected to witness cumulative healthcare expenditures of over US$5 billion from 2009 to 2013.

2009 KPMG International. KPMG International provides no client services and is a Swiss cooperative with which the independent member firms of the KPMG network are affiliated. All rights reserved. 20866NSS

Global Infrastructure: Trend Monitor Indian Healthcare Edition 8

Insight
Against a world average of around four hospital beds per 1000 population, India lags behind at just over 0.72. This is a clear indication of the insufficiency of healthcare infrastructure in India. The Indian healthcare industry is estimated to double in value by 2012 and more than quadruple by 2017 The . main factors propelling this growth are rising income levels, changing demographics and illness profiles with a shift from chronic to lifestyle diseases. This is likely to result in considerable infrastructure challenges and opportunities. Indian healthcare infrastructure over the last decade has not kept pace with growth in population3. The available capacity has increased but not in line with rising demand. This is likely to be in part due to lack of capacity building in semi urban and rural areas. The Indian healthcare system is controlled by respective state authorities, presenting an opportunity to improve responsiveness to healthcare needs at a more local level. Our analysis suggests that there is uneven focus on healthcare infrastructure in India. The variety of organizational structures and processes in healthcare delivery may result in greater inequalities between geographical areas. Government has a growing agenda to deal with the issues of urban healthcare infrastructure as rural to urban migration has significantly increased demand for these services. The healthcare sector in India is undergoing considerable reform prompted by the continuing phase of rapid economic growth. Emerging markets, such as diagnostic chains and medical device manufacturers, are attracting increasing amounts of investment. We believe there is a growing appreciation for the role private involvement may have in meeting public demand and government is piloting the use of PPP models to help improve infrastructure and healthcare provision.

2 KPMG/Confederation of Indian Industry (2008) Health Insurance Inc.: The Road Ahead 3 ibid 2009 KPMG International. KPMG International provides no client services and is a Swiss cooperative with which the independent member firms of the KPMG network are affiliated. All rights reserved. 20866NSS

9 Global Infrastructure: Trend Monitor Indian Healthcare Edition

Method
This publication draws on data from sources named below and insights from professionals in KPMGs Indian member firm, in order to present both model outputs and commentary on the Indian healthcare infrastructure market. Information on market size has not been readily available and as such it is produced using an econometric model, utilizing data sourced externally and a limited number of explicit assumptions. The dataset4 of our econometric model is presented in the Appendix. Our forecasts of the future size of the healthcare infrastructure markets across India encompass expenditure at different levels of government as well as the private sector on building and maintaining healthcare infrastructure for uses such as medical research, drug production or primary care services. Our modeling relies on past trends to project the future and does not attempt to capture the undercurrents of political risk, financial and other market fluctuations, population growth, or sudden spikes in infrastructure activity. The process of data gathering and presentation was as follows: Construction output data (2000-2006) for 32 Indian states was obtained from Indian National Income Accounts at factor cost and converted to market prices. The construction output data was converted to US$ as at June 1, 2000 exchanged rate and rebased in 2006 prices using a price index from U.S. Bureau of Economic Analysis. Construction output for each state was multiplied by 0.66 to arrive at healthcare construction output (including new build as well as repair and maintenance). This ratio is based on the average long-run ratio in UK Construction Statistics Annual (UK Department of Business Enterprise and Regulatory Reform). Healthcare construction output was multiplied by 3.6 to include the expenditure on design and professional services, land, plant and materials. This ratio was derived from the UK Construction Statistics Annual and UK Quarterly Capital Expenditure Inquiry (UK Office of National Statistics). The forward-looking expenditures up to 2013 were estimated by linear extension of the line of best fit for the historical data. The per capita expenditures where created using 2006 population sizes (www.india.gov.in) except for Jammu and Kashmir (2005), Nagaland (1997), West Bengal (2004), and Puducherry (undated) due to availability of data. The population sizes were considered to remain unchanged in the forecast. It should be noted that the numbers for India are not directly comparable with those presented in other editions of Global Infrastructure: Trend Monitor as different sources and methods have been used in producing them.

4 The datasets have been produced in collaboration with Dr Stephen Gruneberg.

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Global Infrastructure: Trend Monitor Indian Healthcare Edition 10

Appendix

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11 Global Infrastructure: Trend Monitor Indian Healthcare Edition

Appendix Historical and forecast future healthcare infrastructure expenditure in India (in US$ millions at 2006 prices) State Andaman and Nicobar Islands Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chattisgarh Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Puducherry Punjab Rajasthan Sikkim Tamil Nadu Tripura Uttar Pradesh Uttranchal West Bengal 2000
7 402 17 109 143 11 37 248 10 386 222 130 69 105 297 370 207 771 24 20 7 10 113 11 164 416 5 481 20 503 58 370

2001
7 408 19 114 144 12 32 287 10 380 273 131 76 100 307 339 230 631 32 21 7 13 125 11 175 386 6 506 27 530 61 389

2002 2003 2004 2005 2006 2007 2008 2009

9 447 25 132 140 23 43 280 11 383 279 142 90 114 350 324 239 678 39 22 9 17 125 11 188 434 8 529 33 554 82 424 10 493 22 119 160 18 46 314 12 432 320 161 102 112 380 397 248 748 44 22 11 19 133 12 196 470 9 572 37 558 88 455 13 547 24 146 145 22 54 334 15 474 342 161 105 127 405 483 268 815 56 24 12 24 139 12 205 590 11 611 43 613 93 554 13 603 29 148 173 31 76 365 16 532 392 184 131 141 443 558 307 1,018 71 25 13 30 156 12 230 569 12 666 45 672 99 608 15 672 30 154 171 33 90 408 19 588 455 210 150 152 499 637 336 1,149 79 26 14 36 154 12 260 781 14 714 51 771 114 760 17 759 33 160 217 40 108 443 21 633 505 278 169 161 550 695 365 1,195 100 27 16 42 165 12 288 866 16 783 62 805 131 819 18 774 35 169 201 42 109 455 22 651 523 258 176 167 567 720 375 1,232 103 28 17 44 171 13 289 867 17 801 64 825 136 850 20 825 37 176 210 46 120 482 23 689 562 277 190 176 603 774 397 1,311 113 29 19 48 178 13 306 934 19 844 70 869 146 917

2010
21 877 39 183 218 50 130 509 25 728 600 295 204 185 640 828 419 1,390 123 30 20 53 185 13 323 1,001 20 887 75 914 156 985

2011
23 928 41 191 227 54 141 535 27 767 639 314 218 194 676 882 441 1,469 134 31 21 57 192 13 340 1,068 22 929 80 958 166 1,052

2012
24 980 44 198 236 58 152 562 28 806 678 332 233 203 712 936 464 1,548 144 32 23 62 199 13 357 1,135 23 972 86 1,002 176 1,119

2013
26 1,031 46 206 245 62 162 589 30 844 716 351 247 212 748 991 486 1,627 155 33 24 66 207 14 374 1,203 25 1,015 91 1,047 186 1,187

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Publication number: 20866NSS
Publication date: July 2009

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