healthcare market overview, india - may 2014
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This document has been produced by Catapult Pte Ltd. Copyright restrictions (including those of 3rd parties) are to be observed. All information, views and advice are given in good faith. Whilst every effort has been made to ensure the accuracy of the information and data contained herein, Catapult accepts no responsibility for any errors and omissions, however caused. Information contained in this document is not legal advice and does not bear any legal responsibility.!
Prepared by Catapult! May 2014!
CAT PULT
India Healthcare Macro Environment!A Brief Overview!
Strictly Confidential 2
Brief introduction to India and its health system!contents!
Note: All data is from published (government or otherwise) sources, unless specified
2. Healthcare in India – brief overview
3. Burden of Disease and Causes of Death
4. Healthcare Industry Market Size
5. Health Infrastructure
1. India – a quick overview
6. Health Services
7. Specialists in India
Strictly Confidential 3
India – a quick overview!!
People ! Population: 1.21 Billion ! Urban and Rural population share at
31% and 69%, respectively ! Top 20 cities account for ~5.3% of its
total population ! 28 states & 7 Union Territories
Key, Select Economic Indicators ! GDP, Purchasing Power Parity basis
- Total: US$ 5.3 Trillion - Per Capita: US$ 4,209
! In 2008, Urban GDP (~30% popln.) accounted for 58% of India’s GDP (share to go up to 70% by 2030)
! Top 5 states (viz., Maharashtra, Gujarat, Andhra Pradesh, Tamil Nadu & Delhi) have highest share of GDP to total
Notes: UT is Union Territory – an administrative division that is under the direct rule of the central (federal) government Sources: GDP estimates from The International Monetary Fund (2013); McKinsey Global Institute (2010 Report)
16
MA P-4
CENSUS OF INDIA 2011PERCENTAGE OF URBAN POPULATION
Tier-1 city Tier-2 city
Strictly Confidential 4
Healthcare in India – brief overview, 1!macro environment!
! Health in India, is a state subject. This means that while the central government enacts laws, the implementation of such laws is left to each state (currently 28 states & 7 union territories) - While India does not have universal health coverage, it does have national health insurance
schemes targeted mainly at the rural poor. Furthermore, some states have implemented health insurance schemes covering the state’s entire population
! While improvements have been made across in macro health indicators, major challenges remain: - Healthcare expenditure as % of GDP is est. at 4%*, of which 12th Plan (2012-2017) goal is to increase
government funding to 2.5% of GDP (from current ~1.4%). Remainder is private expenditure - ~60% of health expenditure is estimated to be out-of-pocket (OOP)* (down from ~67% in 2000)
* 2010 Data (best estimates) Note: Various govt. estimates are available for OOP expenditure on health – some reports suggest OOP to be ~70% of total Sources: Report of National Commission on Macro-Economics & Health (2005); Confederation of Indian Industry (Dec 2012)
Backdrop
Health Services
! Nearly 80% specialist doctors work in urban areas - Estimates suggest that ~700 Mn. people (i.e. ~60% of popln.) have no access to a specialist doctor
! Government has not kept pace on infrastructure needs to provide access to patients " private sector dominates existing bed capacity, currently at 63% of total beds (vs. 49% in 2002)
Strictly Confidential
Healthcare in India – brief overview, 2!key, select indicators!
5
Disease / Health Condition
# of Cases (2005)
# of Cases (2015E)
HIV / AIDS 5.1 Mn. 19.0 Mn
Cancers 0.807 Mn. 1.00 Mn.*
Diabetes 31 Mn. 46 Mn.
Cardiovascular 29 (2000) 64 Mn.
Injuries – deaths 0.98 1.1 Mn.
* 2012 Estimate Notes: Exchange rate of 1 US$ = INR 60; Private spending includes spending by employers, NGOs & international entities Sources: National Commission on Macroeconomics & Health (2005 Report); World Bank; High Level Expert Group on Universal Health Coverage for India (2011 Report); GLOBOCAN Project for International Agency for Research on Cancer
Top 10 cancer types in India 1. Breast 2. Cervix 3. Lip, Oral Cavity 4. Lung 5. Colorectum
6. Stomach 7. Oesophagus 8. Other Pharynx 9. Liver 10. Larynx
73
27
1 Private Public
1,820 (or, US$ 30)
Health spending in Indian Rupees (2009-10), per capita per year
2,787
1,007
585
372
205
Top Quintile
20-40%
40-60%
60-80%
Bottom Quintile
Most private spending is by the
wealthiest households
basis National Sample Survey of households (66th national round)
Sele
ct D
isea
ses
Strictly Confidential 6
Burden of Disease and Causes of Death!!
