Study on theNot-for-Profit
Hospital
Model in India

June 2021

Study on theNot-for-Profit
Hospital
Model in India

June 2021

Study on the Not-for-Profit Hospital
Model in India
Publishing Agency: NITI Aayog
Year of Publication: 21-06-2021
Book, English
ISBN : 978-81-949510-1-8
DOI: 10.31219/osf.io/ba5vu
Suggested Citation: Sarwal Rakesh,
Gopal K Madan, Mehta Rana, Matani
Preet, Aggarwal Ashwani, Arora Vishal,
Sunderarajan SamuelForeword
India’s policies and programmes are aimed at achieving Universal Health Coverage by 2030. Witha population of about 1.38 billion and counting, India has an ever-increasing need for healthcare
services. Although multiple efforts across different areas spearheaded by the Government aremeeting this vast need, statistics available in the public domain reveal a significant gap in theaccessibility and availability of healthcare across all segments of the population. The private sector
plays a significant role in bridging the gap in healthcare availability; however, it usually faces
the challenge of providing affordable care to a large section of the population, while ensuring its
own sustenance and efficiency.
The “Not-for-Profit” Hospital Sector has the reputation of providing affordable and accessible
healthcare for many years. This sector has done yeoman service over the years with some institutions
from even before Independence. Although various institutions have been established for different
purposes, this sector provides not only curative healthcare, but also preventive healthcare, andlinks healthcare with social reform, community engagement, and education. They utilize theresources and grants provided to them by the Government to provide cost effective healthcare to
the population without being overly concerned about profits. However, this sector remains largely
understudied, with a lack of awareness about its services in the public domain.
The aim of this study is to understand the operating model of some of the prominent institutions
across the country, including their premise of service, human resource availability, cost containment
levers, and the challenges they face. This study will facilitate policymakers in deciding how they
can assist this sector to sustain, grow, and in turn, help reach the unreached sections of society.

Dr. Vinod K Paul
Member, NITI Aayog

3

Acknowledgments

Acknowledgments
We wish to thank the following for their assistance and cooperation in this study
Designation

Organization

Sr. NoName

1.

Dr Vijayanand Ismavel

Medical Superintendent

Makunda Christian Leprosy & General
Hospital

2.

Dr J V Peter

Director

Christian Medical College, Vellore

3.

Dr Narasimhan

Medical Superintendent

Sri Sathya Sai General Hospital,
Prasanthi Nilayam, Puttaparthi

4.

Dr Sanjeev K Singh

Medical Superintendent

Amrita Institute of Medical Sciences,
Kochi

5.

Dr S P Kalantri

Medical Superintendent

Mahatma Gandhi Institute of Medical
Sciences, Sevagram

6.

Dr Anant Pandhare

Medical Director

Dr Hedgewar Rugnalaya, Aurangabad

7.

Dr Pankaj Shah

Medical Superintendent

Sewa Rural Kasturba Hospital, Jhagadia

8.

Dr Rekha Bhatkhande

Medical Director

Shushrusha Citizen’s Cooperative
Hospital, Dadar

9.

Mr. Joy Chakraborty

Chief Operating Officer

PD Hinduja Hospital, Mahim

10.

Dr R V Prabhakara Rao

Chief Executive Officer

Basavatarakam Indo-American Cancer
Hospital, Hyderabad

11.

Mr. M Abdunnasir

General Manager

EMS Memorial Cooperative Hospital,
Perinthalmanna

5Study on the Not-for-Profit Hospital Model in India

STUDY TEAM
Overall guidance
Dr Rakesh Sarwal

Additional Secretary

NITI Aayog

Dr K Madan Gopal

Senior Consultant,

NITI Aayog

Mr. Anurag Kumar

Health Economist

NITI Aayog

Dr Rana Mehta

PartnerPwC India

Dr Preet Matani

Director

PwC India

Dr Ashwani Aggarwal

Associate Director

PwC India

Dr Vishal Arora

Principal Consultant

PwC India

Mr. Samuel Sunderarajan

Senior Consultant

PwC India

Designed by6

List ofAbbreviations
ABPMJAY– Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana

CAPEX– Capital Expenditure

CBC– Complete Blood CountCGHS– Central Government Health Scheme

CMC– Christian Medical College

CMCHIS– Chief Minister’s Comprehensive Health Insurance Scheme

ECG– Electrocardiogram

HACCP– Hazard Analysis Critical Control Point

ICU– Intensive Care Unit

IPD

– In-patient Department

ISO– International Organization for Standardization

MGIMS– Mahatma Gandhi Institute of Medical Sciences

MJPJAY– Mahatma Jyotiba Phule Jan Arogya Yojana

NA– Not Applicable

NABH– National Accreditation Board for Hospitals and Healthcare Providers

NSS– National Sample Survey

OHSAS– Occupational Health and Safety Management Systems

OPD– Out-patient Department

OPEX– Operational Expenditure

ORIF– Open Reduction Internal Fixation

PNDT– Pre-Natal Diagnostic Techniques

PPP– Public Private Partnerships

PSUs– Public Sector Undertakings

TUV– TUVRheinland

USG– Ultrasonography

7

Contents
Foreword

3

Acknowledgments

5

List of Abbreviations

7

1.

Background11

2.

Objectives

143.

Approach15

4.

Criteria for Classification of Hospitals

16

5.

Methodology

20

6.

Key Findings

22

7.

Challenges Faced by the Not-for-Profit Hospitals

30

8.

Proposed Policy Interventions to Promote the Not-for-Profit Hospital Sector32

9.

Annexures36

9.1 Questionnaire36

9.2 Information Request List

38

9.3 Brief hospital profiles

39

10. References

43

9

1
BackgroundIn the recent past, the NITI Aayog has been endeavoring to study the Private Sector Healthcare
Delivery landscape in India to ascertain the reach of quality healthcare, the health seeking behaviorof the masses, and the healthcare expenditure borne by patients, through various studies. The
studies revealed the lack of penetration ofquality healthcare, especially among the
%Beds
100%
economically weaker sections of society in both90%
20%
urban and rural areas. During these studies, the
28%
39%
80%
work done by the private not-for-profit hospitals
70%
came up for reckoning. There were many
60%
50%
examples of commendable work being done to40%
provide quality healthcare to the unreached at
80%
72%
61%
Rural
30%
low cost; however, all these examples were in
Urban
20%
silos, and unknown to the larger section of the
10%0%community. This prompted the need for a
Public Beds Private Beds Total Beds
targeted study to gain a crisp and structured
Fig.1: Breakup of Hospital beds in India
understanding about the not-for-profit hospital
Source: World Bank, NSS 75th round, NHRR, IMS study.
model in India.
6.0
5.5
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0

Bed Density (No. of Beds per 1000 Population)
5.6

2.4
1.0
India

2.4

1.4

1.2

Low
income2.7

MiddleincomeLow &MiddleincomeWorld European
Union

Fig.2: Bed density (number of Hospital beds per 1000
population) in India compared to other parts of the world
Source: World Bank

Despiteeconomic
growthandmodernization, India continues to facesignificant challenges of unavailability andunaffordability in healthcare services. Thisis substantiated by the fact that India has
a lower Bed Density than the rest of theworld (Fig.2).
In addition, existing hospital beds (Fig.1)
and hospitalization services have a highlevel of concentration in urban areas,
which in turn impact the accessibility andaffordability of hospitalization services.

