Good morning, everyone. I welcome you to Aster DM Healthcare Earnings Conference Call for the Fourth Quarter of FY 2024. The company declared the Q4 and full- year financial results for FY 2023-24. With this, we have the senior management of Aster DM Healthcare, namely Ms. Alisha Moopen, Deputy Managing Director, Mr. T.J. Wilson, Non-Executive Director, Dr. Nitish Shetty, Chief Executive Officer, India, Mr. Amitabh Johri, Chief Financial Officer, GCC, Mr. Sunil Kumar, Chief Financial Officer, India, and Mr. Hitesh Dhaddha, Chief of Investor Relations and M&A. I would like to inform everyone about how we will conduct this call. All external attendees will be in listen mode for the duration of the entire call. We will start the call with opening remarks by management, followed by an interactive Q&A session.
During the Q&A session, you will have a chance to ask a question by raising your hand by clicking on the Raise Hand icon in Zoom application at the bottom of your window. We will call out your name, after which your line will be unmuted, and you will be able to ask your question. We request you to please limit your question to two, but not more than three per participant at a time. Certain forward-looking statements may be discussed in this meeting, and such statements are subject to certain risks and uncertainties, like government actions, local political or economic developments, technological risks, and many other factors that could cause actual results to differ materially.
Aster DM Healthcare Limited will not be in any way responsible for any action taken based on such statements, and undertakes no obligation to publicly update these forward-looking statements to reflect subsequent events or circumstances. With this, I will ask Ms. Alisha Moopen to start with opening remarks. Over to you, Ms. Alisha.
Thank you, Puneet. Good morning, everyone, and thank you for joining our Q4 and Full-Y ear FY 2024 Earnings Call. Ladies and gentlemen, I'll be sharing a brief on our India quarterly and full- year performance, along with the successful completion of the GCC segregation, before Dr. Nitish talks about the India business performance, including the cluster-wise performance details. I'm really happy to inform that we have finally concluded the segregation of our India and GCC businesses successfully on the third of April, 2024, post obtaining all the regulatory approvals and fulfilling the conditions diligently. I want to express my deepest appreciation for ushering in a new era to shape Aster India's future. The segregation has clearly allowed us to tailor our strategies to the distinct growing needs of these geographies, and also positions us to seize the unprecedented growth opportunities in the Indian healthcare market.
I want to appreciate the wealth of expertise which was contributed by our board, our top management team, to make this transaction happen. Their diverse backgrounds and experiences have been invaluable in overcoming the many challenges that we faced during this transaction. Despite its complexities, the collaborative efforts and strategic insights have guided us through and made us stronger and more resilient, paving the way for the successful transaction, demonstrating the exemplary level of governance maintained by our board, especially considering its nature as a related party transaction. The overwhelming support from all the proxy agencies and the strong shareholder approval in the majority of minority resolution were true reflections of how governance was upheld. This speaks volume about the transparency, fairness, and integrity with which this transaction was conducted, reaffirming our commitment to the highest levels and standards of corporate governance.
Looking ahead, the prospects for Aster India remains truly promising. We are focused on growth through brownfield and greenfield projects, aiming to add 1,700 beds within the next 3 years. We also acknowledge the trust and long-term investment, investment that our shareholders have made with us, with a significant portion of the proceeds from the transaction paid as dividends. This entire transaction has resulted in a substantial inflow of cash proceeds amounting to $907.6 million. I'm delighted to mention that we have distributed approximately 80% of the receipts from the sale of the GCC business as a special dividend of INR 118 per share, underscoring our strong cash position. The remaining 20% of the proceeds have been earmarked for strategic initiatives, particularly in organic growth opportunities.
This will enable us to explore and capitalize on acquisitions and partnerships that can enhance our service offerings and expand our market footprint. Now, coming to the overall India long-term performance. Over the last five years, our India operations have experienced significant growth with a CAGR of 23% in revenue and 38% in operating EBITDA up to 2024. This growth has been driven by a significant capacity expansion, ARPO growth, increasing international revenue, as well as advanced quaternary and tertiary healthcare services.
Our India revenue experienced significant growth during the year of, during the year, with a 24% year-on-year growth, surging to INR 3,699 crore, supported by addition of bed capacity of 550 beds in the last year, and year-on-year growth of 10% in ARPOB, which is now reaching to INR 41,100 in FY 2024. Our revenue from international business has also shown a remarkable growth of 44% year-on-year growth to INR 188 crore, vis-a-vis INR 131 crore in FY 2023. Now coming to the EBITDA, our India operating EBITDA exhibited strong growth, increasing 30% year-on-year, reaching INR 620 crore in FY 2024. Overall, India operating EBITDA margin has increased to 16.8% in FY 2024, as compared to 16% last year.
