NARAYANA HRUDAL

BET 620 FINAL REPORT

[Date]

roy
[company name]
NARAYANA
HRUDALAYA
BET 620 FINAL REPORT

MARCH 31, 2020

UNIVERSITY OF WATERLOO
Contents
Introduction...........................................................................................................................................2
Company History..................................................................................................................................3
Mission..................................................................................................................................................4

Product and Service................................................................................................................. 4

Theory of Change and Logic Model........................................................................................6
Business Model......................................................................................................................................7
Competitive Landscape.........................................................................................................................8
Legal Structure.......................................................................................................................................9

Future SROI.............................................................................................................................9

Recommendations................................................................................................................................11
References...........................................................................................................................................14
Introduction

More than three million Indians need cardiac care each year. Only a miniscule two percent, or
roughly 60,000 of those procedures are done in a given year. (Deloitte, 2018) What impedes
the remaining 98% of the other who are suffering from getting treatment? In a country where
the gross domestic product per capita is roughly $1,900, cardiac surgery and other health care
is cost prohibitive for a vast majority of the Indian populace. As a result, the misfortune poor
lack access to proper medical care and die.

While the Indian healthcare sector has improved significantly over the last few decades, it is
still way below international standards. The improvements have been marked with inequities
based on gender, rural vs. urban, and more conspicuously social status still remain. As a
result of poor healthcare infrastructure, 80% of all out-patient and 60% of all in-patient care
is handled by the private sector which accounts for 68% of all hospitals in the country
(Deloitte, 2018). Healthcare financing also remains a key challenge. In 2010, 5.0% of the
GDP was spent on healthcare, less than any other BRIC nation, out of which the government
spend was a meagre 0.9%. Further, 74% of total health spending in India was out-of-pocket
(OOP), with only 14% of the population being covered by some form of health insurance.
(WHO, 2018)

There is another extremely worrying fact is that cardiovascular diseases account for around
one-fourth of all deaths in India. 24.8% of these deaths occur in people between the ages 25
and 69. This implies that India is losing its productive workforce to cardiac diseases. Various
research articles suggest that between 2008 and 2018, India is projected to have lost USD
236.6 billion because of heart disease, stroke, and diabetes, eroding 1% off the GDP. This
death toll translates into a loss of 9.2 million years of productive life, almost six times the
figure for US. The Indian government spends only 1.1% of its gross domestic product on
health care. Health insurance still is under-penetrated in India. Healthcare is one of the major
causes of bankruptcy and an estimated 20 million people in India fall below the poverty line
every year due to health-related expenses.

The quality of care is abysmally low at public hospitals. As a result, even the poor prefer to
sell off their houses to be able to access quality care from private hospitals, in case a need
arises.

With the vision to provide high quality and affordable healthcare to all, Dr. Devi Shetty set
up Narayana Hrudalaya in 2001. He mastered the art of ‘frugal innovation” and developed a
“focused factory” where a narrow range of services are offered with excellence, operational
costs are minimized, and a high-quality brand drives demand. No wonder, he is also known
as the “the Henry Ford of healthcare.”

Formerly the Narayana Hrudayalaya Hospital Group, Narayan Health (NH) is a private group
of hospitals founded in 2001 by Dr. Devi Shetty. It provides low-cost healthcare to an
economically diverse set of patients in India. Over the years NH has expanded out from its
initial focus on cardiac services and now handles cases in neurology, pediatrics, nephrology,
urology, and gynecology. In 2013, the group had 24 hospitals (including four major health
centers called “health cities” in Bangalore, Ahmedabad, Jaipur, and Kolkata), comprised of
97 operating theaters and 6,400 beds, and serving over 80,000 patients per month. NH
provides more than 10 percent of the cardiac services in India, with each hospital performing
about eight times more surgeries per day than India’s average.
Why Narayana Health?

In a hugely capitalistic healthcare industry, NH has established itself as a company that

focuses on its core mission of providing excellent healthcare to all regardless of their ability
to pay. It has positioned itself uniquely as a hospital for the poor, that also takes care of the
rich. This bold positioning has been able to attract investors who acknowledge that there is a
huge gap in the affordability and access to quality healthcare in the emerging economies. The
economies of scale present a huge opportunity to address and tackle grave issues like
healthcare in an innovative manner. Our vision at the MBET Impact Fund is to support
companies that are relentlessly trying to break the norms and create new models of
excellence. Thus, NH fits well in our investment framework.