11

Study on the Not-for-Profit Hospital Model in India

The not-for-profit hospitals currently account for only a miniscule share of hospitalization cases(Fig.3).
Public hospitals that offer healthcare at negligible cost are overstretched. The burden of healthcare
provision shifts to private hospitals, which generally offer healthcare at a higher cost to the patient,
as they must sustain themselves.
Private hospitals are largely divided into “for-profit hospitals,” which account for 23.3% of treatedailments and “not-for-profit hospitals,” which account for only 1.1% of treated ailments, as of June
2018. (Fig.3). The disparity is further revealed in terms of hospitalization cases (Fig.4), wherein
the for-profit hospitals account for 55.3% of in-patients, while the not-for-profit hospitals accountfor only 2.7% of in-patients in the country, according to the findings of the NSS 75th round survey
on Health in India.
Percentage breakup of treated ailments
by type of provider (OPD)

Percentage breakup of hospitalization cases by type of
Hospital (IPD)

Urban

Rural

70

50

60

40

Urban

44.3
41.4

40

51.9
50

Rural

45

61.4

35

45.7

30
35.3

32.5
26.2

25

30

27.3
20.8

20
15

20

10
10
2.4
0

Govt. Hospitals

Private Hospitals

Not-for-Profit
Hospitals

Fig.3: Percentage of IPD Treatment
Source: NSS 75th round survey

3.3

4.3

5
0

0.9 1.3
Govt.
Hospitals

PrivateHospitals

Not-for-Profit
Hospitals

0.9
PrivateClinics

Informal
ProvidersFig.4: Percentage of OPD Treatment
Source: NSS 75th round survey

A not-for-profit hospital does not make profits for its owners from the funds collected forpatient services. The owners of these hospitals are often charitable organizations or non-profit
corporations. The fees for service at these hospitals are generally lower than for-profit hospitals andthe income from fees (above the cost of service) are reinvested in the hospital. These hospitals area potential remedy to the challenges of unavailability and unaffordability of healthcare in India.
The infrastructure, services, and charges of these hospitals are positioned to cater to the unreachedand underprivileged population of the country. In addition, these hospitals have managed tocreate a perception of goodwill in the country not only through selfless healthcare services with asocial cause, but also through various community engagement programs for education, vocational
training, hygiene, sanitation, women’s empowerment and employment.
Despite their limited presence, which is seen disproportionately in Western, Southern andNorth East India (Fig.5), the not-for-profit hospitals have a disproportionate impact on the local
communities they serve.

120.1 to 1%
1.1 to 9%
9.1% & above

Fig.5: Percentage of treated ailments (OPD) by Not-for-Profit Hospitals state-wise
Source: NSS 75th round survey

13

2
Objectives
The not-for-profit Hospital sector remains a largely understudied sector in India with very lessspecific information available in public domain. Thus, this study aims to achieve the following
objectives:




14

To document the dynamics of operations of prominent not-for-profit hospitals in the
country

Are these hospitals providing low cost care?



Are these Hospitals providing acceptable quality of care?

What are the various levers that help them offer low-cost, high-quality care?

What are the best practices of these Hospitals that can be replicated?

What are the challenges that these hospitals face?

To suggest policy interventions to promote this sectorHow can these hospitals become publicly more visible?

How can these hospitals become operationally more viable?



Can their expertise and network be leveraged to improve healthcare service delivery
in Tier 2/ 3 cities and rural areas?

How can these hospitals associate in a better way with Government schemes?

3
Approach
The following approach was conceptualized to complete this study:i.	Categorization of the prominent not-for-profit hospitals basedon the premise of services and their ownership
Detailed primary and secondary research on prominent hospitals was used to arrive atreasonably clear categories in which these hospitals could be classified. This categorization
would be useful to understand the vision behind the establishment of these hospitals andthe guiding force behind them.

ii. Understanding the business model of the hospitals
In addition to the basic understanding of these hospitals, the intent of this study is tounderstand the operating model of these hospitals, along with the financial viability, andtheir dependence on donations and grants for meeting their operational needs. This study
also attempted to understand how these hospitals have managed to keep their costs lower
than their peers and the focus on quality across these hospitals.

iii. Understanding the challenges faced by these hospitals
Another important objective of the study is to understand and classify the challenges facedby these hospitals in terms of criticality and universality on a day-to-day basis and the factors
limiting the growth of this sector in the countryiv.	Formulation of recommendations for policy interventions topromote the sector
Based on the information gained from the above-mentioned aspects, the intention is toascertain and propose targeted interventions, which will not only mitigate the challenges
faced operationally, but also provide insights for the overall growth of the sector from astrategic perspective.

15

4

Criteria forClassification of
Hospitals

Using the above-mentioned approach and secondary research, the following four categories were
defined for the not-for-profit hospitals (Table 1):Faith-based HospitalsCommunity-based Hospitals

Cooperative Hospitals



Private Trust Hospitals

a. Faith-based Hospitals
These hospitals work on the premise that selfless service to the society is done as service
to God. A noteworthy feature of all major faiths has been their emphasis on charity andsharing wealth with others, especially the poor. Throughout the ancient and medieval
periods, voluntary activity found its natural expression through religions institutions. This
concept further accelerated with the advent of western influence and presence in India.
Individual missionaries or religious trusts have founded many such hospitals based on theprinciples of religions or deities.
The salient features of the operations model of these hospitals are as follows:i.

Large number of general wards where underprivileged patients pay minimal costs andreceive full/partial charity when required.

ii.

Few private wards, where affording patients pay slightly more than basic costs.

iii. Some hospitals even provide free services to all patients.

16

iv.

Most such hospitals provide Secondary-Tertiary level of care, while some even provide
Quaternary care.

v.

Economies of scale through high volumes allow low cost of care and internal crosssubsidization in services.

Criteria for Classification of Hospitalsvi.

Doctors and staff sacrificially volunteer to serve for salaries, which are about 50% ormore lower than other hospitals.

vii. These majorly serve in remote areas, where there is negligible penetration of quality
healthcare. They engage the local population through various projects focused on healthand sanitation education, empowerment, vocational training, and so on.
viii. The capital expenditure, and at times, operational expenditure is funded by generous
donations from devotees or from funds accumulated by the trusts.

b. Community-based Hospitals
These hospitals are not necessarily influenced by any faith but operate on the premise thatselfless service to the underprivileged will result in all-round social reform. Highly motivateddoctors, or a team of likeminded doctors, desiring to give back to society, have founded manysuch hospitals, often in the same community where they were born/raised.
The salient features of the operations model of these hospitals are as follows: i.

Large number of general wards, where underprivileged patients pay minimal costs andreceive full/partial charity when required.

ii.

Few private wards where affording patients pay slightly more than basic costs.

iii. Economies of scale through high volumes allow low cost of care and internal crosssubsidization in services.
iv.

These hospitals mainly provide secondary-tertiary level of care.

v.

Doctors and staff volunteer to serve for salaries that are about 50% or more lower thanother hospitals.

vi.

These majorly serve in remote areas, where there is negligible penetration of quality
healthcare. They engage the local population through various projects focused on healthand sanitation education, empowerment, vocational training, and so on.

vii. The capital expenditure, and at times, operational expenditure is funded by generous
donations from philanthropists or from Government grants.

c. Cooperative Hospitals
These hospitals are set up on the premise of self-sufficiency in healthcare by self-participation.
They believe that quality healthcare at an affordable cost (commensurate to the locality of
the hospital) is a right of all citizens and can result in the overall benefit of both the hospitaland its patients.
Individual doctors or a likeminded team of doctors convinced of the same philosophy, havefounded many such hospitals.
The salient features of the operations model of these hospitals are as follows:i.

They invite patients and their families to pay a membership fee – either annual/ or
lifetime/ or through purchase of hospital shares/ or as a hospital-run insurance scheme,
through which the members obtain substantial discounts in out-patient/ in-patient
treatment, investigations and medications.

17

Study on the Not-for-Profit Hospital Model in India

ii.

They give priority in non-emergency services to the patients enrolled as members.

iii. They engage the local population through various projects focused on health awarenessand education, camps for senior citizens, and vulnerable citizens.
iv.

They engage in marketing and fund-raising activities to increase the number of members.

v.

These hospitals mainly provide secondary-tertiary level of care.

vi.