This has been mainly aided by cost efficiencies, operational leverage, as well as an EBITDA breakeven in our lab business. As a result, overall ROC from the India business reported at 16.4% in FY 2024, vis-à-vis 13.4% in FY 2023. Our core hospital business has delivered an EBITDA margin of 19.5% in FY 2024, vis-à-vis 18.9% last year. In fact, our mature hospital, which are the hospitals with more than six years of vintage, it contributes to 77% to our hospital segment revenue, and it's delivered a 22.4% EBITDA margin FY 2024, with an impressive growth in ROC standing at 32% in FY 2024 versus 24.7% in FY 2023.
Our deliberate efforts to establish a sustainable model is clearly demonstrated in our well-diversified, specialty revenue mix, with actually no single specialty accounting for more than 15% of the total hospital revenue in FY 2024. Now, coming to our new businesses of both labs and pharmacy, they've grown at a faster rate of 32% year-on-year at INR 286 crore in FY 2024, now contributing to approximately 8% of the total revenue. The lab businesses have demonstrated EBITDA breakeven in Q4, FY 2024. The India profit before tax has increased 34 year-on-year to INR 281 crore in FY 2024, and India PAT has increased 28% year-on-year to INR 188 crore in FY 2024.
On Q4, FY 2024, PAT was impacted by a one-off item, which Sunil will be explaining in more detail. Adjusting to that one-off item, our PAT has actually grown by 84% year-on-year in Q4 FY 2024. Our balance sheet, it remains strong, with a net debt to EBITDA pre-Ind AS reducing to 1.1 x as of March 31, versus the 1.3 x as of March 31, FY 2023. Coming over to our CapEx investments, we've added 550 beds during the year, which includes 286 beds in Whitefield, Bangalore. I'm really excited to share about our success at the Whitefield Hospital, which actually achieved the EBITDA breakeven in just 3 months at ARPOB of INR 70,000+ for Q4 FY 2024.
At the outside of our expansion plan, we're on track to increase our bed capacity through a prudent mix of both brownfield as well as greenfield projects, which will result in our Aster Medcity and Aster CMI hospitals expanding to 900+ beds and 850 beds, respectively. Both our greenfield projects in Trivandrum and Kasaragod are progressing well, and we're also exploring the opportunities to expand into nearby states such as Maharashtra and Tamil Nadu, as well as North Indian geographies such as UP. This expansion will not only increase our capacity and footprint, but also enhance our offerings in specialized medical care with best clinical outcome. We're really happy to be able to receive some very prestigious awards in the last financial year.
Our commitment to outstanding healthcare delivery was recognized at the Financial Express Healthcare Awards 2024, where we were honored as the Best Hospital Chain of the Year, and also conferred of the title of the Hospital Chain of the Year at the Economic Times Healthcare Awards. Additionally, our multiple hospitals, such as Aster Medcity, Aster CMI, were ranked amongst the top multi-specialty hospitals across India by Economic Times, Times of India, Outlook, and The Week. We've also been awarded for excellence in CSR by the Economic Times. I just want to conclude by sincerely thanking you all for your trust that you've shown in our strategy of segregating our businesses. Identifying the significant demand-supply gap in India's healthcare sector reinforces the confidence in our approach.
We are truly excited about our journey ahead as a pure-play India entity with a much sharper focus and remain opposed to providing not only value, but also sustained growth in the coming years with a leadership team in place. Your confidence, it motivates us, and we are eagerly anticipating to exceed your expectations and achieving shared success. Our expansion initiatives for India are robust, and we will surely deliver strong performance and help to generate value for our shareholders. I will now request our India CEO, Dr. Nitish Shetty, to elaborate more on India's performance, including segmental and cluster-wide performance. Thank you all very much. Over to you, Dr. Nitish.
Thanks, Alisha. A very good morning, and thank you all for joining our Quarter four financial year 2024 earnings call. The Indian Minister of Health has increased his budget to $11.3 billion for the financial year 2023-2024, representing a notable 13% increase from the previous year. This move underscores the government's commitment to improving healthcare services in India. With this in mind, we are fully dedicated to expanding our healthcare services and continuously strive to harness this potential. Moving to the updates on the India business performance for the full year of financial year 2024.
Alisha has covered most of the aspects, but I'll add a few more, important points here. Our continuous effort pertaining to capacity expansion of 550 beds over last one year has supported in 24% year-on-year revenue growth and 30% operating EBITDA growth of overall India business in the financial year 2024. Coming to the core hospital business performance, our core India hospital business, including the clinics, grew by 23%, showed an impressive revenue of INR 3,590 crores for the financial year 2024. The effective implementation of cost optimization and operational leverage has resulted in a notable growth of 28% in the core hospital operating EBITDA, delivering operating EBITDA margins of 19.5% in the financial year 2024.
Excluding our O&M model hospitals, our core India hospital business grew by 20%, reaching to a revenue of INR 3,395 crore in the financial year 2024. The effective implementation of cost optimization and operational leverage has resulted in notable growth of 25% in core hospital operating EBITDA, excluding O&M models, delivering operating EBITDA margins of 20.3% in the financial year 2024. Coming to our new business performance, the revenue from labs and pharmacy business grew by 28% and 36% respectively in the financial year 2024, with lab business achieving EBITDA breakeven in quarter four of financial year 2024.
