infrastructure trend monitor india 2009
TRANSCRIPT
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ADVISORY
GlobalInfrastructurTrendMonitorIndian Healthcare Edition:
Outlook 20092013
The Global Infrastructure:
Trend Monitoris a series
of publications allowing
infrastructure investments
to be compared across
geographies. In this thirdedition, 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.
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ii Global Infrastructure: Trend Monitor Indian Healthcare Edition
Foreword
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
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.
Kai RintalaHead of Infrastructure Intelligence
KPMG in the UK
Pradip KanakiaHead of Markets
KPMG in India
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Global Infrastructure: Trend Monitor Indian Healthcare Edition iii
Contents1. Foreword
2. Key findings
3. Important notes
4. Model outputs
5. Insight
6. Method
7. Appendix
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
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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 morethan 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.
Webelievethereisgrowingappreciationfortheroleprivateinvolvementmayhave 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.
Unlikeindevelopedmarkets,wherethereisafocusongeneratingspecializedhealthcare 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 socio
economic 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
Basedontheoutputsofoureconometricmodelexpenditureonhealthcareinfrastructure 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.
Ofthe32statesconsidered,thesixstatesofMaharashtra,Rajasthan,WestBengal, Uttar Pradesh, Tamil Nadu and Andra Pradesh are forecast to represent
approximately 50 percent of the expenditures for the 2009-2013 period.
Ofthelargerstates,expenditureonhealthcareinfrastructureisexpectedtogrowthefastestinKerala,Rajasthan,andWestBengal.
1 KPMG/Confederation of Indian Industry (2008) Health Insurance Inc.: The Road Ahead
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Global Infrastructure: Trend Monitor Indian Healthcare Edition 2
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 period2009-2013 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
Important Notes
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 KPMG s Indian member firm
to seek to present a better informed view of the
future.
Definitions and classifications
Size and prospects of individual states:
Largeandgrowingfast
stateswhere2006
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.
Largeandgrowingslowly stateswhere2006 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.
Smallandgrowingfast stateswhere2006 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.
Smallandgrowingslowly stateswhere2006 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 territoriesof Dadra and Nagar Haveli; Daman and Diu;
andLakshadweepwereunavailable. 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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1
2 3
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1314
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2223
24
25
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27
28
29
30
31
32
1
2 3
4
5
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7
8
9
10
11
12
1314
15
16
17
18
19
20
21
2223
24
25
26
27
28
29
30
31
32
3 Global Infrastructure: Trend Monitor Indian Healthcare Edition
India: expenditure on healthcare infrastructure in 2006 by state (percentage of total)
1.1. Maharashtra 12.0%2.2. Rajasthan 8.2%3.3. Uttar Pradesh 8.1%4.4. West Bengal 7.9%5.5. Tamil Nadu 7.5%6.6. Andhra Pradesh 7.0%7.7. Kerala 6.7%8.8. Gujarat 6.2%9.9. Karnataka 5.2%10.10. Haryana 4.8%11.11. Delhi 4.3%12.12. Madhya Pradesh 3.5%13.13. Punjab 2.7%14.14. Himachal Pradesh 2.2%15.15. Bihar 1.8%16.16. Orissa 1.6%17.17. Assam 1.6%18.18. Jharkhand 1.6%19.19. Jammu and Kashmir 1.6%20.20. Uttranchal 1.2%21.21. Chattisgarh 0.9%22.22. Manipur 0.8%23.23. Tripura 0.5%24.24. Nagaland 0.4%25.25. Chandigarh 0.3%26.26. Arunachal Pradesh 0.3%27.27. Meghalaya 0.3%28.28. Goa 0.2%29.29. Andaman and Nicobar 0.2%
Islands
30.30. Mizoram 0.2%31.31. Sikkim 0.1%32.32. Puducherry 0.1%
1
2 3
4
5
6
7
8
9
1011
12
1314
15
16
17
18
19
20
21
2223
24
25
26
27
2829
30
31
32
Key:Large and growing fastLarge and growing slowlySmall and growing fastSmall and growing slowly
Analysis: KPMG International, refer to Method section of this report
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India: expenditure on healthcare infrastructure in 2006 (US$ m illion)
India: expenditure on healthcare infrastructure in 2006 per person (US$ )
US$
US$m
AndamanandNicobarIslands
AndhraPradesh
Arunac
halPradesh
AndamanandNicobarIslands
AndhraPradesh
Assam
ArunachalPradesh
Bihar
Assam
Chandigarh
Bihar
Chattisgarh
Chandigarh
Delhi
Chattisgarh
Goa
Delhi
Gujarat
Goa
Haryana
Gujarat
Himac
halPradesh
Haryana
Jammua
ndKashmir
HimachalPradesh
Jharkhand
JammuandKashmir
Karnataka
Jharkhand
Karnataka
Kerala
Kerala
Madh
yaPradesh
MadhyaPradesh
M