They have a designated Indigent Patient Fund for treatment of non-affording patients
based on documentary verification.

vii. Treatment for the members is cross subsidized by the treatment of non-members who arecharged slightly lesser than the market rate but higher than the charges for the members.
viii. Their capital expenditure is funded by the corpus membership fees and by donations
received from philanthropists.

d. Private Trust Hospitals
These hospitals operate with the premise of no profit and no loss and are primarily locatedin Tier 1/ Tier 2 cities. Famous businessmen/ philanthropists/ politicians, have founded manysuch hospitals in response to social causes based on individually observed needs.
The salient features of the operations model of these hospitals are as follows:i.

They have highly advanced infrastructure with the latest technology.

ii.

They provide high-quality care at slightly less or at par with market rates to all patients.

iii. They have a designated indigent patient fund for the treatment of non-affording patients
based on documentary verification.
iv.

Most such hospitals provide Secondary-Tertiary level of care while some even provide
Quaternary care.

v.

The model involves a Robin-hood concept, wherein the affording patients cross-subsidize
the non-affording patients.

vi.

They have separate pricing structures for international patients and underprivileged
patients.

vii. Their capital expenditure is funded by the revenue of the hospital and by donations
received from philanthropists.

18

Criteria for Classification of Hospitals

Table.1: Categorization of not-for-profit Hospitals
Faith Based
Hospitals

Community Based
Hospitals

Cooperative
Hospitals

PremiseSelfless service
to the society as
service to God.

Selfless service tothe underprivilegedof the society,not necessarily
influenced by faith.

Self-sufficiency inhealthcare by selfparticipation

Service rendered on ano profit and no loss
basis

Founders

Individual
missionaries orreligious trustson the principles
of religions ordeities.

Individual doctors,
or a team of
likemindeddoctors, who
desire to giveback to society,often in the samecommunity where
they were born/raised.

Individual doctors
who wish to harness
the contributions of awider population in
the nearby areas sset
up these institutions.

Eminent businessmen/
Philanthropists/
Politicians, in response
to a social cause
based on individuallyobserved needs.

Interviewed
Hospitals

MakundaChristian Leprosy& General
Hospital,
Karimganj

Dr Hedgewar
Rugnalaya,
Aurangabad

Shushrusha Citizen’s
Cooperative Hospital

Basavatarakam IndoAmerican Cancer
Centre, Hyderabad

CMC Vellore
Amrita Institute ofMedical Sciences,
Kochi

Sewa Rural,
Jhagadia

MGIMS Kasturba
Hospital, Sevagram
EMS Memorial
Cooperative Hospital& Research Centre,
Perinthalmanna

Private Trust
Hospitals

PD Hinduja National
Hospital & Medical
Research Centre,
MumbaiSri Sathya Sai
Central Trust
Hospitals in
Puttaparthi

195
Methodology
This study involves the following steps:i.

Secondary research for information about the sector
In addition to the information available on the websites of the hospitals, all available
information was mined from Government authorized studies and statistical analysis, suchas the websites of the Ministry of Corporate Affairs, Ministry of Statistics & Programme
Implementation, and so on, to gain reliable and relevant information about these not-for-profit
hospitals and the sector overall.

ii. Identification of prominent not-for-profit hospitals
Based on our secondary research, and the inputs from industry experts and consultations at
NITI Aayog, we shortlisted 11 prominent not-for-profit hospitals were shortlisted (Fig.6) which
was a good representation in terms of locations – Tier1/2/3/Rural, Bed size– 100 to 3000
bedded Hospitals, and level of care – Secondary, Tertiary & Quaternary. These Hospitals
were contacted telephonically and after being informed adequately about the nature, purpose
and scope of the study, they gave their consent to participate in the studyiii.	Formal engagement of the top management members of these
hospitals and scheduling of interviews at pre-decided times
A formal invitation to the key stakeholders of the shortlisted hospitals was sent from NITI
Aayog, mentioning the nature, purpose, and scope of the study. After obtaining consent fromthese hospitals, a discussion was scheduled with the senior leadership to obtain specificinsights about the operating model of the hospitals, and the challenges they faced continually.

iv.	Formulation of a comprehensive questionnaire for interviewing
the top management members of identified hospitals
A targeted questionnaire was designed for the hospitals being interviewed to obtain objective
and subjective information from the senior leadership of these hospitals. The questions

20

Methodology

were grouped under the sub-topics of General Information, Operations & Business, Human
Resources, Quality and Community Impact, and were designed to provide adequate
quantitative and qualitative information. The questionnaire is attached as Annexure 1.

v.	Formulation of a list of specific data requirements from these
hospitals
In addition to the qualitative and quantitative information gained from the questionnaire,
an Information Request List (IRL) was designed to capture specific data points, which gave
quantitative insights, such as Volumes, ALOS, Occupancy, OPD and IPD pricing, and soon, for the shortlisted hospitals. The hospitals were also requested to provide their recent
financial statements. This is attached as Annexure 2.

vi. Collection and analysis of specific data
The data received from the hospitals during the interviews and as a response to the IRL wasgrouped, tabulated, and analyzed to provide meaningful insights about the above-mentioned
objectives of the study.

Category

Faith based

Community
based

Cooperative
Hospitals

PrivateTrustsHospitals
interviewed

4

2

3

2

Kasturba Hospital,
Sewagram (Hosp-8)
SEWA Rural,
Jhagadia (Hosp-6)
Dr Hedgewar Rugnalaya,
Aurangabad (Hosp-5)
PD Hinduja National & ResearchCentre, Mumbai (Hosp-11)

Basavatarakam Indo-American
Cancer Hospital, Hyderabad (Hosp-10)

GujratMaharashtra
Karnataka

Shushrusha Citizen's Cooperative
Hospital, Mumbai (Hosp-7)
Amrita Institute of Medical
Sciences, Cochin (Hosp-3)

Makunda Christian Leprosy &General Hospital, Assam (Hosp-1)

Assam

KeralaAndhraPradeshSri Sathya Sai Central Trust
Hospitals in Puttaparthi (Hosp-4)

Tamil Nadu

Christian Medical College,
Vellore (Hosp-2)
EMS Namboodripad,
Perinthalmana (Hosp-9)

Fig.6: The Hospitals identified under the defined categories
This map is not to scale. It is an indicative outline intended for general reference use only.
The accuracy of this product is dependent upon the source data and therefore absolute accuracy for navigation or legal
purposes cannot be guaranteed.
The above mentioned hospital numbering (Hosp-1, Hosp-2... Hosp-11) is kept consistent through the entire document.

21

6
Key Findings
Based on the detailed deliberations with the top management members of the selected hospitals
between December 1, 2020 and December 22, 2020, and the analysis of the specific data provided
by them, the following are the key findings:

i.

Most of the not-for-profit hospitals charge lower than the forprofit hospitals

The cumulative cost of care at not-for-profit hospitals is lesser than for-profit hospitals by about
one-fourth in the in-patient department. This is reckoned by the package component of cost,which is approximately 20% lower, the doctor’s or surgeon’s charges, which are approximately
36% lower and the major aspect being the bed charges, which are approximately 44% lower
than the for-profit hospitals.
Table 2: Average Medical Expenditure (for Hospitalization Cases) in INR
Hospital Type

Cost item

Government
Settings*

For-Profit
Settings

Not-for-profit
Settings

All

Package component

557

10060

7959

6012

Doctor's/Surgeons Fee

179

5710

3674

3332

Medicines

2184

6903

5680

4888

Diagnostic Tests

791

3038

2658

2084

Bed Charges

128

3690

2062

2150

Others

612

2444

2201

1668

Total

4452

31845

24233

20134

Source:NSS 75th round survey

		*Cost considered for Government settings is only Out-of-pocket expenditure by patients, in addition to this,Doctor’s salaries, consumable costs etc., are borne directly by the Government.
		

The above charge structure is not specific to any ailment as studied in the NSS 75th round survey.