Our insurance payer mix, this is a very important aspect, where we have seen the overall payer mix has changed in the financial year 2024, with the insurance patients have increased by 120 basis points and year-over-year growth of 27.3% compared to the previous year, and indigent patients have also grown by 5.4%, improved by 76 basis points year-over-year, offset by CAF and scheme patients. Coming to our cluster-wise performance, our Karnataka and Maharashtra cluster performed diligently and with a contribution of 31% in overall hospital business revenue. The revenue of the cluster grew by 35% year-over-year, and operating EBITDA grew by 44% for the financial year 2024, with a strong start of Whitefield Hospital at Bangalore location.
I'm very pleased to share that our Whitefield Hospital in Bangalore has achieved EBITDA breakeven within three months in the quarter four of financial year 2024, giving us the confidence to create similar successful model in upcoming geographies. While reflecting further upon the Whitefield Hospital project, its success is attributed to strategic decisions such as focusing on underserved specialties like oncology, creating a standalone mother and child hospital adjacent to a multi-specialty hospital, attracting top talent by offering a comprehensive range of services, and addressing the demand for single rooms. The hospital design and the service offerings cater to the current and future needs of the patient and healthcare professionals, contributing to its rapid growth and success.
Our Kerala cluster continues to contribute 57% in the overall hospital business revenue, showed a decent performance, including revenue growth of 19% year-on-year and EBITDA growth of 21% year-on-year in the financial year 2024, aided by the sustained high occupancy levels and price growth. ARPOB of Kerala cluster witnessed a growth of 10% year-on-year at INR 39,800 in the quarter four of financial year 2024, which is a reflection of price hike, changes in specialty mix, and reduction of scheme work. Andhra and Telangana cluster performance remains steady, with the revenue increased by 20% and EBITDA grew by 29% year-on-year basis in the financial year 2024.
Coming to the clinical performance, we are very proud to mention that we have significantly grown on the clinical side, providing cutting-edge medical treatments and performing 100+ transplants in the financial year 2024 versus 430 transplants in financial year 2023. More than 1,040 robotic surgeries in financial year 2024 versus 480+ robotic surgeries in the financial year 2023, and many more, areas of achievement in the clinical space. Coming to the CapEx, with more than 10% of our current bed capacity added in financial year 2024, we are now reached to a 4,867 bed capacity as of today.
To capitalize the opportunities of India's large population and low hospital bed density, we are making substantial capital investment, aiming to increase our total bed strength capacity to 6,500 by the financial year 2027, with plans to add approximately 1,700 beds in next three years. As we enter the financial year 2025, we are confident that our increased focus on India will bring positive results. We look forward to sharing updates on our progress in the coming quarters. I'll now request our CFO, Mr. Sunil, to elaborate more on our financial performance. Thank you very much.
Thank you, Doctor. Good morning, everyone. For the quarter ended 31st March 2024, revenues have increased to INR 978 crore, up by 22% from INR 8.4 crore in quarter four FY 2023, and operating EBITDA has increased to INR 167 crore with a margin of 17.1%, compared to INR 135 crore in quarter four FY 2023, with the growth of 24%.
Adjusted PAT post NCI for quarter four FY 2024 is at INR 87 crores compared to INR 48 crores in quarter four FY 2023, with a growth of 84% year-on-year. For the year ended 31 March 2024, India revenues have increased to INR 3,699 crores, up by 24% from INR 2,983 crores in FY 2023, and operating EBITDA has increased to INR 620 crores, with a margin of 16.8% compared to INR 477 crores in FY 2023, with a growth of 30%. Adjusted PAT post NCI for FY 2024 is at INR 240 crores compared to INR 147 crores in FY 2023, with a growth of 63% year-on-year.
Adjusted PAT for Quarter Four and FY 2024 excludes recognition of one-time net deferred tax liability of INR 52.5 crores, which is a non-cash item, arising out of transition to the new tax regime following the segregation of our GCC business. ARPO for FY 2024 has seen an overall growth of 10%, rising from INR 36,500 to INR 42,100. Excluding our owned and satellite hospitals, the ARPO increased by 14%, from INR 37,000 to INR 42,100. This growth has been achieved through revenue assurance, price increase, and improved case mix. In terms of cost optimization, our material cost percentage, excluding wholesale pharmacy, has steadily declined over a period of time, which was 25.3% in FY 2022 to 23.5% in FY 2023, and further reduced to 22% in FY 2024.
This reduction reflects our effective cost management, strategic procurement, and operational efficiencies implemented across our business units. In addition, we have continued to maintain positive operating EBITDA for the past two consecutive quarters in our owned and satellite hospitals, and achieved EBITDA breakeven in our diagnostic segment, Aster Labs, in Quarter 4, FY 2024. For the year ending thirty-first March 2024, our CapEx, capital expenditure totaled INR 392 crore, with approximately 60% spent towards expanding our capacity. Over the next, three years, we aim to add nearly 1,700 beds, with 60% of these being brownfield expansion, to ensure there is no dilution of our margins. Optimized cash allocation, coupled with margin movement, our ROC has experienced significant growth. ROC surged by 300 basis points year-on-year, reaching 16.4%.
