Diagnostic Industry Analysis

Industry Analysis

MACROECONOMIC OVERVIEW OF INDIA

A review of India’s GDP growth
In 2015, the Ministry of Statistics and Programme Implementation (“MoSPI”) changed the base year for calculating the gross domestic product (“GDP”) between fiscal year 2005 and fiscal year 2012. Based on this, India’s GDP increased at an eightyear compound annual growth rate (“CAGR”) of 6.6% to ₹ 146 trillion in fiscal year 2020 from ₹ 87 trillion in fiscal year 2012.

After contracting in the first half of fiscal year 2021 because of the Covid-19 pandemic, the economy rebounded in the second half, growing 0.5% and 1.6% on-year in the third and fourth quarters, respectively. While the economy shrank as a whole in fiscal year 2021, agriculture and allied activities, and electricity, gas, water supply and other utility services were the outliers, logging positive growth. On the other hand, contact-intensive trade, hotels and transport sectors, and services related to broadcasting were hit the most and continued to shrink in all the quarters. Construction – a labour-intensive sector – was also severely hit in the first half, but rebounded in the second half.

Fiscal year 2022 base case GDP growth expected to be 9.5%
India is getting back on its feet slowly, with divergent growth trends. Though data suggests there has been some pick-up in recent months, recovery is weak and uneven. The scars of the pandemic continue to run deep for small businesses, the urban poor and most of the services sector.

Fiscal year 2022 is seen emerging as a story of two halves. The first half will be characterised by a base effect-driven recovery amid the challenge associated with resurgence in Covid-19 infections, while a more broad-based growth is expected in the second half, as vaccine rollout and herd immunity support sectors that are lagging. The gains made by the economy in the fourth quarter of fiscal 2021 seem to have fizzled out in the first quarter of fiscal year 2022 because of the fierce second wave of Covid-19, leading to localised lockdowns in most states. At the same time, monetary policy has begun normalising, and some tightness in domestic financial conditions is inevitable. Against this backdrop, policy support remains critical, apart from action in the external environment.

In fiscal year 2021, the policy response to the pandemic focused more on damage control and measures to support the economy. In the current fiscal, the government is expected to normalise some of the extraordinary or unconventional policy moves, while trying to ensure there is smooth revival in growth. This will pertain to most of the services sectors, especially contact-based travel, tourism and entertainment. Also, stronger global growth should support India’s exports to some extent. Revival will not be uniform across sectors, though. So far, the rural economy has been more resilient than the urban.

Forecasts fiscal year 2022 GDP growth to rebound to 9.5%
CRISIL Research forecasts that India’s GDP growth will rebound to 9.5% in fiscal year 2022, as four drivers converge:
1. Weak base: A 7.3% contraction in GDP in fiscal 2021 will provide a statistical push to growth next fiscal.
2. Global upturns: Higher global growth in calendar year 2021, as world GDP is set to rise by 5.0%, advanced economies by 4.3% and emerging economies by 6.3%, should lift exports.
3. COVID-19 curve: India is witnessing the second wave of COVID-19 infections and at the same time learning to live with the virus, with the rollout of vaccines. These should broaden growth next fiscal year, especially in the services and unorganised sectors.
4. Fiscal push: A stretch in the fiscal year glide path and focus of Union Budget 2021/2022 on capital expenditure are expected to have a multiplier effect on growth.

India’s per capita income rose at a healthy pace between fiscal year 2012 and fiscal year 2020
India’s per capita income, a broad indicator of living standards, rose from ₹ 63,462 in fiscal year 2012 to ₹ 94,556 in fiscal year 2020, at 5.1% CAGR. This growth was led by better job opportunities, propped up by overall GDP growth. Moreover, population growth remained fairly stable at around 1% CAGR.