The cumulative cost of OPD care (Table .3) in not-for-profit hospitals is about one-third lesser
than private for-profit hospitals. The NSS 75th round data revealed that the not-for-profit hospitals
provide medicines to patients at about 26% lesser than the for-profit hospitals, while the doctor’sfees are approximately 18% lower in not-for-profit hospitals.

Key Findings

Table.3: Cumulative Price comparison with other types of Hospitals (OPD)
Hospital Type

Cost item

Government
Settings*

For-Profit
Settings

Not-for-profit
Settings

All

Medicines

272

683

396

447

Diagnostic Tests

36

167

211

80

Doctor’s Fee

8

151

105

85

Other

15

52

20

24

Total

331

1062

732

636

Source:NSS 75th round survey

		*Cost considered for Government settings is only Out-of-pocket expenditure by patients, in addition to this,Doctor’s salaries, consumable costs etc., are borne directly by the Government.
		

The above charge structure is for one treatment episode on OPD basis as studied in the NSS 75th round survey.

A glance at the basic price comparison (Fig.7) of the different categories of not-for-profit hospitals
against a for-profit hospital shows that Faith-based Hospitals and the Community-Based Hospitalcharge lower OPD consultation charges than the for-profit hospital. The General Ward Chargesof the Faith-based Hospitals, Community-based Hospital, and the Cooperative Hospital, are lower
than the for-profit hospital. The ICU charges of the Faith-based Hospitals, Community-Basedhospital, and the Cooperative Hospital are lower than the for-profit hospital.
9,500

10,000
9,000

9,000

8,000
7,000

6,195

6,000
5,000
4,000
3,000
1,700

2,000
1,000
0

3,000

2,600 2,500
1,000
50

235

100

Hosp-1

Hosp-2

Hosp-5800

Hosp-7 Hosp-11 For Profit

OPD Consultation

1,450

1,000
100

200

Hosp-1

Hosp-2

Hosp-5525

500

Hosp-7 Hosp-11 For Profit

Hosp-1

General Ward Bed Charges

Hosp-2

Hosp-5Hosp-7 Hosp-11 For Profit

ICU Bed Charges

Fig.7: Basic Price comparison with a for-profit Hospital
Source:Primary discussions with stakeholders		

Hospital Number is taken from Fig.6

ii. OPD prices of Rural Community Based Hospital are lower, while
Rural Cooperative Hospital prices are comparable with CGHS
Delhi rates (Fig.8)
The OPD and Diagnostic charges of pathology and radiology for routine investigations suchas Complete Blood Count, X-ray Chest, Lipid Profile, Fasting Blood Sugar, Ultrasonography of
Abdomen, Electrocardiogram and OPD Consultation (General Medicine) was compared for thehospitals under the study. A Price Index was calculated with the CGHS Delhi NCR rates as thebase rate and the other hospital’s price index was mapped accordingly.

23

Study on the Not-for-Profit Hospital Model in India

Category

Community
based

Faith based

Cooperative
Hospitals

450

PrivateTrusts

CGHS

420

400
333

Pricing Index

350
300
250

150
100

168

161
110

100
54

50
0

212

212

200

CGHS

Hosp-1

Hosp-2

Hosp-5Hosp-6

Hosp-7

Hosp-8Hosp-9Hosp-10

Fig.8: Specific OPD Investigation price index comparison with CGHS Delhi Rates.
Source:Primary discussions with stakeholders		

Hospital Number is taken from Fig.6.

When compared to the CGHS Delhi rates, the overall price indexing shows that the Out-patient
Department price index of Rural Community-based Hospital (54) is lower, while the Rural
Cooperative Hospital price index (110) is comparable with CGHS Delhi rates. The prices of theFaith-based Hospitals – Rural (168) and Tier 2 (333), Tier 2 Community-Based Hospital (212), Tier
2 Cooperative Hospital (161), Tier 1 Cooperative Hospital (420), and the Private Trust Hospital(212), are higher than the CGHS Delhi price index.
The CGHS Delhi applicable prices are as of 2014 and are pending revision.

iii. IPD prices of the Rural Community-based Hospital are 40–60%
lower, while Rural Cooperative Hospital prices are on par withCGHS Delhi prices and ABPMJAY prices (Fig.9)
Category

600

Faith based

Community
based

Cooperative
Hospitals

CGHS

ABPMJAY
507

492

500
445

Pricing Index

400
322

300
200
176

100
100

125

115

50
0

59

CGHS

ABPMJAY

Hosp-1

Hosp-2

Hosp-5Hosp-6

Hosp-7

Hosp-8Hosp-9Fig.9: Specific IPD (end bill to patient) price index comparison with CGHS Delhi and ABPMJAY Rates.

24

Source:Primary discussions with stakeholders		

Hospital Number is taken from Fig.6.

Key Findings

The end price to the patient for common IPD procedures such as Normal and Cesarean Deliveries,
Hysterectomy, Appendectomy, Cataract, ORIF, Laparotomy and Cholecystectomy was compared
for the not-for-profit hospitals under the study. A Pricing Index was calculated with the CGHS
Delhi rates as the base rate and the same was benchmarked against the ABPMJAY rates.
The comparison revealed that the Rural Community-based Hospital charges are approximately
40–60% lower than the CGHS Delhi NCR rates and the ABPMJAY rates. The prices of the Faithbased Hospitals – Rural (176) and Tier 2 (445), Tier 2 Community-based Hospital (322), Tier 2
Cooperative Hospital (507), Tier 1 Cooperative Hospital (492).

iv. Most of the Not-for-profit Hospitals are empaneled with Stateor Central Government Healthcare schemes (Table.4)
Table.4: Empanelment status with State and Central Government Health Schemes
Faith Based
Hosp-1

Hosp-2

Community Based
Hosp-6

Cooperative
Hospitals
Hosp-7 Hosp-8

Hosp-3Hosp-4Hosp-5

Assam
State
Arogya CMCHIS None
Schemese
Nidhi

NA (Freeto all)Mukhyamantri
MJPJAYMJPJAY Amruta, Chiranjeevi
MJPJAY Karunya Arogyasri
appliedBal SabhaNone

ABMJAYNA (Freeto all)

None

None

None

Hosp-9

Private Trusts
Hosp-10 Hosp-11

CGHS/
ECHS
ESI
Service provided

Almost all of the identified not-for-profit hospitals are empanelled either with the State Health
Schemes of their respective State, or with the Central Government Health Schemes such as
the Central Government Health Scheme (CGHS), Ayushman Bharat- Pradhan Mantri Jan Arogya
Yojana (ABPMJAY), Ex-servicemen Contributory Health Scheme (ECHS), and Employees State
Insurance (ESI).

v. The not-for-profit hospitals use various levers to facilitate their
low cost of clinical care and reduced operational expenditurea.

Human resource levers
Human resource costs make up a significant amount of the operational expenses in hospitals.
The discussions with the selected hospitals showed the following levers, which they used tokeep the human resource cost as low as possible:


Salaries of doctors are 50–75% lower than market benchmarks:
The Faith-based Hospitals and Community-based Hospitals had set a conscious ceiling
limit of salaries for their senior doctors who are unanimously likeminded to serve
humanity. In contrast, doctors at for-profit corporate hospitals earn a much higher salary,25

Study on the Not-for-Profit Hospital Model in India

which also increases with the doctor’s seniority and growth in position. For example, ina Rural Faith-based Hospital, a Pediatric Surgeon with over 30 years of work experience
receives a meager salary of INR 1 lakh per month, which would be approximately
20–30% of the salary that a consultant with comparable experience would expect to
get in a for-profit hospital.


Salaries of staff are ~20–30% lower than market benchmarks:
The staff at Faith-based and Community-based Hospitals and Tier 2 Cooperative Hospitals
was working at lower salaries than what they would earn at a for-profit hospital.