Hospital and clinic segment, excluding owned and satellite hospitals, ROC rose to 24% from 20.9% in FY 2023. Matured hospitals saw an impressive increase in ROC by over 700 basis points, reaching 32% in FY 2024. Aster India net debt stands at INR 556 crores as on 31 March 2024, compared to INR 510 crores as on 31 March 2023, with net debt to EBITDA excluding lease liabilities ratio improving to 1.1x as compared to 2.3x in FY 2024. On that note, I conclude my remarks. We would be happy to answer any questions that you may have. I now request Puneet to open the question and answer session. Thank you.
Thanks, Sunil. We can now move on to the Q&A session. Before moving on to the Q&A session, I would like to request to all the participants, if you can introduce yourself with your name and the company that you are associated with before asking the question. If you are not associated with any company and you are an individual investor, you can highlight that also. Moving on to the Q&A session. The first question is from Amey.
Hello?
Unmute you, Amey.
Yeah. Yeah, this is Amey here from JM Financial. Thank you for giving the opportunity, and congrats to management on good set of numbers. So the first question I have, regarding the, ARPOBs, we saw, we saw around 14% ARPOB growth in the non-O&M hospitals. Is it possible to, give some guidance on the price hikes for last year, and also outlook for the next year, and how ARPOBs are looking like for the next year?
Sunil, do you want to come in?
Thank you, Amey. So as I called out in my speech, right, overall, we've grown at a 10% ARPOB growth, and excluding the owned and satellite, because owned and satellite hospitals already have a very blended and lower ARPOB around INR 20,000. And also, we are treating more scheme patients who don't have that ability to do the price increase there. So if you exclude that, we are at a 14% growth. Now, if you look at historically, we have grown ARPOB at something like 9%, right? At least 5-year CAGR, if you look at, it's 9% growth what we have taken. Now, this 14% growth has happened because of the multiple reasons.
One is the price increase, second is the revenue assurance project, which we internally took across, basically trying to ensure that, the 19 hospitals, what we have today, how can we leverage among these various services which we build, and also with the single service master, and also we address a lot of revenue leakage, right? With that, we are able to address this one. In addition to price increase revenue assurance, also, major thing is related to the key, you know, case mix also, and also the MVT revenue, next one. Because if you look at MVT revenue, in the year, FY 2023, we did around 4.6% or so, with a INR 130 crore odd, and that, MVT revenue has jumped almost by 40 odd percentage, moving to INR 188 crores, contributing 5.4% of our top line.
These are the major, various reasons which has added. Now, but in the future, and also for another question of the price increase component, right? Price increase component out of 14% would be around something like, 3.5%-4% is what the price increase component would be. And I think that, that is, around 3%-4% is what of the ARPOB . In, the future also, we can look for the price increase bit of it. And in the future, ARPOB growth, because we did, you know, optimization projects in this year, that's where the ARPOB growth is little higher. But going forward, we can look at something between 8%-9%, minimum, is what we can think the ARPOB growth will be. Thank you.
Sure. And the second question I have is on the Andhra Telangana region, where the year-on-year performance have been on the occupancy side and the ARPOB side have been slightly muted. So if you can address that. Thank you.
Doctor, you want to take it?
Yeah. Yeah, Amey, we do accept the fact that the performance in our question today. We are presently in a discussion with the promoter there, who is running the business for us, Ramesh. So we are in a discussion with them to see where we can do the intervention and improve the performance parameters. We are confident that whatever has happened in the past will be reversed, the performance aspects will be reversed in between months, and we are confident of the performance in the next quarters. And we are looking at some kind of concrete solution to address the situation like this. At this moment of time, we can only give the assurance that we are working.
We are aware of the fact that the performance parameters are not up there compared to other geographies, but we are taking all measures to ensure that in the quarters that concern will be addressed.
Sure. And also one supplementary question related to Andhra region, particularly outside Hyderabad. So, how has been the space in terms of? Because I have seen our ARPOBs for most of the companies operating outside Hyderabad are quite low. So is it driven by the fact that, as in the case mix is quite inferior or, because of the pricing, these ARPOBs are on the lower side?
Yeah. Amey, to answer this question, see, in Andhra, most of the cities are on Tier 2 and Tier 3 cities. They're smaller towns and cities, where of course, doing a high-end work is always a challenge. But, we are seeing that thing is different in Kerala. We are able to demonstrate, we are able to do secondary care and quaternary care, tertiary care, and improve the ARPOBs. I think there's something similar needs to be done in other geographies, right? Right now, the challenge in the Andhra state is, in the Tier 2, Tier 3 cities, most of the hospitals are doing secondary care work and little bit of tertiary care work.