Social and healthcare-related parameters

India’s current healthcare expenditure lower than other developing countries
According to the Global Health Expenditure Database compiled by the World Health Organization (the “WHO”), India's current expenditure on healthcare was 3.5% of GDP in 2018. To put this into greater perspective, while India’s real GDP in fiscal year 2019 was ₹ 139.8 trillion (at constant fiscal year 2012 prices), India’s current healthcare expenditure (“CHE”) was approximately ₹ 4.9 trillion. In fact, India trailed not just developed
countries, such as the US and the UK, but also developing countries, such as Brazil, Malaysia, Nepal, Singapore, Sri Lanka, Thailand, and Vietnam, in terms of healthcare spending as a percentage of GDP as of 2018.

India’s current healthcare expenditure steadily growing with its GDP but with private sector accounting for lion’s share
India's CHE, though, has increased with its expanding GDP. Between 2010 and 2018, the current healthcare expenditure has grown at a CAGR of 6.2%

However, at an overall level, the healthcare expenditure in India is low primarily because of under-penetration of healthcare services and low individual spending on healthcare. Further, India's per-capita total expenditure on healthcare (at international dollar rate, adjusted for purchasing-power parity) was only $73 in 2018 compared to other emerging countries such as $112 for Indonesia, $152 for Vietnam, $157 for Sri Lanka, $276 for Thailand, $427 for Malaysia and $848 for Brazil.

Market size of the diagnostic industry in India
Diagnostic services is a key sub-segment of Indian healthcare market
Evidence-based treatment has become the norm for many doctors, as diagnosis enables prescription of correct therapy, and, thereby, faster recovery. Hence, in the spectrum of healthcare delivery services, diagnostic services play the key role of information intermediary, providing useful information for correct diagnosis and treatment of diseases.

Diagnostic services currently have an 8 to 14% share in the overall healthcare spending on account of variation between rural and urban across institutions such as government-owned, charitable/trust-based and private.

Indian diagnostic industry to sustain pace of growth up to fiscal years 2023
With diagnostic services becoming the cornerstone for recommending requisite treatments, as well as monitoring recovery posttreatment, the industry has posted healthy growth over the past few years. The diagnostic industry achieved a healthy CAGR of 13 to 14% from fiscal years 2017 to 2020, tracking the growth of healthcare delivery services. However, in fiscal year 2021, CRISIL Research estimates the industry’s growth rate will sharply decelerate to approximately 4% on-year to ₹ 710 to ₹ 730 billion, owing to the fallout of the COVID-19 pandemic. In fiscal year 2021, COVID-19 put the brakes, albeit temporarily, on the growth story of the diagnostic sector, especially for small laboratories. With treatments at hospitals being deferred, outpatient footfalls dropping and lockdowns in quarter 1 of fiscal year 2021, the regular volume of diagnostic services took a hit. According to industry players, after a sharp fall in revenue in April and May 2020, there was some revival in demand from June 2020 onwards. Pent-up healthcare demand contributed to revenue during a traditionally lean quarter from a diagnostic perspective, with recovery to pre-COVID-19 levels occurring in the third quarter of fiscal year 2021.

However, between fiscal years 2020 and 2023, the industry is expected to return to a healthy growth trajectory of 12 to 13% CAGR, reaching ₹ 920 to 980 billion. The industry is however expected to achieve a higher CAGR between fiscal year 2021 and fiscal year 2023 in the range of 14 to 16% on account of a low growth in fiscal year 2021 due to the COVID-19 pandemic.

Going forward, CRISIL Research expects there to be medium-term growth arising from the increase in demand for in-patient as well as outpatients treatments. The demand for diagnostic services in any given year also experiences marginal seasonality during epidemics, such as dengue and malaria, and the flu season. Moreover, as literacy rates, health awareness and disposable incomes rise, individuals increasingly demand better healthcare facilities and quality of care, and increase their spending on preventive and wellness, leading to high volume growth of in-patients and outpatient treatments. The rise in healthcare demand has also received a boost from increases in urbanisation and lifestyle-related diseases, such as cardiac diseases, diabetes and cancer, prompting many diagnostic service providers to enhance their offerings in metropolitan areas and tier-I and tier-II cities.