Let us look at the key drivers that support the investment rationale in NH.

1. Indian Healthcare Industry: A Huge Opportunity in an Underpenetrated Market

[1]

 Out-of-pocket expenditure on
healthcare is ~61% - highest in the
world

 Shortage of doctors in rural areas

(3% specialist physicians cater to
rural areas which comprises >70%
of population

 Inadequate insurance coverage for

the larger population

 Underpenetrated insurance market

 Large unaddressed market with 7

beds per 10,000 people

 Rising income levels and life

expectancy to push demand for
healthcare services
 [1] Source: Crisil, WHO Estimates, WHO-
World Health Statistics, 2014, IRDA

2. Rising Prevalence of Non-Communicable Diseases [2]

 Shifting disease profile in India

 Rise in the number of chronic illnesses

such as cardiovascular, diabetes and
cancer

 More than 60 % deaths due to Non-

Communicable Diseases (NCD) is over
60%

 More than 25% deaths caused due to

heart related diseases

[2] Source: NCAER, WHO Estimates

The Narayana Opportunity

1. Unique Business Model Tailored to the Dynamics of Industry [3]

  Widespread network in India

 47 Healthcare Facilities

 6,579 Capacity Beds

 5,770 Operational Beds

 $3.2 million Average Effective

Capital Cost per Operational
Bed

 30+ Specialities

 17,261 Full-time Employees

 3,682 doctors

[3] Source: NH Annual Report, 2019

2. Focus on building hub and spoke model [4]

 Building hospitals in tier 2 cities

 NH creates regional clusters across various states in India thereby creating profitable
Regional Healthcare “Ecosystems”

[
[4]Source: NH Annual Report, 2019
ARPOB: Average Revenue per Operational Bed
EBITDAR: Earnings before Income Tax, Depreciation and Amortization

3. Unique “Asset-right” model of Capital Expenditure [5]

 Highly Efficient Model

of Capital Deployment

 Low ownership of
fixed assets

 Unique model of
offering managed
services to existing
hospitals looking at
creating scale and
operational efficiencies

[5] Source: EY Indian Healthcare Report 2018, NH Annual Report, 2019

4. Established brand in Cardiac and Renal Care [6]

 Multispecialty Hospital with more than

83 specialties

 Strong Presence in Cardiac and Renal

care

 41% of inpatient revenue from

cardiology and cardiac surgery and
15% from renal sciences in FY19

 Six core specialties account for ~82%

of revenue in FY 19

5. In line with our investment objective: Creating huge social impact by delivering
quality healthcare at affordable prices [6]
  Unique model leveraging Economies
of scale

 Process Innovation helps in creating

cost efficiencies

 Strict standardization of processes and

procurement practices

 Extensive use of cloud based ERP

system and network of telemedicine
centres

6. Recognised Brand Name Associated with Excellence [6]

 Multiple international

 20+ Awards and Accreditations

received since 2010

 Awards from marquee institutions

such as WHO, Financial Times,
BCG and Frost & Sullivan

 Strong brand equity and goodwill

among peers

[6] Source: HBR, NH Annual Report, 2019

7. Strong Financial Growth [7]

 NH revenues growing at a CAGR of

10%

 Strong performance track record

 Revenues grew at a CAGR of 20.4%

from FY15- FY19

 Successful launch of new hospitals

 Growth through partnerships and six

acquisitions.

 FY20 revenue growth at 12.4%

[7] Source: Pitchbook, ICICI Securities, NH Annual Report, 2019

Key Financial Performance Indicators [8]