But if you migrate to doing the high-end work, the talent is available, and if you are willing to put up the infrastructure and create an environment, this challenge of low RPOP can be addressed. Now, what is happening, a lot of patients from Andhra are going out of state for the high-end treatment. So if once we are, the, the operators there are able to stop this flow of patient out of Andhra, the issue of RPOP can be addressed. At the same time, another way of addressing is to encourage the, the, penetration of the private insurance. We have seen a great benefit when you do tertiary care and quaternary care work. The insurance penetration helps in making the high-end work accessible to everybody, especially the insured patients.
So, one is the insurance penetration, and two is focus on tertiary care and quaternary care will help in increasing the ARPOB, especially in the state of Andhra. Telangana is different because most of the business comes from Hyderabad, and it's a metro city. It's very easy to do tertiary care and quaternary care work. But in the Tier 2, Tier 3, I think we should emulate what we have done in Kerala.
Sure. Just last question, if I can squeeze in. If we can provide the gross block number for the year, for the India business. Thank you.
Amey, we will separately, communicate that information.
Sure, sure. No problem. Thank you so much.
Thank you, Amey. The next participant who is asking the question is Mr. Sanjay Shah. If you can unmute yourself and ask the question.
Am I audible?
Yes, sir, you are audible.
Yeah, sorry. Yeah. Congratulations to the team, Aster, and appreciate the deal successfully done. So now the thing was, we are now focusing on Indian operation. I would like to understand through from the management about the trajectory of growth from here, as you rightly pointed out, about the CapEx, what we are planning in organic. We're focusing on ARPU growth. Can you highlight upon a small—which is a small business, but it's still material, have an impact on the com—on the hospital as a segment that is pharmacy and lab. That was my first question.
And my second question was, since we are now separated from GCC, but still we have our management over there, so do we in future see any synergies to bring in international patient? Because still we have reached 5% of our revenue. Is there any scope of bringing, doubling there or maybe more from here in international incoming patient?
So, Sunil, why don't you talk about the pharmacies?
Yeah. Sanjay, thanks for the question. See, labs and wholesale pharmacy, what we have today, right? That contributes only to the 8% of the overall revenue for us. And also, you are aware, and we have communicated, you know, previous interactions, that this whole labs and pharmacy is not something which we are trying to become a all India chain, you know, so that's not the focus here. The focus has always been to continuity of care. So we have 92% of the, you know, business coming from this one, and also more than 3.3 million patient footfalls what we have. So how we thought about, and also we are trying to bring our own digital app in next 6-9 months.
So the whole idea was that how can we create an ecosystem wherein we are giving the OP services, there is a teleconsultation already, we have the IP, related services, and how can that be in the future, the lab and pharmacy also can be inbuilt into this, right? That's exactly the reason why we brought in the labs and pharmacy.
And even if you see, in case of labs, we currently have around 232 facilities, wherein we have got out of the 15 satellite labs, which only processes the samples, and balance are all our collection centers, which we call it as a patient experience center. G ood thing is that we've already broken in quarter four, so the cash burn, the cash burn has stopped. And now and also, it has got a combination of the Aster and non-Aster business. And over a period of time in last year, we have already reached the non-Aster business component out of our total revenue to almost 25%, which in FY 2023 it was only 17%-18%. That is one of the reason why we're able to break even.
Now, going forward, the idea is that we don't. We are present mainly in the states of Karnataka and Kerala, and we are not looking for any reason to add the satellite labs, so that means there is no major CapEx to be spent. It's all about increasing the footprint through patient collection centers, right? With that, home care adding to that, we should be able to drive good volumes and achieve the, you know, higher margins. Coming to pharmacy. Pharmacy also, we are only present in Telangana, Karnataka and Kerala. Overall, our pharmacy is around 215 pharmacies, what we are present. And you have seen that, right? We have more or less like stabilized the pharmacy growth.
We are not adding like, you know, previously, till first two, three years, we have ramped up the growth because you need to have a certain bandwidth for the number of stores to drive the volume and also get the leverage on the purchase procurement also. So that's where we achieved 215. Now, the idea is to increase the revenue per day per store and also achieve the breakeven. The way we achieved the Labs breakeven, we are thinking that at least by FY 2026 end, we should be able to breakeven in the pharmacy business also. I hope that answers your question, Sanjay.
Yeah, very helpful, sir. Very helpful. My second question regarding international patients.
Yeah. So, Sanjay, I'll come in on that one. So, so you're right. I mean, there has been a flow of patients from GCC as one of the regions. Of course, India sees the patients from across Africa, from Maldives, Bangladesh, and, many other countries. But definitely the arrangement we have with the GCC is that we'll continue to sort of, make sure that patients that cannot be served in GCC will be sort of funneled to Aster India. I think there are many services which, India will always do, in terms of quaternary care, the transplant programs, oncology work, which, which is nowhere in the horizon for GCC, and we see that the trust in the brand, which is there, so we'll continue to funnel those cases, to India. Dr. Nitish, anything you want to add?