Sources: Report on Macroeconomics and Health in India (Burden of Disease in India, Background Papers) 2005; India Health Beat – a publication of WHO & Public Health Foundation of India (Jun 2012 Issue)
50.3%
33.0%
16.7% Communicable Diseases, Maternal & Perinatal Conditions
Non-Communicable Diseases
Injuries
1998 2005
39.0%
50.0%
11.0%
36.2%
29.0%
16.0%
10.8%
8.0%
Communicable Disease
Cardiovascular Disease
Other Chronic Diseases
Injuries
Cancer
2005
21.0%
35.9% 19.1%
12.1%
11.9%
2025 Forecast
Burden of Disease
Main Causes of Death
Strictly Confidential 7
Burden of Disease!summary notes!
Non-Communicable Diseases (NCDs) ! Overall, NCDs will become the leading cause of death & has been projected to see a two-fold in its risk by
2025 (by WHO). India already faces serious challenges, as briefly summarized in select examples below: - CVD occurs earlier among Indians (by at least 10 years, relative to developed countries) & at lower risk
factor thresholds; India is already termed as the diabetes capital of the world, with est. 51 Mn. people with diabetes (2010) & likely to go up to 87 Mn. by 2030*; A estimated 214 Mn. people will suffer from hypertension by 2030
Communicable Diseases (CDs) ! Even though NCD burden will become larger, by no means the burden from NCDs be contained sharply.
India faces many challenges & select few are summarized below: - In 2002, it was estimated that ~40% of population of all ages has Mycobacterium tuberculosis infection &
that TB is the single most important cause of death; Similarly, with about 2.5 Mn. HIV infected persons, India has the world’s 3rd highest number of cases in absolute numbers – though much less so in rates
Overview ! In the 2005 NCMH study, 17 priority health conditions were identified as significant public health problems ! Within communicable diseases, HIV, TB, Malaria, Diarrhoea, Acute Respiratory Infections, Maternal &
Perinatal conditions accounted for nearly half of India’s disease burden in 1998 ! Within NCDs, Cardiovascular disease (CVD), Diabetes, Respiratory conditions (asthma & COPD) &
mental health disorders are expected to account for a sharp increase in disease burden in the future
* people with diabetes aged between 20-79 years Sources: Report on Macroeconomics and Health in India (Burden of Disease in India, Background Papers) 2005 Study; India Health Beat – a publication of WHO & Public Health Foundation of India (Jun 2012 Issue); WHO India Country Cooperation Strategy 2012-17
Strictly Confidential 8
Healthcare Industry Market Size!snapshot!
2008 2012 Others 0.5 1.0 Diagnostics 1.2 2.5 Medical Equipment 0.4 6.7 Delivery 27.4 54.5
-
10.0
20.0
30.0
40.0
50.0
60.0
70.0
Mar
ket S
ize
(US$
Bn.
)
30
65
Overall Market
22% CAGR
Note: numbers rounded-off
Healthcare Services Market Characteristics ! Healthcare services delivery in India is
private-sector dominated & highly fragmented
! While overall market has grown at 20%+ CAGR, medical equipment & diagnostics markets have grown faster
! Between 2000-2011, estimated Foreign Direct Investment in hospitals & diagnostics sector was US$ 1 Bn. - Diagnostics sector has received the largest
number of FDI approved projects (though not the maximum $ investments)
! Various policy initiatives have been taken to promote investments in healthcare services incl. automatic approvals for up to 100% ownership, reduction in customs duty for import of medical equipments, among others
Note: Market estimate excludes pharma, biotech & the health insurance sector; Others includes medical tourism market Sources: ASSOCHAM-Yes Bank Report (2012); other secondary reports; Catapult analysis
Strictly Confidential
Health Infrastructure!overview!