aharashtra
Maharashtra
Manipur
Manipur
Meghalaya
Meghalaya
Mizoram
Mizoram
Nagaland
Nagaland
Orissa
Orissa
Puducherry
Puducherry
Punjab
Punjab
Rajasthan
Rajasthan
Sikkim
Sikkim
TamilNadu
TamilNadu
Tripura
Tripura
UttarPradesh
UttarPradesh
Uttranchal
Uttranchal
Global Infrastructure: Trend Monitor Indian Healthcare Edition 4
India: expenditure on healthcare infrastructure in 2006 (US$ million)
1,400
1,200
1,000
800
600
400
200
0
Analysis: KPMG International, refer to Method section of this report
India: annual expenditure on healthcare infrastructure in 2006 per person (US$)
40
35
30
25
20
15
10
5
0
Analysis: KPMG International, refer to Method section of this report
2009 KPMG International. KPMG International provides no client services and is a Swiss cooperative with which the independent member firms of the KPMG network are affiliated. All rights reserved. 20866NSS
W
estBengal
WestBengal
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India: forecast average annual growth rate in healthcare infrastructure expenditure 2009-2013 (perce
India: forecast cumulative expenditure on healthcare infrastructure in 20092013 (US$ billion)
US$bn
5 Global Infrastructure: Trend Monitor Indian Healthcare Edition
India: forecast average annual growth rate in healthcare infrastructureexpenditure 2009- 2013 (percent)
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
Analysis: KPMG International, refer to Method section of this report
2009 KPMG International. KPMG International provides no client services and is a Swiss cooperative with which the independent member firms of the KPMG network are affiliated. All rights reserved. 20866NSS
8
7
6
5
4
3
2
1
0
Analysis: KPMG International, refer to Method section of this report
India: forecast cumulative expenditure on healthcare infrastructurein 20092013 (US$ billion)
Andaman
andNicobarIslands
AndhraPradesh
ArunachalPradesh
Assam
Bihar
Chandigarh
Chattisgarh
Delhi
Goa
Gujarat
Haryana
HimachalPradesh
J
ammuandKashmir
Jharkhand
Karnataka
Kerala
MadhyaPradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Orissa
Puducherry
Punjab
Rajasthan
Sikkim
TamilNadu
Tripura
UttarPradesh
AndamanandNicobarIslands
AndhraPradesh
ArunachalPradesh
Assam
Bihar
Chandigarh
Chattisgarh
Delhi
Goa
Gujarat
Haryana
H
imachalPradesh
Jam
muandKashmir
Jharkhand
Karnataka
Kerala
MadhyaPradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Orissa
Puducherry
Punjab
Rajasthan
Sikkim
TamilNadu
Tripura
UttarPradesh
Uttranchal
Uttranchal
WestBengal
WestBengal
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India: forecast cumulative expenditure on healthcare infrastructure in 20092013 per person (US$)
India: ratio of forecast cum ulative expenditure on he althcare 2009 2 013 to the forecast averag e fo
Ratio
Global Infrastructure: Trend Monitor Indian Healthcare Edition 6
India: forecast cumulative expenditure on healthcare infrastructure in20092013 per person (US$)
300
250
200
150
100
50
0
India: ratio of forecast cumulative expenditure on healthcare2009 2013 to the forecast average for all states
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
US$
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
3
.66
Maharashtra
Rajasthan
2.6
6
AndamanandNicobarIslands
2.6
2
WestBengal
AndhraPra
desh
UttarPradesh
2.3
9
ArunachalPra
desh
TamilNadu
2.3
2
Assam
AndhraPradesh
2.3
1
Bihar
Kerala
2.2
0
Chand
igarh
Gujarat
1.9
1
Chattis
garh
Karnataka
1.6
9
Delhi
1.5
9
Haryana
Goa
Delhi
1.3
3
Gu
jarat
1.1
0
MadhyaPradesh
Haryana
Punjab
0.8
5
HimachalPra
desh
HimachalPradesh
0.7
8
JammuandKas
hmir
Bihar
0.5
7
Jhark
hand
JammuandKashmir
0.5
4
Karnataka
0.4
8
Orissa
K
erala
Assam
0.4
8
MadhyaPra
desh
0.4
8
Jharkhand
Mahara
shtra
Uttranchal
0.4
1
Manipur
Chattisgarh
0.3
5
Meghalaya
Manipur
0.3
3
Mizoram
Tripura
0.2
0
Nagaland
Nagaland
0.1
4
O
rissa
Chandigarh
0.1
3
Puducherry
0.1
0
ArunachalPradesh
Punjab
Meghalaya
0.0
8
Rajas
than
0.0
7
Goa
AndamanandNicobarIslands
0.0
6
Mizoram
0.0
5
Sikkim
0.0
5
Puducherry
0.0
3
Sikkim
TamilNadu
Tr
ipura
UttarPra
desh
Uttranchal
WestBengal
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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,WestBengal, 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
togrowthefastestinRajasthanand 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
ofRajasthanandWestBengalare projected to witness cumulativehealthcare 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
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Global Infrastructure: Trend Monitor Indian Healthcare Edition 8
Insight
Against a world average of around fourhospital 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 isestimated 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 overthe last decade has not kept pace with
growth in population3. The available
capacity has increased but not in linewith 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 iscontrolled 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 agendato 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 isundergoing 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 ofinvestment.