Hospital-based diagnostic centres
Usually, secondary and tertiary hospitals have pathology laboratories and radiology centres in-house; but some also engage third-party players such as SRL Limited (“SRL”), Metropolis Healthcare Limited (“Metropolis”), and Apollo Diagnostics (“Apollo Diagnostics”) (a division of Apollo Health and Lifestyle Limited) to manage their diagnostic facilities. Major hospital chains, such as Apollo Hospitals Enterprise Ltd, HCG, Max Healthcare and Fortis Healthcare have diagnostic arms.

Typically, hospitals with 100 to 150 beds or less prefer to outsource their tests rather than set up an in-house laboratory testing facility. Tertiary hospitals, which may not have the equipment to conduct advanced tests, may also send samples to advanced laboratories. Given that equipment for advanced tests is expensive, many hospitals find it economically unviable to operate these, owing to the low testing volume. For example, a hospital may have the equipment to test whether a patient is HIV-positive or not; but to determine a virus count, the sample is sent to a specialised pathology lab. Specialised tests with low patient volume at the hospital may also be outsourced to a chain or standalone diagnostic laboratories offering advanced diagnostic facilities.

Diagnostic chains
Diagnostic chains such as Thyrocare Technologies Limited (“Thyrocare”), Dr Lal PathLabs Limited (“DLPL”), SRL, Metropolis, Apollo Diagnostics are present either in a specific region/geography or have a multi-regional presence, and offer either or both, pathology and radiology testing services. There are also prominent regional chains in different geographies, such as Vijaya Diagnostic Centre Private Limited (”Vijaya”), Medall Healthcare Private Limited (“Medall”), Suraksha Diagnostics Private Limited (“Suraksha”), Suburban Diagnostics (India) Private Limited, Aarthi Scans Private Limited (“Aarthi”), etc, which have created brand resonance. These players’ operating margins tend to be on par with multi-regional chains.

Standalone centres
Standalone diagnostic centres make up 45 to 50% share of the market. Low entry barriers and the absence of stringent regulations have helped small pathology laboratories and radiology centres proliferate. These carry out basic tests that require minimal investment and space, and typically have a conventional X-ray and an ultrasound machine. There are also centres with restricted presence offering specialised tests such as magnetic resonance imaging (“MRI”) scans, computerised tomography (“CT”) scans, advanced positron emission tomography CT (“PET CT”) scans and gamma.

Other business models in diagnostic industry in India
Different business models are being introduced in the diagnostic industry. These are shop-in-shop or PPP model, aggregator model, chain model (via franchisees) and players which focus only on niche tests. Diagnostic chains provide a bouquet of services to a diversified clientele, process samples from smaller hospitals and diagnostic centres, and offer corporate wellness programmes. Players also operate on an aggregator-based model, controlling logistics and quality with partner laboratories.

Out-of-hospital diagnostics market in India to log 12 to 13% CAGR over fiscal years 2020 to 2023

As per CRISIL Research estimates, the Indian out-of-hospital diagnostic industry is valued at ₹ 390 billion to ₹ 395 billion in the fiscal year 2020, having achieved a CAGR of approximately 12% over fiscal years 2017 to 2020. Deeper penetration of diagnostic chains has given the out-of-hospital market a push in the past three fiscals. Diagnostic chains have not only increased penetration by way of consolidation with standalone diagnostic players, but also tied up with hospitals to cater to their diagnostic services. The latter not only reduces hospitals’ capital expenditure on equipment, but also helps them save on the effort needed to maintain their diagnostic services. The out-of-hospital market, estimated to account for 56 to 58% of the entire domestic diagnostics market, is estimated at ₹ 400 to ₹ 410 billion as of fiscal year 2021. The out-of-hospital market is further projected to grow at a CAGR of 12 to 13% over fiscal years 2020 to 2023 to reach ₹ 555 to ₹ 565 billion in fiscal year 2023. This growth
can be attributed to consolidation in the industry and increase in B2C business on account of increasing health awareness among people. Also, the COVID-19 pandemic has boosted demand for radiology testing services, as dependence on high-realisation radiology tests (CT scan over X-ray) has gained traction.