 Revenue: $446 miilion

 Profit Margin: 13.9%
 EBITDAR: $62.1 miilion
 Strong ROI growth since inception

 Sustained revenue margins on each

operational bed

 Tight control on costs helps to

maintain cost efficiencies

 Doctors salaries at 21% visavis

industry average of 33%

 FY 20 operational costs were down

by 2% as compared to FY19

[8] Source: Statista, NH Annual Report, 2019

 Company’s History

“Like we get oxygen, air and water, health care should become available to everyone on this
planet naturally. And that can be done.”
Dr. Devi Shetty
I had a chance visit to Dr. Devi Shetty’s Narayan Hrudalaya in 2004. I was studying in Pune and
was in Bangalore, India for an internship. One of my closest friend’s Dad (a rich Indian
businessman) had suffered a massive heart-attack. Despite the presence of big hospitals in Pune,
he was immediately flown to be brought in Dr Shetty’s care. It was my first ever visit to a big
hospital and I was impressed to see that rich and poor flocked the hospital alike. Amused, I
researched and found out that Dr. Shetty was a pioneer in making healthcare affordable in India.
Years later, I had the fortune of working with Dr. Shetty and the company closely when it went
public. His surgical skills and his commitment to never turn away the poor is highly admirable.
But perhaps even more impressive is his entrepreneurship and his vision of making healthcare
affordable for everybody.

Narayana Hrudayalaya (known today as Narayana Health) was founded in 2000 and has since
revolutionized health care in India. The company has grown from a single 225-bed hospital to 49
health care facilities and 5,576 operational beds. It was set up as a cardiac care center and has
since gone on to treat multiple diseases. Currently, Narayana Health Group of Hospitals manages
23 hospitals across 14 cities. After 15 years in business, in December 2015, NH went public and
raised $952 million. It is also recreating its model at Cayman Islands.
Dr. Shetty pioneered the concept of a ‘Health City’, a 2000-5000 bed conglomeration of
multiple super- specialty hospitals within a single campus cross-utilizing their resources to
gain scale and drive down costs across all segments. The economies of scale achieved through
this health city enable the Group to provide affordable healthcare to thousands. In 2003, he
also designed the world’s cheapest comprehensive insurance scheme, Yeshasvini Co-operative
Farmer’s Health Care Scheme, which provides cover to poor farmers across 805 surgical
procedures for just 25 cents every month.

Mission

“Japanese companies reinvented the process of making cars. That's what we're doing in health
care. What health care needs is process innovation, not product innovation.”
Dr. Devi Prasad Shetty

NH’s mission is “to deliver high quality, affordable healthcare services to the broader population
in India. Its core values are represented by the acronym "iCare", which encompasses innovation
and efficiency, Compassionate care, Accountability, Respect for all, and Excellence as a culture.
Simultaneously, NH seeks to generate a strong financial performance and deliver long-term
value to its shareholders through its unique business strategy.

Product and Service

NH aims to provide the masses with high quality affordable access to primary, secondary and tertiary
care. The service offerings are as follows:

1. Transparent, and packaged treatment offerings

2. Critical Procedures such as heart transplants, open heart surgeries and kidney transplants
3. Consultation on 83 specialty sciences
4. Diagnostic Services
5. Medical Consumables & Drugs
6. Operative and post-operative care requirements of patients
7. Telemedicine
 Theory of Change and Logic Model

The mission of NH is to provide affordable healthcare to all. Dr. Shetty is a cardiac surgeon
and he revolutionized the Indian healthcare by “walmartizing” it. He achieved this by
building economies of scale and innovating ways to minimize operational costs. In doing so,
he created small islands of excellence through the entire value chain. NH’s core value is to
provide high-quality, affordable cardiac care to everyone, regardless of ability to pay.

Long Term Establishing a set up that provides affordable healthcare to all, No poor patient ever denied
Outcome care

Affordable treatment for all, Low Prices, High Quality healthcare, Motivated Employees
Intermediate
Standardization of healthcare
Outcome

Affordable treatment for all, Low Prices, High Quality healthcare, Motivated Employees
Short Term
Standardization of healthcare
Outcome

Affordable treatment for all, Low Prices, High Quality healthcare, Motivated Employees
Outputs
Standardization of healthcare

Activities Conduct surgeries, Outpatient Consulting, Training staff to achieve operational excellence,
Outreach programs, Negotiations with suppliers