Yeah. Yeah. Thanks, Alisha. This, Sanjay, see that presently, out of 5.2% revenue what we generate from MVT, around 40% only is contributed from GCC. Around 60% is coming from the non-GCC countries, especially from Africa and SAARC countries. And that there's a bigger opportunity in the SAARC countries. As we all know, the Maldives, the Bangladesh, Afghanistan, there's a huge potential there, which will continue to drive the MVT business.
But at the same time, GCC, like Alisha mentioned, we still have kind of an understanding with the GCC counterpart to continue further the growth of high-end work, because all our hospitals are equipped to do the tertiary care and quaternary care work, which might take some time for GCC hospitals to enable them to the level what we are in India in terms of quaternary care delivery. So if you really look at a mix of a patient, around 60%-70% of international patients come to India for quaternary care and tertiary care work.
Correct.
Only 10% for general work. So in that sense, we are nicely placed to take our revenue growth in next up 10% in next, in the coming years, enabled by the inflow of a lot of patients from SAARC countries. And then, of course, GCC always continues to contribute, because we have the common brand, brand name in both GCC and India, which will help. We. Then we are confident of leveraging on that.
So, Doctor, are we have any plan to enter Tier 1 cities to bring growth from on the ARPU side?
See, if you really look at our mix 70% of our business comes from the smaller, not the metros. Tier 1, I assume it is metros, but the Tier 2, Tier 3 are very smaller town, smaller cities like Kochi, Calicut. And 70% of our business are already coming from there. And with— Through the asset-light model, we have already made plans to enter the Tier 3 cities, and we have been successful there. But we are mindful about the, the operating parameters, like RFPs and all are not, might be to the level of our larger cities, so we are being cautious in that space. But, as a group, we are known to be functioning out of Tier 2, Tier 3 city. That's been our strength.
In fact, we are the only group, I can say confidently, that to a large extent, we deliver tertiary care and quaternary care in Tier 3 cities. If you see a hospital in Kolhapur, a hospital in Kottakkal or Kannur, are all enabled to do tertiary care and quaternary care work. This also presents an extraordinary opportunity to attract the international patients, because the international patients, if you see, the SAARC country patients and African country patients, are little price sensitive. They would like to avail, avail, avail treatment in the country. Of course, quality is important for them, but the price is also very important.
So, their expectation can be met in the Tier 2, Tier 3 cities, like in Kochi, Calicut, where the price difference between the metro and these cities are around close to 20%-30% sometimes for a high-end work. So if just it's a matter of having better connectivity to these cities, all the inflow of international patients will happen to Tier 2, Tier 3 cities. Right now, it has been constrained by the air connectivity. So, GCC is different, because GCC has a very good air connectivity with Kerala hospitals, Kerala geography. But if that changes and we have better air connectivity across, I think, most of the inflow of the international patients will happen to Tier 2, Tier 3 cities.
So Doctor, coming back to what I understood, since we are doing really very good remarkably on tertiary and continuity side, and plus, we are bullish on international incoming patient also, and also we gradually increase our presence in Tier 2 also. So don't you think this ARPU growth of around 8%, what you cited, is bit conservative side?
That's a reality. See, like I said, ARPU, like Sunil mentioned, it's a virtue of three or two or three components. One is the price increase and specialty mix, and then also revenue, revenue augmentation. There are many factors which play in improving the ARPU. But we are kind of following the industry standards, and some years we exceeded the industry standard. But considering we are in a majority present in Tier 2, Tier 3 , we have a headroom to improve that, but we have stuck our projection to the industry standard.
Thank you, sir. Very helpful, and thank you very much. Good luck to you also.
Thanks, Sanjay. The next question is from Pinaki. Pinaki, if you can mute, mute, unmute yourself.
Sir, am I audible, sir?
Yes.
Hello. Yeah, okay, good morning to everyone. Sir, actually, I've got a couple of questions. Sir, first, actually, sir, you are looking into expansion to areas like Maharashtra and also UP. So actually, can you explain what kind of expansion will it be? Will it be an outright acquisition, or we will be looking for a strategic partner or an asset-light model?
Can you come in here?
Yeah, sure. Thanks, Dr. Nitish. So hi, Pinaki. We are looking at M&A opportunities, single hospital M&A opportunities, and we are open to exploring multiple models there. It could be acquisition or it could be lease as well, and, you know, we can also look at partnership options there. So we're exploring in these markets. I think we already have a presence in Maharashtra at Kolhapur, and we want to expand our presence further in Maharashtra region. Also, we want to start exploring the UP region as well, as we see that region being very attractive. You know, given how the demand is growing on that side, and a lot of the patients actually go to Delhi cluster for there.
There is a significant opportunity that we see in that market.
Okay, sir. So my next question is actually, so what is your actually the number, how many number of patients were international patients or in a broader sense, and what is your take on international medical tourism, which is Kerala is now almost is one of the hot destinations. So what is your strategy going forward regarding this?