We believe there is a growingappreciation 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
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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:
Constructionoutputdata(2000-2006)for 32 Indian states was obtained fromIndian National Income Accounts at
factor cost and converted to market
prices.
Theconstructionoutputdatawasconverted 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.
Constructionoutputforeachstate 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
andRegulatoryReform). Healthcareconstructionoutput
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).
Theforward-lookingexpendituresup to 2013 were estimated by linear
extension of the line of best fit for the
historical data.
Thepercapitaexpenditureswherecreated 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 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
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
MeghalayaMizoram
Nagaland
Orissa
Puducherry
Punjab
RajasthanSikkim
Tamil Nadu
Tripura
Uttar Pradesh
Uttranchal
West Bengal
7 7 9 10 13 13 15 17 18 20 21 23 24 26
402 408 447 493 547 603 672 759 774 825 877 928 980 1,031
17 19 25 22 24 29 30 33 35 37 39 41 44 46
109 114 132 119 146 148 154 160 169 176 183 191 198 206
143 144 140 160 145 173 171 217 201 210 218 227 236 245
11 12 23 18 22 31 33 40 42 46 50 54 58 62
37 32 43 46 54 76 90 108 109 120 130 141 152 162
248 287 280 314 334 365 408 443 455 482 509 535 562 589
10 10 11 12 15 16 19 21 22 23 25 27 28 30
386 380 383 432 474 532 588 633 651 689 728 767 806 844
222 273 279 320 342 392 455 505 523 562 600 639 678 716
130 131 142 161 161 184 210 278 258 277 295 314 332 351
69 76 90 102 105 131 150 169 176 190 204 218 233 247
105 100 114 112 127 141 152 161 167 176 185 194 203 212
297 307 350 380 405 443 499 550 567 603 640 676 712 748
370 339 324 397 483 558 637 695 720 774 828 882 936 991
207 230 239 248 268 307 336 365 375 397 419 441 464 486
771 631 678 748 815 1,018 1,149 1,195 1,232 1,311 1,390 1,469 1,548 1,627
24 32 39 44 56 71 79 100 103 113 123 134 144 155
20 21 22 22 24 25 26 27 28 29 30 31 32 33
7 7 9 11 12 13 14 16 17 19 20 21 23 24
10 13 17 19 24 30 36 42 44 48 53 57 62 66
113 125 125 133 139 156 154 165 171 178 185 192 199 207
11 11 11 12 12 12 12 12 13 13 13 13 13 14
164 175 188 196 205 230 260 288 289 306 323 340 357 374
416 386 434 470 590 569 781 866 867 934 1,001 1,068 1,135 1,203
5 6 8 9 11 12 14 16 17 19 20 22 23 25
481 506 529 572 611 666 714 783 801 844 887 929 972 1,015
20 27 33 37 43 45 51 62 64 70 75 80 86 91
503 530 554 558 613 672 771 805 825 869 914 958 1,002 1,047
58 61 82 88 93 99 114 131 136 146 156 166 176 186
370 389 424 455 554 608 760 819 850 917 985 1,052 1,119 1,187
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
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through the lifecycle of complex infrastructure projects.
Our teams have extensive local and global experience advising infrastructure contractors, operators and
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Publication name: Infrastructure Trend MonitorPublication number: 20866NSSPublication date: July 2009
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