Primary Health Centers
Hospitals
Med. Colleges
Type Total
Medical Colleges 335
All Hospitals (General, Specialized) 11,993
Primary Health Centers (incl. private clinics, community
centers & sub-centers) 176,820
Notes ! Of the nearly 12,000
hospitals, nearly 7,500 hospitals (~62%) are in rural areas
! Community centers (4,809) are in semi-urban areas & combine villages & small towns, whereas primary centers (23,887) & sub-centers (148,124) cover even smaller areas / population
! India lags behind all macro-indicators (WHO guidelines), whether on bed capacity (0.9 per 1000 population), or number of health professionals (doctors, nurses)
! Private sector has taken a lead role in development / addition of new bed capacity " private bed capacity has increased at nearly 3 times the rate of govt. owned bed capacity between 2002-10 and is now nearly double that of public facilities at an aggregate
Notes: Community centers (covering a district) may be classified as a hospital; World Average of Beds per 1000 population is 3.96 Sources: National Health Profile of India (2011), Central Bureau of Health Intelligence, Ministry of Health and Family Welfare; Confederation of Indian Industry Study (Dec 2012)
All forecasts suggest supply will not keep pace with demand for services
9
Strictly Confidential 10
Key Overall Challenges ! Disease-related: India faces serious burden of disease,
whether CDs, or NCDs. While significant progress has been made across many diseases, much remains to be done
! Trained Health Staff: While health infrastructure has expanded substantially in the past decade, the picture for trained health staff is not as encouraging. Surveys suggest even basic services (e.g. no. of deliveries) are not fully utilized due to lack of trained health staff at facilities
! Quality of Services: While there exists the challenge of providing health services to the population, on the other hand India is recognized as an emerging leader in medical tourism " Highest-quality health care is available if there exists the ability to pay (mainly) out-of-pocket
! Significant progress has been made in certain CD areas (e.g. HIV/AIDS, TB) due to concerted effort (with support of various multi-lateral agencies) to contain the spread
! Since states (not central govt.) are primarily responsible for implementation of health policies, certain states have successfully implemented insurance schemes that cover a large part of their population
! Innovative models of treatment are being taken up that are not only improving patient access, but significantly lowering treatment costs (e.g. ‘Aravind Eye Hospital’ for eye care – http://www.aravind.org)**
CDs is Communicable Diseases and NCDs is Non-Communicable Diseases ** https://globalconnections.hsbc.com/global/en/articles/frugal-innovation-healthcare Sources: National Health Profile of India (2011), Central Bureau of Health Intelligence; Tertiary Care Institutions, 12th 5-Yr Plan (2012-17), Planning Commission of India; HLEG Report on Universal Health Coverage for India (2011), WHO India Country Cooperation Strategy 2012-17
Health Services!overview!
Strictly Confidential 11
Specialists in India!chronic shortage to persist!
Notes: Gastroenterology Surgeons members, as of October 2011; Seats incl. Medical Council of India (MCI) and Diplomate of the National Board (DNB); best estimates as not all members register in various associations; all date are best estimates only Sources: respective Associations, (various) Secondary sources; Catapult analysis
2. General Surgeons, performing laparoscopy surgeries
4. Gastroenterology Surgeons
Key Specialties
1. Total registered General Surgeons
There are are an 16,000 ‘practicing’ general
surgeons across India
Though membership list is estimated to be ~25,000, no other data is available to
further validate these numbers
An est. 5,000 surgeons practice the laparoscopy
technique
An est. 700 surgeons (across specialties) perform large number of
surgeries, in the top 30 cities
862 surgeons, across 240 cities
An est. 300 surgeons perform large number of surgeries, in the top 26 cities
5. Intervention Radiologists
200-240 surgeons, practicing (largely) in top
20 cities n.a.
Overall Estimates Notes
In all, across surgical disciplines (only), there are 1593 seats for super-specialties courses, of which Urology, Cardiothoracic & Vascular Surgery, Neuro, Plastic and Paediatric surgical
disciplines (top 5) account for 70% of all seats
3. Nephrologists An est. 800-850 practicing nephrologists
Vast majority of nephrologists in the top 30 cities
Strictly Confidential
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