Multitasking workforce reduces the number of total staff required:
The doctors and staff of the Faith-based and Community-based Hospitals (in three hospitals
in the study) were undertaking more activities than their routine job description. Doctors
were performing managerial functions, which reduces the need for administrative staff.

b. Infrastructure and equipment levers
The discussions with the selected hospitals also revealed that as most of them depended on
external funding for capital expenditure; they made judicious use of the resources provided
to them to achieve cost optimization and customization of services, according to the needsof the target population in the following manner:


90–95% general ward beds:
Some of the Faith-based and Community-based Hospitals had a greater number ofgeneral ward beds and negligible number of private ward beds. This was in line with
their purpose of low-cost care and it helped in reducing infrastructural costs.

Energy-efficient construction and judicial installation of air conditioning:
Some of the Faith-based and Community-based Hospitals especially had their majority
of beds without air conditioning and their in-patient rooms had windows to the outsideof the building. This allowed natural light in the rooms and ambient ventilation.

In-house manufacturing of equipment, such as beds, dental chairs:
One of the Faith-based Hospitals has ventured into in-house manufacturing of equipment,
which helps them reduce purchase costs from external vendors.



Using high cost equipment beyond the recommended lifespan:
Most of the Faith-based and Community-based Hospitals use their diagnostic andother equipment for much longer than the recommended lifespan. They could ensure
quality and efficiency because of highly competent biomedical engineers and robust
maintenance regimes.



Scavenging for usable parts from condemned equipment:
Some of the Faith-based Hospitals were salvaging usable parts from condemned
equipment and using them as spare parts for existing equipment, with the help of highly
competent biomedical engineers.

26

Key Findingsc.

Hospital operations levers
The qualitative and quantitative analysis of the selected hospitals revealed their use of thefollowing lean operations based on the analysis of their volumes, health seeking behavior,and paying capacity of their target population:


Cross-subsidization – This was commonly found across all the categories of nor-for-profit
hospitals, as follows:

Across patients – The revenue from patients who paid full charges were used tocross-subsidize the bills of the patients who could not pay the full charges.



Across departments based on volumes – In one of the Faith-based Hospitals, therevenue from departments that had high volumes and a significant margin of revenue
above the cost price was used to cross-subsidize the services of other departments.



Most of the Tier 2 and rural not-for-profit hospitals used generic low-cost medicines andengaged in direct procurement from the manufacturers at lower prices.



Most of the Tier 2 and rural not-for-profit hospitals spent only a minimal amount onmarketing activities. They also had a no-referral commission policy.



Most of the not-for-profit hospitals could break even and be self-sustaining at low costs
because of the high volume of patients utilizing their services.



One Faith-based Hospital and one Private Trust Hospital had highly competent Anesthesia
teams, which enabled them to perform many day care surgeries. This helped themincrease productivity in the utilization of their services.

d. Operational expense levers
One of the indicators for cost-efficient operations is the management of operational expenses.
Despite the relatively low pricing of services, a significant number of patients are unable to
pay their bills, which potentially affect operational cash flows. The qualitative and quantitative
analysis of the interviewed hospitals revealed the following practices to manage operational
expenses:

Some of the not-for-profit hospitals could engage in a mutual understanding withcorporates, non-governmental organizations, and other willing donors, for funding thedues of certain non-affording patients.

Almost all hospitals have no debt, as the capital expenses are mostly funded byGovernment grants or by donations from philanthropists. Thus, they can re-use theirrevenue on operational expenses

vi. Not for profit Hospitals have lower operating costs ascompared to For-Profit Hospitals (Fig.10)
The recent financial statements of certain Not-for-Profit Hospitals were analysed in detail. The
cost categories were grouped under Employee costs, Material Costs, Repair & maintenance Costs,
Electricity & fuel costs and even other miscellaneous operating costs. In comparison to the industry
benchmarks (which is an average of professionally run Hospitals in Tier 1 cities which are 200
beds or above and in Tier 2 cities which are 100 beds or above), it was found that the interviewed

27

Study on the Not-for-Profit Hospital Model in India

Not-for-Profit Hospitals spent lesser amounts on the above mentioned cost heads. The operating
cost per bed was also significantly lower than the industry average of operating costs in Tier 1& Tier 2 cities.

Category
Faith based
Community
based
Cooperative
Hospitals
PrivateTrustsInd Avg.
(Tier 1)
Ind Avg.
(Tier 2)

*Industry average is an average of professional run greater than 100 bed hospital; Tier 2 being for 100 bedded and Tier 1
being for 200 bedded Hospitals. All costs shown as per bed per day.
Source: Discussions with stakeholders and PwC analysis.
		 Hospital Number is taken from Fig.6.

Fig.10: Breakup of Operational Costs of Not-for-Profit Hospitals

28

Key Findingsvii. Focus on Quality practices
This study found a strong focus on quality care across all categories of not-for-profit hospitals,
as most of them had some form of accreditation for their services (Table 3). They also hadstrong Internal Quality Assurance teams, which performed clinical audits and utilization
audits regularly. Additional Accreditations include ISO 270001:2015, TÜV (OHSAS), Collegeof American Pathologists, HACCP, and so on.
Table.5: Accreditation status of the not-for-profit Hospital categories
ISO 9001

NABH (Entry Level
complete)

Additional
Accrediations*

Faith Based

Not Accredited

Accredited

Not Accredited

Community Based

Not Accredited

Accredited

Not Accredited

Cooperative Hospitals

Not Accredited

Accredited

Not Accredited

Accredited

Accredited

Accredited

Private Trusts*Additional Accreditations include ISO 270001:2015, TÜV (OHSAS), College of American Pathologists, HACCP etc.

29

7Challenges Facedby the Not-forProfit Hospitals

In the interviews, the top management of the selected hospitals reported various challenges thatwere critical to their operations and sustenance. Using the Mini-Delphi method, we arranged thechallenges in the decreasing order of criticality and applicability to all interviewed hospitals, as
follows:i.

Recruitment and retention of doctors & staff
Most of the hospitals find it difficult to recruit and retain doctors and staff because of thefollowing reasons:

Two of the Faith-based and two of the Community-based Hospitals stated that the lower
salaries offered than the for-profit hospitals form a hindrance, especially, for recruiting
specialist and super-specialist consultants.



Five of the interviewed hospitals stated the remoteness of location of the hospitals,
especially those in rural areas, as a challenge. Although these hospitals provide oncampus accommodation, as they lack many basic facilities for living in rural areas, notmany doctors and staff would join them or continue for a long time.

Owing to the above-mentioned reasons, one of the Rural Cooperative Hospitals has
a high volume of patients with cardiac ailments; however, they have been unable torecruit a full-time cardiologist. They depend on a cardiologist visiting from the nearest
available Tier 2 City thrice a week to perform cardiac procedures.

ii. Reimbursements for treatment of Government health scheme
beneficiaries
As Table.4 shows, most of these hospitals are empaneled with State or Central Government
Health schemes, and they offer treatment to a significant number of beneficiaries.


Most of the interviewed hospitals have cited perennially delayed reimbursements andlong-pending amounts, despite their persistence, causing strain in their cash flows, andin turn, burdening their operations.

Challenges Faced by the Not-for-Profit Hospitals

Two of the Private Trust Hospitals also have reported that for some of the procedures,
especially, where there are added procedures due to perioperative complications, there
are no set codes, and thus, the hospitals must absorb the additional cost. This is also achallenge that other stakeholders in the Healthcare industry face, such as the for-profit
hospitals.

iii. Infrastructure and equipment expansions
Many of these hospitals are dependent on external funding in the form of philanthropy andgrants for capital expenditure components, such as infrastructural expansion, purchase of newtechnology, and advanced equipment. Some hospitals could contribute only a small amountof their operational revenue toward the purchase of much-needed new equipment, andhence, can only purchase/expand with the help of external funding.


Three of the Faith-based and one of the Community-based Hospitals reported instancesof delay in expansion project approvals from regulatory bodies.