Out-of-hospital diagnostics market in Andhra Pradesh and Telangana to log 12 to 13% CAGR over fiscal years 2020 to 2023

Within the Indian diagnostic industry, South India forms about 27 to 29% of the total diagnostic market as of fiscal year 2020. Among the South India market, the share of Andhra Pradesh and Telangana diagnostic market is about 44 to 46% with a value of approximately ₹ 87 billion as of fiscal year 2020, making it one of the largest markets in South India.

CRISIL Research estimates the size of the diagnostic industry in Andhra Pradesh and Telangana to have grown to approximately ₹ 87 billion in fiscal year 2020 from approximately ₹ 59 billion fiscal year 2017, at a healthy CAGR of approximately 14%, mirroring growth of the South Indian diagnostic industry market (estimated at ₹ 190 to ₹ 195 billion as of fiscal year 2020). The out-of-hospital market, which accounts for 58 to 59% of the diagnostics market in Andhra Pradesh and Telangana, is estimated to have grown to ₹ 51 billion in fiscal year 2020 from ₹ 35 billion in fiscal year 2017, at a CAGR of approximately 13%.

Going forward, the diagnostic industry in Andhra Pradesh and Telangana is expected to grow at a three-year CAGR of 12.5 to 13.5% to reach ₹ 120 billion to ₹ 130 billion in fiscal year 2023 similar to the projected growth of the South India diagnostics industry that is expected to reach ₹ 275 to 285 billion in fiscal year 2023, at a CAGR of 13 to 14% during fiscal years 2020 and 2023. This growth can be attributed to rising non-communicable diseases (“NCDs”) in the state, increasing share of aged population along with the other fundamental growth drivers such as rising health awareness, conducive government schemes related to healthcare and growing health insurance coverage. Mirroring growth in the Andhra Pradesh and Telangana market, the out-of-hospital diagnostics market is projected to grow to ₹ 70 to ₹ 75 billion in fiscal year 2023 from ₹ 51 billion in fiscal year 2020, at a CAGR of 12 to 13%. 

A diagnostic centre generally offers either pathology or radiology services, but few offer both. Typically, advanced radiology testing services are rendered by either secondary or tertiary care hospitals or standalone radiology centres (owned by the MD radiologist) or diagnostic chains (regional/multi-regional) as they entail heavy investments in order to obtain the best-in-class equipment, technology and specially trained professional to operate the equipment. Advanced radiology tests such as PET CT, CBCT and bone densitometry are critical, but at the same time there is a paucity of these services. Specialised testing has also seen many new entrants since substantial growth is expected in this area owing to the shift in disease epidemiology in India, as well as inclinations toward preventive and early diagnosis.

Multi-regional diagnostic chains such as DLPL, Thyrocare, and SRL offer both pathology as well as radiology testing services (SRL and DLPL offer both basic and advanced radiology testing services whereas Thyrocare offers only advanced radiology service). Among regional diagnostic chains, Vijaya provides a combination of diagnostic services under an integrated services model across pathology, radiology, nuclear medicine, imaging, gastroenterology, cardiology and neurology, making it a comprehensive diagnostic centre.

Comprehensive laboratory preferred due to multiple services under one roof and convenience to customers

A comprehensive laboratory has many advantages, including:

Availability of multiple diagnostic services under a single roof;

Convenience and comfort to customers;

The diagnostic centre does not lose opportunities (due to their inability to provide either radiology or pathology testing services) to its competitors, thus enabling it to capture a higher wallet share than others who provide only select services;

Higher chances of B2B partnerships, as the packages offered are wholesome in nature; and

Trust among doctors as a comprehensive laboratory will need to employ only trained professionals in order to handle equipment and qualified doctors in order to ensure quality of results.

Radiology to achieve a CAGR of 13 to 14% over fiscal years 2020 to 2023
As per CRISIL Research estimates, the Indian radiology market achieved a three-year CAGR of 14% to reach ₹ 291 billion infiscal year 2020. Going forward, CRISIL expects the radiology business to grow at a higher trajectory with adequate support from factors such as newer and advanced technology, growing dependence on radiology, and preference for high-realisation radiology tests such as CT scans over X-rays. Fundamental factors such as higher dependence on evidence-based treatments along with growing NCDs in India also support growth. Thus, the radiology market is projected to reach around ₹ 420 billion to ₹ 430 billion by fiscal year 2023, at a three-year CAGR of 13 to 14%. 