Inputs Staff, Qualified Doctors, Money, Infrastructure, Paying Customers,

Business Model: Lean Model to Scale Services

“When a corporate hospital is developed, they tell the employees, ‘This is a hospital for the rich,
but we take care of the poor, also. But this is a hospital for the poor, and we also take care of the
rich. That is why we exist.”
- Dr. Devi Shetty
NH operates a blended model of affordable yet high-quality healthcare services. NH has been
successful at combining innovative technology and a highly efficient delivery system that
enable NH to minimize costs substantially and enhance productivity. As a result, NH has both
increased its treatment capacity and the setting up of health cities has helped it to expand the
number of specialty services offered. Every year more than half of its patients receive free or
subsidized inpatient care, with an average discount of 15 percent. This is accomplished
through philanthropy and a cross-subsidy model, in which higher-income patients pay more
for non-clinical amenities, such as private recovery rooms and post-operative care packages.
The quality of healthcare has attracted both rich and poor patients alike. It is a sustainable
business model as it successfully attracts numerous patients who can pay full price.

Further, NH has established itself as a “frugal factory” in the healthcare industry. NH

leverages its brand equity to offer its managed services on a fees-based model. The medical
treatments are offered using a fee-for-service model “in which direct payment is made by the
patient or health insurance scheme. Of the total revenue, 80% is generated from inpatient
procedures, 10% from outpatient procedures, and 10% from remote consultants and
diagnosis. In addition, the strong philanthropic ideals and commitment of Narayana generate
donations that support free or heavily subsidized treatments to patients from disadvantaged
populations.”

Keeping costs low for the poor is one of the key elements of NH. Dr. Shetty’s visionary
approach which has allowed NH to work closely with the government and other partners to
create low-cost insurance schemes such as Arogya Raksha (in the private sector) and
Yeshaswini (in the cooperative sector). This allowed the poor to pay access state of the art
healthcare at extremely low premiums that were only accessible to the wealthy. The NH
business model also included philanthropy. It aimed to motivate people through its social
mission and influence others to underwrite the cost of surgeries by donating to the foundation
[WHO, India]. NH achieved this goal successfully as both patients and non-patients, through
word-of-mouth, poured in close to US$1 million every month. “We treat about 3.3 percent of
our patients without accepting any fees while ten percent of cases receive substantial
support,” said Lakshmi Mani, the person responsible for running NH’s philanthropy wing.
This did not include the lower fees that the staff determined for poor patients based on their
needs.

In the financial year that ended in March 2005, NH established to the world that a social
enterprise can be economically sustainable by posting 20 % in profits. This was in contrast
with 16 % profits made by one of the biggest corporate hospitals in India. The business model
was underpinned by a frugal factory approach via process innovation and cost minimization.
This is made possible through a cross-subsidy model in which patients can choose different
levels of infrastructure according to affordability, but the quality and uniformity of the
clinical services is strictly maintained.

Why is the business model successful?

The success of the model is achieved through several steps that allow NH to create a low
cost, high quality standardized experience for everyone. These include:
 Leveraging Economies of Scale
NH has been a pioneer in creating economies of scale using process innovation. This
is one of the major reasons for NH to be able to cross subsidize the costs of their
patients (approximately 80 percent -plus receive some form of discount or other). NH
also receives a huge influx of international medical tourists who benefit from the price
arbitrage. Higher number of specialized doctors allows NH to work on an increased
number of shifts. Hence, the operation theaters are utilized for longer hours
contributing to high volumes.

 Using Assembly Line Concepts for Surgery

NH performs 8 times more cardiac procedures everyday as compared to other Indian
hospitals. It also conducts 500 blood tests on a machine everyday vis-à-vis other
comparable hospitals which run 2 tests on a machine. It has also brought down the
 turnaround time of operation theaters to 15 minutes from a global average of 30
minutes. A production-line approach to surgery, combined with task-shifting among
staff allows each surgeon to perform 400 to 600 procedures annually, compared with
100 to 200 in the U.S. [WHO, India]. All staff members work on in their areas of core:
surgeons perform only the tasks they are uniquely qualified to do, while other
clinicians perform tasks such as preoperative preparation, patient education, and
charting. This enables many surgeries to be performed in a row, with surgeons
completing one procedure and quickly beginning the next on a fully prepped patient.
This high volume drives lower costs and better-quality outcomes, with surgeons
quickly gaining experience and mastery.

 Reducing the Average Length of Stay (ALOS)

NH, through its process optimization has brought down the ALOS from 5.3 days in
FY13 to 3.5 days in FY 20 [NH Annual Report, 2019]. This is a huge reduction of 34
% which enhances its ability to take on more patients. Protocols have been established
in both clinical and non-clinical activities such as patients’ reception, transfers, and
billings. There is a centralised procurement mechanism to buy medicines, surgical
tools and equipment. These set systems allow a quicker discharge time and reduced
operational costs.