Pinaki, we lost you in between there. Can you kind of repeat your question?
Am I audible, sir?
Yeah, you're audible.
Yeah, yeah. Sir, actually, I want to know actually of the now total number of patients, how many were of, how many were international? Or in a broader sense, what is your take on international medical tourism, which where Kerala is now actually a hot destination?
Yeah, Pinaki, I explained earlier also, there's a huge opportunity, in terms of, international patients traveling to India for the kind of work we do in the hospitals. And, I, I specifically emphasize on the fact that, international patients who come to India also look for a quality care at a, at a reasonable pricing, right? In that sense, the large cities are becoming expensive for certain category of international patients, like in Delhi or metro cities. There's a huge price difference, like I can give an example. We have hospitals in Bangalore and hospitals in Kerala. The hospitals in Kerala, larger hospitals in Kerala, do at par clinical work with Bangalore hospitals. There's no difference in terms of the capability. We don't refer, Kerala, hospitals don't refer to Bangalore, though Bangalore hospitals are in metro.
So in the clinical competence, they are up there. But, and then the price is also 30% lesser than the metro cities. But GCC's connectivity is helping driving patients from GCC to Kerala hospitals. But, from the rest of the geography, like Africa and SAARC, we do get a lot of patients from Maldives, but from Bangladesh and other geography, we have a challenge in terms of air connectivity. And also we don't have embassies in the smaller cities. Everything is there in Delhi or in the large metros. If these two issues, because the embassies presence helps in processing the visa, because all the international patients come visit India with the average stay is more than 15 days, they need a lot of support from their local embassies. So air connectivity and embassy is the key factor.
If these things are get addressed, there's a huge opportunities in Tier 2, Tier 3 cities. Patients will have a treatment in Tier 2, Tier 3 cities, smaller towns, for the price and also quality of work. Since we have presence in both the geographies, we have presence in metro and we have in the Tier 2, Tier 3 , we are very bullish about what is going to happen now and in the future also. And we have a large presence in GCC with a robust brand name, and, the GCC flow will only improve, but at the same time, because of the pricing and the quality of work we do, we'll also have a lot of patients coming to the other geographies, hoping with the conviction, because government is doing a lot of work.
Recently, I got a circular from FICCI saying that Air India is trying to connect Bangalore and Hyderabad to various geographies and various geography, even to Vietnam and those countries to the metros now, but eventually they are also going to connect, give the air connectivity to Tier 2, Tier 3 cities. So there's a huge potential. The biggest constraint as I see is the air connectivity. If air connectivity improves, there's a huge potential waiting.
Okay, sir. So that's all from my end, and thanks and all the best for the future.
Thanks, Vinu. The next question is from Mr. Sumit Gupta. Sumit, can you unmute yourself, please, and ask the question? Sumit, can you unmute yourself? Okay, we'll move on to the next. The next question is from Alankar Garude. Can you please unmute yourself?
Yeah, hi. Thank you for the opportunity. So first question, in the GCC deal valuation, there was a $70 million earn-out based on EBITDA achieved by the GCC business in FY 2024. Can you please let us know the gap between the target EBITDA for this earn-out and the actual reported EBITDA by GCC in the fiscal?
Amitabh, do you want to?
Thank you. So Alankar, if you go back to the terms that were there for the transaction, it was that there was amounts set aside as $17 million of earn-out, which was between $130 million of EBITDA to $150 million EBITDA, wherein for every dollar of an EBITDA, there was a $3.5 million of earn-out. As we look through the numbers of GCC, the reported EBITDA, despite all the adjustments which were there in the SPA for the EBITDA to be computed, we still arrive at a number which is in the range of $127-$128 million, subject even after all the adjustments. So it's unlikely that we will get into the range where the earn-out will get triggered.
Understood. Amitabh, there was another $30 million based on certain other contingent events.
That's right.
Can you elaborate on those as well?
That's right. So if you look back to the consideration, the initial consideration that was set aside was $903 million, and what we finally paid out was $907 point something. So that, $ 4.78 million that was there, was towards the Vahat EBITDA that was arrived at, versus which the, the consideration was worked out. The balance that was sitting in that amount was for any other further recoveries. Those recoveries are not yet being made. We are in the process of pursuing those. As that, as and when that happens, we shall let the shareholders know, but as of now, we don't have any further amount to be offered to the shareholders as a part of that 28.
Sure, that's helpful. Thank you. Coming to India, if you look at the secondary mix in AP Telangana, clearly that higher secondary mix in the region is a slight deviation from a relatively much lower secondary mix in Kerala and Karnataka. And we have been present in this cluster for quite some time now. And, Nitish, sir, you did mention about a lot of performance improvement initiatives and discussions happening. So strategically, I just wanted to understand, how are we looking at this business? Are we also open to kind of divesting from this business if some of these performance improvement initiatives do not really play out?