One Faith-based Hospital reported an overall time frame of five years for the regulatory
permission to operationalize a newly constructed additional wing.

iv. Regulatory challenges
Some of the hospitals, especially those in remote areas, reported challenges because of thehigh compliance burden of staffing requirements of the Regulations for running a blood bank,
Clinical Establishments Act, PNDT Act, and Quality standards.


The Rural Faith-based Hospital and the rural Community Hospital have difficulty inrecruiting a full-time pathologist for the manufacture of blood products/ plasma in a
blood bank; hence, they are dependent on an external blood bank far away, whichcauses inconvenience to patients’ relatives and donors.

Some of the hospitals in rural areas also reported a high burden of paperwork andrecord keeping in addition to the challenges with periodic online submission of reports
for certain regulatory compliances.

Fig.11 Challenges faced by the Not-for-Profit Hospitals in a Criticality vs Count matrix
Source: Discussions with stakeholders

31

8

Proposed Policy
Interventions
to Promote theNot-for-Profit
Hospital Sector

The proposed policy interventions have been classified into four broad categories: Identification
and Promotion, Leveraging Expertise, Human Resources, and Finance based on the nature ofrecommendations. In addition, they have been classified into Short Term and Long Term.
Table.6: Proposed policy interventions to promote the Not-for-Profit Hospital Sector
with the proposed timeline
Identification &Promotion
Short Term

 Develop criteria
to identify these
Hospitals
 Develop
Mechanisms
to rank these
Hospitals on a
performance Index
 Create a national
level portal/
directory of these
Hospitals

Long Term

Promote the top
hospitals for facilitating
philanthropy,
investments andpatient flows

Leveraging
expertise

Human Resources

Financial

Representatives ofhigh-performing
not-for-profit
Hospitals
across different
geographicallocations can be
invited to shareexperiencesin relevant
policy making
committees

Posting ofGovernment Medical
College students
for their mandatoryinternships inthese hospitals(To be explored inaccordance with
Medical Educationlaws)

 100% exemption for
donations (Section
80G) (Currently 50%)

Involving highperforming
Hospitals in
PPP models for
managing PHCs,
operations ofGovernment
Facilities, PSU
Hospitals

 Develop amechanism toincentivize superspecialists towork in remoteareas.

 Extension of a lowcost credit line (Esp.
Working Capital
Loans)
 Income Tax exemption
for membership fees
paid at Cooperative
Trust Hospitals
 Single window
clearance for Govt.
reimbursements

 Revisiting of
the compliancerequirements ofregulations like
CEA, PNDT,Blood Bank

 Grant in Aid scheme(Similar to Gujarat
Model)
 Timely allocation of
unencumbered landProposed Policy Interventions to Promote the Not-for-Profit Hospital Sector

SHORT TERM
a. Identification and promotion
Develop criteria to identify these hospitals
Formulation of objective criteria such as type, size, location, level of care offered and theirownership, infrastructure and equipment expansion initiatives, community engagement initiatives
along with their latest photographs/videos, and so on.

Develop mechanisms to rank these hospitals on a performance index
Creation of a rating scale based on the volume of services utilized annually, the extent of charity
work done, impact on the community health indicators of the location, operational efficiency,
and self-sufficiency, to rank the top few hospitals (e.g., Top 50, which can be determined later
based on the details received from the hospitals).

Create a national level portal/directory of these hospitals
Creation of a national portal/directory in the public domain, wherein all the not-for-profit hospitals
can be listed to highlight the hospital and its functions in the public domain.

b. Leveraging expertise
Representatives of high-performing not-for-profit hospitals across different
geographical locations can be invited to share their experiences in relevant
policymaking committees
The not-for-profit hospitals have vast experience in providing low-cost high-quality care to theunreached sections of society, some of them existing since before India’s Independence, yet, theyremain largely unknown and understudied. To obtain a comprehensive understanding of the sector,
and to tap into this vast expertise, the representatives of high-performing not-for-profit hospitals
across different geographical locations can be invited to relevant policymaking committees.

c. Human resources
Representatives of high-performing not-for-profit hospitals across different
geographical locations can be invited to share their experiences in relevant
policymaking committees
The not-for-profit hospitals have vast experience in providing low-cost high-quality care to theunreached sections of society, some of them existing since before India’s Independence, yet, theyremain largely unknown and understudied. To obtain a comprehensive understanding of the sector,
and to tap into this vast expertise, the representatives of high-performing not-for-profit hospitals
across different geographical locations can be invited to relevant policymaking committees.

33

Study on the Not-for-Profit Hospital Model in Indiad. Financial
100% exemption for donations under section 80G
Income-tax exemption could be increased from the current 50% exemption to 100% exemption forphilanthropy toward the identified not-for-profit hospitals. This could be a catalyst in channelizing
the much-needed funds to deserving hospitals.

Extension of a low-cost credit line (esp. working capital loans)
The Government can consider the provision of working capital loans with lower interest rates,
which would be more financially viable for the not-for-profit hospitals and would assist in adequate
cash flows during times of need.

Income-tax exemption for membership fees paid at Cooperative Trust
Hospitals
To enable higher membership at Cooperative Trust Hospitals, enabling them to achieve their goalof self-sufficiency in healthcare through self-participation, Income-tax exemption can be given formembership fees paid at Cooperative Trust Hospitals.

Single window clearance for Government reimbursements
Most of the not-for-profit hospitals reported long-pending reimbursements for the treatments ofGovernment scheme beneficiaries, which remain uncleared despite persistent follow-ups. The
timely release of these funds can be a substantial boost to their working capital for operations.

LONG TERM
a. Identification & Promotion
Promote the top hospitals for facilitating philanthropy, investments andpatient flows
The Top 50 hospitals should be prominently displayed along with the amount of funding received
over a specific timeline, the amount of funding needed for capital expenditure, and the appropriate
channel for philanthropy and investment, clearly and transparently. These could be listed on
philanthropy-based portals, after adequately verifying the credentials of such hospitals.

b. Leveraging of expertise
Involving high performing Hospitals in PPP models for managing PHCs,
operations of Government Facilities, PSU Hospitals
One Faith-based, one Community-based, and one Private Trust Hospital mentioned that they areinterested in using expertise in provision of cost-efficient high-quality healthcare to the unreachedand underprivileged in association with the Government by professionally managing PHCs,
PSU Hospitals, and other Government facilities. They perceive that they can use the available
infrastructure of the existing Government facilities and achieve efficient utilization to promote
Health for All. The National Health Mission guidelines on Public Private Partnership can be used
for such endeavors.

34

Proposed Policy Interventions to Promote the Not-for-Profit Hospital Sectorc. Human resources
Revisiting the compliance requirements of regulations such as CEA, PNDT,Blood Bank
It is necessary to customize the mandatory manpower requirements of the above-mentioned
regulations to make them more relevant to the realities of the remote areas, making them lesscumbersome for these hospitals, who genuinely wish to serve the unreached and underprivileged
with the available low resources. Provision can be made for the representation of top management
members of these not-for-profit hospitals in decision-making committees to understand theirperspectives and practical challenges.

Develop a mechanism to incentivize super-specialists to work in remoteareas
To mitigate the manpower scarcity challenge, super-specialist doctors should be given someincentives and motivation to engage with hospitals in remote areas where there is a dire needfor their services. These identified hospitals can be granted a certain amount of remuneration per
full-time super-specialist associated with them.
The current e-Sanjeevni program can be integrated and the benefits of this program should be
extended to not-for-profit hospitals.
In addition, to foster learning, associations of Trust Hospital super-specialists in various specialties
can be created and linked virtually.
The penetration of telemedicine can be increased to facilitate e-consultation in unreached areas.

d. Operations & Financial
Grant-in-Aid scheme
Other States can consider the implementation of a Grant-in-Aid scheme similar to the Gujarat
Model, wherein the Government funds up to 75% of admissible costs of the not-for-profit hospitals.
The Grant is provided to various hospitals and dispensaries, run by voluntary organizations andcharitable trusts. The norms of allocation are as per Government Resolution dated December 19,
1991, Health & Family Welfare Department, Gandhinagar. This would enable better cash flows
for operational expenses and can possibly help in creating a fund for future expansions in termsof infrastructure or equipment.