 Cost Optimization
NH has re-engineered its whole strategy of design, materials, and use of medical
equipment to reduce the cost of ownership. It used generic drugs that are 80 % cheaper
than market rate. Doctors get a competitive fixed salary instead of a revenue sharing
model (senior doctors receive anywhere between 100,000-250,000 USD) and then
urged to increase the number of surgeries per day. This helps bring down the cost per
surgery.

 Technology As An Enabler
Use of information technology and data promote efficiency and standardization
throughout Narayana Health. A centralized cloud environment connects all the
hospitals, helping to streamline administrative tasks and enable performance
 monitoring. Profit-and-loss statements are reviewed on a daily basis to address capital
flow issues as they arise. Monthly reviews happen with unit heads and the CEO. NH
has a real-time patient-complaint resolution process that enables it to identify and
quickly correct performance issues. Infrastructure boasts of compact design, maximum
use of natural light, reduced entry spaces, fabricated structure and simple tiles.
Machines are taken on lease and payments made on use basis for reagents used to run
the machine. No long-term contracts are signed with the suppliers to maintain
bargaining power. Data analytics software is used to maintain minimum inventory.

 Partnerships
NH has major partnerships with the private and public sector organizations. It has
partnered with Biocon Foundation, a subsidiary of a major Indian pharmaceutical
company that sells generic drugs at a 20 to 30 percent cheaper price to NH.
Microinsurance schemes with the Government of Karnataka (Yeshasvini) and Tamil
Nadu etc., have helped many people from poor economic conditions to avail NH’s
services. NH also works on creating innovation led partnerships. For example, NH has
tied up with Texas Instruments. NH and Texas Instruments tied up to drive down the
cost of equipment such as X-Ray plates (the cost was brought down from 82000 USD
to 300 USD).

 Telemedicine

NH has partnered with Indian Satellite Research Organization (ISRO) to use modern
telecommunication technology to increase the access of cardiac health care to the poor in
rural areas. NH trained and placed doctors at these government and charity-run hospitals.
These hospitals were also equipped with beds, ECG machines, defibrillators, ECHO
machines and video conferencing equipment for telemedicine. Doctors at CCU referred
patients to NH. “ Narayana’s telemedicine network connects its 24 urban-based specialty
hospitals to 800 centers, extending its reach into Indian’s vast and impoverished
countryside at very little cost.” Telemedicine enables a hub-and-spoke system to
efficiently and economically serve patients seeking care, thereby lowering the out-of-
pocket expenses (lost wages during time away from work, the cost of travel, and room and
board) for the patients in rural areas.
All these steps have led NH to bring the average cost of open-heart surgery to less than
$2,000. The same procedure at a U.S. research hospital typically costs more than $100,000.
This razor-sharp emphasis on standardization of processes and relying on core competencies
translates into a final cost which is nearly 40 percent of other private hospitals.

Competitive Landscape

The below table illustrates how NH is positioned vis-à-vis other leading hospitals in India.
SJICR is a nonprofit hospital while Apollo and Max Healthcare are run by prominent business
houses in the country.

Narayana Apollo Max

Health SJICSR Hospitals Healthcare
Type
(Primary,
Secondary,
Tertiary) All Tertiary All All
"Health Cardiac Multi- Multi-
Positioning City" Care specialty specialty
Cardiac
Surgery Price
(USD) 2000 2000 4500-6000 4500-6000
Target General
audience Population Affluent Affluent Affluent
Key
competitive Affordable Affordable
advantage for all for all
Not
Profit Margin 14% Available 14% 12.50%
Return on
Capital Not
Employed 9.35% Available 10.25% 11%
 Tier 2 &
Geographical Tier 3 Rural Tier 1 & tier 2
Focus Cities Areas Tier 1 Cities Cities

NH is uniquely positioned to capture an underpenetrated healthcare market. It offers high quality

at affordable prices in comparison to some of the other leading tertiary care providers. Its peers
focus a lot on attracting international medical tourists. Narayana needs to ramp up its efforts to
grow this segment of high margin customers.