COVID-19 has fuelled demand for radiology, increasing its share in diagnostic services

COVID-19 testing has fuelled demand for both pathology and radiology testing services. However, increasingly, reverse transcription polymerase chain reaction (“RT-PCR”) testing is being used to detect the virus due to its higher sensitivity. As per industry sources, radiology testing services have been crucial to gauge the intensity of infection, especially in the lungs. Hence, a lot of impetus has been given to chest CT scans by practitioners to detect early warning. The share of radiology testing services within diagnostic services increased from nearly 41% in fiscal year 2017 to approximately 43% in fiscal year 2020 at approximately 14% CAGR; CRISIL expects the share to be maintained at 43 to 44% in fiscal year 2023. 

Industry shifting towards diagnostic chains

The Indian diagnostics industry is highly fragmented given the high proportion of standalone centres and hospital-based centres, which collectively comprise 83 to 88% of the total market as of fiscal year 2020. Diagnostic chains comprise only 12 to 17% as of fiscal years 2020 further split into regional and multi-regional chains, of which regional chains account for the majority. However, the industry has witnessed a shift from standalone centres to diagnostic chains due to increasing trend of patients’ reliance on diagnostic chains for their quality of service and unavailability of complex tests with standalone centres, not only at an overall country level but also in regional markets.

The profitability of the industry is defined on the basis of high volume of testing and optimal utilisation of laboratories. Also, high capital expenditure requirements for radiology testing services deter standalone players from investing beyond basic radiology. Given the low entry barriers and lack of a strong regulatory environment, the industry has many standalone players. This has made the industry highly competitive and fragmented, and hence smaller players are finding it hard to stay profitable. Competition has intensified with the entry of aggregators (online healthcare players), who prefer to partner with established diagnostic chains.

On the regional front, players in Andhra Pradesh and Telangana with a strong brand value and trust (like Vijaya and others) have been able to maintain growth in volumes and profitability. However, smaller players are witnessing a decline in volumes, margins and market share due to intense competition and high expectations by consumers in the region. Hence, large regional players are looking at favourable acquisitions of smaller standalone labs in places which might not only attract them higher volumes, but also help them increase their penetration and reach over the long term.

Diagnostic chains, on the other hand, have stronger financial discipline and negotiating power with suppliers, greater capital and administrative resources to meet the needs in order to sustain the business compared with standalone diagnostic centres. Diagnostic chains have expanded into geographies where they have limited presence via inorganic routes. Tier II and III cities are the major focus of these established players, where struggling standalone centres become prime opportunities for acquisition. 

Preventive and wellness testing packages to boost biochemistry testing
Mid-sized to large diagnostic chains and hospital-based diagnostic centres are increasingly marketing their test menus in the form of preventive and wellness packages. These health packages help identify pre-existing diseases or the likely risk from particular diseases before the actual symptoms appear. The tests are expected to help people take corrective action before chronic conditions take hold.

Most packages either specifically screen for a given chronic disease or contain a slew of tests to ascertain the overall health of a person. Moreover, most of the preventive and wellness tests consist of biochemistry tests to check an individual's risk to chronic diseases, such as cardiovascular diseases and diabetes, among others. However, some diagnostic centres, which have both pathology and radiology services, may add basic imaging tests such as ECG, X-ray, and ultrasound to the test packages.

Many diagnostic chains are currently providing bundled services (primarily comprising pathological tests, and a few even offer basic imaging tests). Corporate tie-ups occur majorly with accredited centres, which fall under the diagnostic chains category. Moreover, for wellness test services to be successful, substantial investments in marketing, a wide distributor network, and a strong brand are vital. So, diagnostic chains have more potential to absorb and cater to new demand for preventive health and wellness packages. Further, comprehensive diagnostic players have high potential, since they can provide a good mix of services under one bucket, owing to the nature of services provided by them under a single roof.