Timely allocation of unencumbered landThis will help many not-for-profit hospitals who face operational delays in their expansion plan
because of permissions and regulatory clearances.

35

9Annexures
9.1 ANNEXURE 1–QUESTIONNAIRE
General1.

In the evolving mindset of hospital operations towards profitability, what is the inspiration
behind the current model of your Hospital’s operations?

2.

What is the current size (beds) of your Hospital? What is the average volume (OPD
Footfalls and IPD Occupancy & Daily/monthly surgery count)?

3.

How has your Hospital grown over the last 5 years (infrastructure/equipment etc.)

4.

What are the currently functioning branches / subcenters of the Hospital ?

5.

What are the key focus areas of the Hospital services and why?

6.

What is your catchment area & target population within it?

7.

What is the management structure & governance mechanism of your Hospital?

Operations & Business1.

Can you please provide the list of Top 10 surgeries/procedures by volume?

2.

We understand that you charge a miniscule amount from patients, what would be theaverage end to end cost for these top 10 surgeries/procedures?

3.

What is the approximate CAPEX and OPEX?

4.

We understand your charging method which is considerably low as compared to theprivate Healthcare providers, are you able to breakeven?

5.

What do you do to keep the costs so low? Do you have to depend on external funding
sources like Gap funding/donations etc?

6.

What are the government schemes which you Hospital is empaneled with? E.g. ABPMJAY, CHGS, ESI, State Programmes etc.

7.

What are the top 5 challenges which the Hospital faces?

8.

What are the innovative strategies practiced by your Hospital?

Human resources
1.

What is the approximate number of clinical and non-clinical staff at your Hospital?

2.

What is the engagement model (full time/fixed salaries/ honorarium etc.) for the doctors?

3.

Are your payouts to the manpower in line with the market standards?

4.

Do you have any employee engagement activities? How do you keep them motivatedin a challenging environment?

5.

What are the charges for treatment of staff at your Hospital?

Quality1.

Is your Hospital Accredited by any of the existing quality accreditation systems?

2.

What is your perception of Quality and the way it should be measured?

Community Impact
1.

What is the measured impact of the Hospital’s services on community Health indicators
like MMR, IMR etc? (optional)

2.

What have been the initiatives to develop trust and goodwill in the community you
serve?

3.

What in your opinion would be 3 major interventions with which the government canhelp you?

Study on the Not-for-Profit Hospital Model in India

9.2 ANNEXURE 2 – INFORMATION REQUEST LIST
1. Tariffs or the following OPD services:a) OPD Consultation (Internal Medicine)b) CBCc) Urine Routined) X-ray Cheste) Lipid Profilef) Fasting Blood Sugarg) USGAbdomenh) CTBrain Plaini) MRI Brain Plainj) ECG
2. Total Bill Amountfor the following IPDservices:a) Normal Deliveryb) Caesarean Sectionc) Coronary Angiographyd) Coronary Angioplastye) Total Knee Replacement (Unilateral)f) Cataract charges without lensg) Open Reduction Internal Fixationh) Laparotomyi) Image Guided Radiotherapyj) Hysterectomyk) Appendectomy1) Laminectomym) Cholecystectomy(In case theabove list has some procedures which are
not applicable to your Hospital, please substitute withany of the Top 5 procedures done at your Hospital)
3. Average volumes (2019-2020)a) OPD Footfallsb) IPD Occupancyc) Monthly surgery Count4. Bed Chargesa) General Wardb) Private Wardc) ICU
5. Latest Financial Report (as a separate attachment)

38

PricesAmrita Institute ofMedical Sciences, Kochi

Christian Medical
College, Vellore

Makunda Christian
Leprosy & General
Hospital
Separate charging structure for non-affording
patients and affording patients

Geographic presence – Karimganj District,Assam; Small Branch in Tripura

No of Units / Beds – 2/200

Depends on Grants for CAPEX
Cross subsidization from revenues of highvolume departments
Separate charging structure for non-affording
patients and affording patients

Level of care – Tertiary to Quaternary

Geographic presence – Vellore, Tamil Nadu;
units in different locations

No of Units/Beds – 7/3000

Depends on Grants for CAPEX
Separate charging structure across units for
non-affording patients and affording patients

Level of care – Tertiary to Quaternary

Geographic presence – Kochi, Kerala;upcoming unit in Faridabad

Governance - Board of Trustees (devotees
from the Math), a Medical Director and a
Chief Medical Superintendent.

No of Units /Beds- 1/1350

The Hospital is self-reliant for OPEX & CAPEX.

Year of inception - 1998

Governance - CMC Vellore Association - theapex body, a Governing council, an Executive
Committee

No of beds – 3000

The Hospital is self- reliant for OPEX.

Year of inception - 1900

Governance – Makunda Christian Leprosy &General Hospital Society, Emmanuel Hospital
Association

Cross subsidization from revenues of highvolume departments

Level of care – Secondary

Operating Model
The Hospital is self- reliant for OPEX andCAPEX.

Year of inception – 1993

About the Hospital

9.3 ANNEXURE 3 – BRIEF HOSPITAL PROFILES

Priority in recruitment for trained tribals
in level 3 staff.

Vocational Training for Tribals

Regular Health camps in neighboring
tribal areas

The Community health and development(CHAD) program under the Community
Health Department of CMC, Vellore
covers approximately 200,000 in therural, urban and tribal community areasof Vellore Districts.

The Hospital has conducted detailed
research into its target population tocustomize the services and tariffs.

The Hospital engaged and trained the
local ASHAs to increase institutionaldeliveries and reduce the MMR & IMR at
Karimganj District by almost 50%

Key Community Engagement activities

Annexures39

40

Sewa Rural Kasturba
Hospital, Jhagadia

Dr Hedgewar
Rugnalaya, Aurangabad

Sri Sathya Sai Central
Trust Hospitals,
Puttaparthi(Sri Sathya Sai General
Hospital, Prasanthi
Nilayam, Puttaparthi& Sri Sathya Sai
Institute of Higher
Medical Sciences,
Prasanthigram,
Puttaparthi)

Depends on Grants for CAPEX
80% of the patients (General ward category)pay ~5% more than the basic cost priceof services, the remaining 20% of affording
patients (private ward category) pay ~25%
more than the basic cost price of services.

Level of care – Tertiary

Geographic presence – Aurangabad,
Maharashtra; Unit in Nasik and Shib Sagar,
Assam

95% general rooms and only 3 private rooms

Geographic presence – Jhagadia, Gujarat

Governance – Board of Trustees along with acore management group

Annual expenses of ~Rs 10 Cr of which~2Cr comes from its own revenue, 3 Cr fromreimbursement of Government schemes, and~3.5 Cr as grants/ donations

Depends on Grants for CAPEX

Level of care – Secondary

No of Units / beds – 1/225

The Hospital is self- reliant for OPEX.

Year of inception – 1980

Governance – Dr. Babasaheb Ambedkar
Vaidyakiya Pratishthan Charitable Trust

No of Units / beds – 1/300

The Hospital is self- reliant for OPEX.

The Hospital gives free treatment to all
patients irrespective of caste, creed, religion,socio-economic condition.

Operating Model

Year of inception - 1989

Governance – Board of Trustees of the
Sri Sathya Sai Central Trust

No of Units / beds – 2/570

Geographic presence – Puttaparthi, Andhra
PradeshLevel of care – Secondary & Tertiary

Year of inception – 1956 & 1991

About the Hospital

Took up the Jhagadia block having 6
PHCs and ~1.8 lakh population andshowed improvement in the community
health indicators

40 slums have a full-time resident doctor
staying in the slum areas and 8 rural
centers are being run at negligible costs

Reached out for medical care andsocial transformation to ~270 villages.
Annually ~300000 patients in
Aurangabad and ~100000 patients arereached out in Nashik through outreachcamps.