NH needs to continually create outreach programs to motivate the paying customers to avail
its facilities. This is critical for to fund its low paying customers and to expands its
operations. NH needs to expend efforts on creating a high word of mouth publicity to get a
larger share of the market. Its unique regional clusters put NH in an advantageous position to
get access to the larger masses.

Legal Structure

NH is a pioneer in creating a business model around Profitable Philanthropy. It operates as a

hybrid model with Narayan Health as the parent organisation and Karuna Trust and NH
Foundation as its non-profit subsidiaries. These non-profits are registered under a Trust. This
allows for NH to avail tax benefits while ensuring no leakage of funds to other uses.

Narayana Health does not turn away patients who cannot afford to pay. Instead, it cross-
subsidises them using full cost prices recovered from those patients who can afford it. As Dr.
Shetty says, “Charity is not scalable but good business principles are. Unlike most hospitals
which are rigid about pricing, we have a package for everyone because we never refuse
patients. We just need to know on a daily basis how many non-paying patients we are
operating on, because that determines the number of paying ones who need to be scheduled
too. This is why we have invested millions of dollars on software—from Oracle and SAP to
cloud computing—so we get a real-time P&L statement every day across all our locations.
Our P&L account is like a cardiac monitor for us because if something is wrong, I can figure
out how to solve it.”

Challenges
 The excellence promised and delivered by NH attracts affluent customers which helps to
subsidize the treatment for poor patients. Narayana Health’s model requires constant and
relentless to lower costs and build efficiencies. This requires government support which is
bureaucratic. Some taxes levied by the government on medical consumables put pressure on
margins. Thus, NH constantly monitors its costs to bring down wastage of time, money and
efforts. For example, around three years ago, NH switched to disposal drapes from the linen ones
which were cumbersome and time-consuming to clean after every surgery.

Social Impact [9]

Nearly 40% of the patients at NH belong to the economically weaker section of the society. Most
of them are subsidized via government or private micro insurance players. About 1% of all
surgeries done at NH for free. Various statistical reports and the annual reports of NH suggest that
NH performs
 150 surgeries per day
 80,000 OPD patients per month
The company’s annual reports have some of the following assumptions and agreements with the
government:
 5 % surgeries should be done free, only medicines and disposables should be charged
 Approximately, 20% cardiac surgeries should be performed at the subsidised rate of
$1000, all expenses included
 15 % out-patients should be given free consultation
 19.2 million OPDs till date
 Diagnostics fees will be charged at 50%

Here are some broad statistics of NH. Till date, NH has performed
 50000+ surgeries
 Tele-Medicine (30000+ consultations)
 Micro-Insurance (3.6 million farmers), Micro-insurance provides a cover of $2000
 Skill Building (20+ PG courses for nurses & doctors)

Economic Impact till date:

5% Free surgeries: 2,500 surgeries * $2000 = $5,000,000 = $5 million
20% Subsidized surgeries (50% discount): 10,000*1,000 = $10,000,000 =$ 10 million
15% Free OPD consultation: 2.8 million * $6.53 = $18.2 million
Microinsurance Penetration Impact: 3.6 million * $2000 = $7.2 billion
Total Impact: Sum of above = $7.5 billion
Capex for hospital:
Fixed Assets: $117 million
Equity: $150 million
Operational Expenses: $250 million
Total Investments = $517 million

Social Return on Investment = Impact/ Inputs = $7.5 billion/ $517 million = 1451%

[9] Source: Squarespace, CDC, NH Annual Report 2019

Investment Rationale

 Strong Brand Equity

 Run by strong professional team

 Asset Right Model

 Regional hub and spoke model enhances outreach

 Underpenetrated industry

 Sustained financial performance

Conclusion

While Narayana Health has been able to successfully scale up in a profitable manner, it has to
keep the momentum going. Some private equity funds have invested in the company. It therefore
become critical for NH to not lose sight from its vision to treat the poor and rich alike. Its latest
set up at Cayman Islands will set NH on the global map. It is an inspiring story of how innovation
can break clichés and that there lies an enormous opportunity at the bottom of the pyramid. An
impact fund like ours can help NH to strategically deliver social impact and financial returns. I
would recommend going ahead with the investment in Narayana Health.
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