Hub-and-spoke model is most preferred for diagnostic chains

Diagnostic chains typically adopt a hub-and-spoke model to widen their catchment area. However, this model is more prominent in pathology testing services. Nevertheless, players in radiology testing services also operate on a similar model, by way of referring patients to hub centres from spoke centres for specialised testing, which are carried out at the hub centres.

Hub-and-spoke model

National centre (main centre): These are located centrally, usually in large metropolitan areas, serving as the corporate headquarters of diagnostic chain companies. These are equipped to conduct routine as well as specialised pathology and radiology tests, and may be spread over 10,000 square feet. Reports generated by the regional / national centre are sent to patients through the collection centres/satellite centres, or can be viewed online. The usual turn-around time (“TAT”) for a national centre for report generation ranges between a few hours (for routine tests, such as blood analysis and sugar tests) and two to four days, depending on the type of test being carried out. Diagnostic centres opt for air logistics for transporting samples collected at their collection centres in other cities. These are usually done for specialised tests that can only be performed at the national centres or, in the context of a hub-and-spoke model, at regional centres. In the case of advanced radiology testing services, an integrated diagnostic company may refer a patient to its main/national centre, which houses advanced equipment such as MRI machines and PET-CT scan machines.

Regional centres: Similar to a national/main centre, regional centres are also usually situated in large metropolitan cities, and act as hubs that collect samples from the satellite centres and collection centres across India. The regional centres also offer comprehensive and specialised testing facilities. With respect to radiology testing services, some of the advanced/ niche imaging tests are also generally carried out in regional centres.

Satellite centres: Satellite centres offer limited range of services. These mainly act as feeders for regional centres and national/main centres. Based on complexity of the test, a satellite centre may choose to transfer samples to a regional centre or a national reference centre (whichever is nearer). Satellite centres may be either owned or franchised by a diagnostic chain company. A satellite centre may also house basic radiology tests, such as ECG, X-ray and sonography. For advance tests, patients may be referred to either the regional centre or main/national centre.

Collection centres: Collection centres are usually located in hospitals, nursing homes, pathology labs, clinics, prime commercial properties, and retail spaces, among other places. These could be company-owned or a franchisee usually catering to an area of 3 to 5 km radius. Collection centres do not carry out testing. The centres have basic equipment in the form of a refrigerator and a centrifuge, and employ minimal staff, such as a receptionist, laboratory technician, attendants, and delivery staff.

Growth drivers, success factors and risks

Fundamental growth drivers for the diagnostic industry

With life expectancy improving and changing demographic profile, healthcare services are a must
With improving life expectancy, India’s demographics are also witnessing a change. According to the Report on Status of Elderly in Select States of India, 2011, published by the United Nations Population Fund in November 2012, chronic ailments, such as arthritis, hypertension, diabetes, asthma, and heart diseases, were commonplace among the elderly, with approximately 66% of the respective population reporting at least one of these. With the Indian population expected to grow to approximately 1.4 billion by 2026 with and an expected surge of 60 years or more to approximately 13% by 2026 from 8% in 2011, considering the above mentioned factors, the need to ensure that healthcare services are provided to this vast populace is an imperative.

Rising income to make quality healthcare services more affordable and preferred
Even though healthcare is considered a non-discretionary expense, considering that an estimated 83% of households in India had an annual income of less than ₹ 0.2 million in fiscal year 2012, affordability of quality healthcare facilities remains a major constraint. Growth in household income and, consequently, disposable income, are critical to the overall growth in demand for healthcare delivery services in India. The share of households falling in the income bracket above ₹ 0.2 million is expected to go up to approximately 35% in fiscal year 2022 from approximately 23% in fiscal year 2017. Higher income levels will also accentuate spending on preventive and wellness tests, thus aiding the diagnostic industry over the long term.

Increasing health awareness to boost preventive/wellness tests
The majority of healthcare enterprises in India are more concentrated in urban areas. With increasing urbanisation (migration of population from rural to urban areas), awareness among the general populace regarding presence and availability of healthcare services for both preventive and curative care is expected to increase, thus paving the way for growth of the diagnostic industry as well.

Risk of the industry

Articles

Comments