Mobile Hospital operates from the 1st
to 12th day of every month at 12 nodal
points (base villages) drawn from 6
mandals from Anantapur District. Serves
patients from 63 target villages alongwith the patients visiting from about
400 villages in the region free of cost.
Diagnostic bus has Pathology, X-ray, USG& Color Doppler, ECG, EEG etc. which
serves remote areas free of cost

Key Community Engagement activities

Study on the Not-for-Profit Hospital Model in India

EMS Memorial
Cooperative Hospital

MGIMS Kasturba
Hospital

Shushrusha Citizens
Cooperative Hospital

Depends on Grants for CAPEXMembers pay Rs 10,000 as lifetime fees, areentitled to the following benefits of Lifetime
discount of 25% for OPD Consultation
and IPD admission, 10% discount on
Investigations and medicines.

Grant-in-aid organization wherein Governmentof India, Maharashtra Government and the
Kasturba Health society share the expenditureof the Hospital & Medical College in the
proportion of 50:25:25

Level of care – Tertiary

Geographic presence – Dadar, Mumbai; unit
in Vikhroli, Mumbai

Year of inception – 1944

Governance – Board of Directors elected fromthe shareholders

No of Units / beds – 1/500

Geographic presence – Perinthalmanna, Kerala

Charges for non-members are ~30-35% lesser
than similar for-profit Hospitals

Membership can be availed by purchasing
shares of Rs 250/- per share. If a person
buys 400 shares @Rs 1 Lakh, he is given
free treatment at the Hospital for himself and
immediate family for the same amount for thatyear

Year of inception – 1998

Level of care – Tertiary

Annual Health Assurance Membership Cardfor Rs 100/- per person per year and give 50%
concession in OPD & IPD services.

Governance – Board of Trustees of Kasturba
Health Society

No of Units / beds -1/ 1000

Geographic presence – Sevagram, Maharashtra

Level of care – Tertiary

Governance – Board.

No of Units – 1/143

The Hospital is self- reliant for OPEX.

Operating Model

Year of inception – 1966

About the Hospital

Started a Tribal Health and socialtransformation project at Atapadi which
serves ~40000 tribal patients.

Dialysis unit with 6 Hemodialysis
machines, is performing 550 free dialysis
per month

Kisan Vikas Manch (Farmers’ club)provides learning for the members to
improve their agricultural yield improvetheir economic status

Achieved the formation of 3-4 Self HelpGroups per village, totally ~170 suchgroups in all the villages of its fieldpractice area; viz. PHC Anji, Gaul andTalegaon for women empowerment andhealth empowerment

The Hospital regularly conducts CPR
training for public.

The Hospital collaborates withneighboring colleges for Anemia
detection in girls (in line with the
National Anemia programme.

The Hospital runs a Senior Citizens
health education and awareness groupwhich meets every alternate week.

Key Community Engagement activities

Annexures41

42

PD Hinduja Memorial
National Hospital

Basavatarakam IndoAmerican Cancer
Hospital, Hyderabad

Separate charge structure for underprivileged
patients and for affording/international patients
Hospital compares the market rate of Private
Hospitals and intentionally positions its own
charges ~ 10-20% lower

The Hospital is self- reliant for OPEX.
Cross subsidize the treatment of theunderprivileged by the revenue generated bytreating the affording patients

Geographic presence – Hyderabad, Telangana

Governance – Board of Trustees of Nandamuri
Basavatarakam Ramarao Memorial Cancer
Foundation (NBTRCF)

Year of inception – 1951

Level of care – Quaternary

Governance – Board of Trustees, Governing
Council, an Executive Council and aprofessional management tire having the CEO,COO

No of Units / beds – 1/300

Geographic presence – Mumbai, Maharashtra
Hospital treats 10% of extremely
underprivileged patients free of cost and
10% of underprivileged patients with 50%
concession, Does additional charity also.

Depends on Grants for CAPEX

Level of care – Tertiary

No of Units / beds – 1/500

The Hospital is self- reliant for OPEX.

Operating Model

Year of inception – 2000

About the Hospital

Runs 12 mobile health clinics in therural area of Palghar having residential
staff which cater to ~100000 patientsannually

Cancer Screening Programs at a regularperiodicity

Cancer awareness and services to thepoor people in avail free cancer diagnosis
through CSP where more than 165000
people were screened in the last 15
years, 80 camps are done in a year and
CSP screens 15000 poor people

Key Community Engagement activities

Study on the Not-for-Profit Hospital Model in India

10
References
1.

Shailender Kumar Hooda, 2015. “Private Sector in Healthcare Delivery Market inIndia: Structure, Growth and Implications,” Working Papers 185, Institute for Studies inIndustrial Development (ISID).

2.

Split of Public and Private beds is taken as 40:60 as per industry estimates; Current
Supply – Different Sources have put current bed density between 0.7 – 1.1. [0.7 as perworld bank 2012, 0.9 as per AHPI – Association of Healthcare Providers (India), 1.3
as per FICCI Heal 2016, 0.95 as per IBEF – India Brand Equity Foundation] – Current
Nos. are shown assuming a density of 1 bed per 1000 population

3.

Ministry of Statistics & Programme Implementation http://mospi.nic.in/sites/default/files/
publication_reports/KI_Health_75th_Final.pdf (NSS); Date Accessed - 1/12/2020

4.

Ministry of Statistics & Programme Implementation http://mospi.nic.in/sites/default/files/
publication_reports/Final_Report_Non-Profit_Instiututions_30may12.pdf (CSO) (now
NSS) Date Accessed - 1/12/2020

5.

Comptroller & Auditor General https://cag.gov.in/webroot/uploads/download_audit_
report/2017/Report_No.27_of_2017_-_Performance_audit_Union_Government_
Assessment_of_Private_Hospitals_Reports_of_Department_of_Revenue_-_Direct_Taxes.
pdf Date Accessed - 1/12/2020

6.

Makunda Christian Leprosy & General Hospital http://www.makunda.in/ Date Accessed- 12/12/2020

7.

Christian Medical College, Vellore https://www.cmch-vellore.edu/ Date Accessed11/12/2020

8.

Sri Sathya Sai Central Trust Hospitals, Puttaparthi https://sssmt.org.in/ Date Accessed11/12/2020

9.

Amrita Institute of Medical Sciences, Kochi https://www.amritahospitals.org/ Date
Accessed- 15/12/2020

43

Study on the Not-for-Profit Hospital Model in India

10. Dr Hedgewar Rugnalaya, Aurangabad https://www.hedgewar.org/ Date Accessed04/12/2020
11. Sewa Rural Kasturba Hospital, Jhagadia https://sewarural.org/ Date Accessed- 11/12/2020
12. Shushrusha Cooperative Charitable Trust Hospital, Dadar http://www.shushrushahospital.
org/ Date Accessed- 5/12/2020
13. Mahatma Gandhi Institute of Medical Sciences, Sevagram https://www.mgims.ac.in/index.php/contact-us?showall=1Date Accessed- 16/12/2020
14. EMS Memorial Cooperative Hospital, Perinthalmanna https://emshospital.org.in/ Date
Accessed- 24/12/2020
15. Basavatarakam Indo-American Cancer Hospital, Hyderabad https://induscancer.com/
Date Accessed- 1/12/2020
16. PD Hinduja Hospital, Mahim https://www.hindujahospital.com/ Date Accessed8/12/2020

44

Contact:
Health vertical
NITI Aayog, New Delhi
Email: health-pc@gov.in
Tel: 91-11-23042547
ISBN: 978-81-949510-1-8

Designed by