One of the most significant trends emerging in the wake of liberalization is the new vigour of the entry of corporate hospitals and multinationals in the health care scenario. The reason for this new tempo is the potential that India offers to NRIs and multinationals. With the current ratio of population to all types of beds being 1300: 1, it has been estimated that there is a huge demand?supply gap which may require nearly 3.6 million beds to overcome it. Taking into account the requirements of primary and secondary health care, the shortfall is estimated to be around 2.9 million beds. In tertiary health care, the gap may be somewhere around 20% of the above total, which amounts to some 0.58 million.

With investment costs per bed per year (including land, building, equipment, support system and medical consumables) ranging from Rs 0.7 million to Rs 3.5 million depending upon the nature of specialty, the resource requirements are enormous. Further, from a survey conducted by the Confederation of Private Sector Initiatives in Health Care, it is estimated that against a requirement of 60 000 super-specialty beds each year, only 3000 multi-specialty beds are being planned in India, which may cost around Rs 7200 million over the next 3 years.

Growing NRI investment in the hospital industry

Realizing the need, the potential for profit and from a desire to develop the States of their original domicile, many NRIs from the USA and UK have taken interest in the development of health care diagnostics or super-specialty hospitals in their hometowns. Between August 1991 and August 1997, the Foreign Investment Promotion Board (FIPB) approved foreign direct investment (FDI) proposals worth US$100 million (about Rs 3600 million) in the Indian health care sector.

The major chunk of this FDI (Rs 1160 million) goes to Delhi, helping in the development of a super-specialty hospital and diagnostic cen tres. Other places in the country to benefit from this NRI investment include Guntur in Andhra Pradesh, Bhuwaneshwar in Orissa (Rs 30 million), Calcutta in West Bengal (Rs 80 million) and Bangalore in Karnataka (Rs 0.6 million). These investments in States other than Delhi are

mostly focused on diagnostic centres and bring with them high-tech care, advanced medical technology and trained Indian medical manpower. This is partly halting and reversing the brain-drain of medical personnel.

Hospital has become a corporate entity

Health care is thus emerging as a blue-chip industry and in recent years has attracted the investment of both domestic and foreign companies. Unlike the earlier image of the private sector, which mainly focused on nursing homes and polyclinics, the new market orientation is towards super specialty care. In this regard, although the pioneering efforts were made way back in 1983 by a group known as Apollo, a number of other companies have now entered the market.

Notable among the latter include successful domestic and foreign companies like CDR, Wockhardt, Medinova, Duncan, Ispat, Escorts, Mediciti, Kamineni, Parkway, Jardine, Nicholas and Sedgwick.9,10 The entry of so many such companies has added towards corporatization of the healthcare industry with a focus on high profit-margin, super specialty and diagnostic care. Mostly these companies have expanded their network in
India's major metropolitan towns.

Increasing participation by multinationals

Given the rising cost of health care in the last 5 years, the foreign companies are aiming to capture the potential of the health insurance market for nearly 135 million people in the upper-middle income segment of the population who can afford private health care. Against an estimated potential health insurance market of between Rs 6500?275 000 million, the present annual health insurance premium market by the General Insurance Corporation and its subsidiaries is merely Rs 1000 million, covering just 1.6 million people. In view of the possible opening of the market to multinationals, many foreign companies have already taken preliminary steps, such as setting up their representative offices or entering into ties with Indian companies.

These companies aim to devise health insurance schemes suited to the Indian situation, to improve coverage by incorporating payments for general physicians (GP), medical tests and specialist charges, and containing costs through appropriate controlling systems. Besides health insurance,

the high-tech, medical, electronic equipment industry has been the other area to attract investment by multinationals following liberalization.

This is due to the high-tech nature of modern diagnostics, which is based largely on foreign technology having a high obsolescence rate of around 5 years and thus high replacement needs. In general, a reduction on import duties on individual components, and high rates of import duties (up to 31'37%) on high-tech finished products (like CT scanners), have together encouraged multinationals to assemble the imported components in India. Consequently, of total imports of medical equipment (Rs 4500 million), more than half (Rs 2800 million) comprise locally assembled medical electronics (like X-ray, ultrasound, CT scanners, patient monitoring equipment, etc.), with the remainder constituting other electronic medical products (like sterilizers, endoscope accessories etc.).