Yeah, Alankar. Yeah, see, like I mentioned in my earlier comments, we are doing everything possible to sense a huge opportunity in Andhra. There is an opportunity, but there is a challenge where the management team there is not able to deliver to our expectation compared to our other, compared to other geography. Now, we have taken two quarters as a way forward to kind of correct those things. We are in a serious engagement with this management there. Like you mentioned, if the worst case scenario, if things are not going to change, we will need to take that extreme steps also. But, at this point of time, we have kind of, we are confident in the next two quarters, we will be making-- Because they have been improving.
There have been a lot of reasons for the subdued performance in the last two years compared to the previous years before COVID. But now we are supporting them in all possible terms. But in next two quarters, we don't see any substantial reversal in performance. We are, like you mentioned, like about divesting, we are all open to all kind of measures, but we would like to wait and watch for next two quarters.
Understood. Maybe a couple of bookkeeping questions for Sunil, sir. Sir, if you look at the cash flow statement for FY 2024 for India, there is a line item, change in other financial assets, loans, and other assets, which is pretty high, to the tune of almost INR 1,700 crore, and that's pulling down our cash flow from operations significantly. Can you please let us know what exactly is this line item?
Yeah, Alankar. See, this is basically because of the, you know, you know that, the reporting change also has happened, right? Today, when you look at the, consolidated financials, we have not usually, because the sale has happened on April third, that is a date taken, and it's a subsequent event after the, you know, book closure of thirty-first March. We are supposed to show it as a, not as a continuing operation, but as a discontinued operations, right? That's why in the balance sheet, you'll see that on the asset side, we have the complete balance sheet asset of the GCC shown under asset held for sale. And on the liabilities, we have shown them as liabilities, related to the asset held for sale, right?
So with that, what is happening is that the INR 1,500+ crores, which we have shown as investment on a non-current investments in the India balance sheet, that we are able to move it to current, investments, right? Because of that changes in the, the continued to discontinued operations, we are able to, that is a line item which is changing. But what we can do is that, we can separately relay, you know, more, detailed, cash flow statement for you for further analysis.
T hat would be helpful, sir. Secondly, if you look at the fixed component of O&M fee, can you quantify that, which is sitting in depreciation, as per Ind AS 116?
Yeah. I think we even shared that in the P&L reco and the Ind AS reco we had given. Just a minute. Yeah. So for example, so for FY 2024, for the full year, in depreciation, whatever the depreciation amount is there, out of the INR 45 crore is related to the Ind AS, Ind AS depreciation. And in finance cost also, out of the total finance cost, INR 57 crore is related to the Ind AS 116 finance cost. I hope that answers your question.
Okay. So basically on top of this 45 + 57, there is that additional impact of the variable component, which is there in our O&M arrangements.
Exactly. Exactly.
Okay. Essentially, for the entire adjustment, we need to add all three components.
Well, that's very right. That's very right. Because see, what-- that's what we had explained in the note. See, usually, Ind AS 116 really works only when your future, lease rentals are fixed of nature, because that's when you are able to calculate what is your future cash outflow, and you bring a present value, and you reverse that EBIT, you know, rental from the PNL, and you bring back again as a depreciation interest. But if it's a variable amount, Ind AS 116 cannot apply there. That's where that will still be above EBITDA. That's where we have brought the differential between operating and, reporting EBITDA.
Understood. Maybe one final question. If you look at the overall reported India EBITDA and the segmental performance, there is a gap which can be explained by all the intercorporate eliminations. So just wanted to understand the nature of these eliminations. So there is INR 106 crores of intercompany revenue adjustment which is there for this year. I mean, there was a similar INR 85 crore number for FY 2023 as well.
Right.
So, I mean, just trying to understand what is the nature out here, and will that number really change with the GCC business going away?
Yeah. See, all the in the note, what we put INR 106 crore, right, the intercompany eliminations, that is related to two particular things. One is on the labs, another is on the AMI, or we call it as a radio or teleradiology, right? So what has happened in the last year is that Aster business, when we talk about last year, we clocked in a revenue for around INR 118 crore. Out of that, 75%, almost, near business comes from the Aster business, right? So that, that's the intercompany. So that is the expense. It's a revenue in the lab business, which is our holding subsidiary, and expense, it's shown as expense in our hospitals, right?
Then the next one is the teleradiology, because, see, the whole reason why we are able to consolidate the labs and teleradiology is to ensure that we are able to reduce our material cost and the HR cost. That's something which we are able to already getting the benefits. And the balance amount, other than the labs, is related to the radiology business. Radiology business is sitting or the consolidated radiology business is sitting in the listed entity, and we are able to give service to all our other subsidiaries within the Kerala and Karnataka and Andhra region. So that is the balance revenue, which is sitting there.
So we expect that you will not feel the same growth happening because, you know, the, this labs, because and also what will happen also is that because non-Aster business is growing very well in terms of both the radiology and the non-labs, you know, labs business. For example, in FY 2023, our non-Aster business in labs only contribute around 17-18%. In FY 2024, it has increased to 24. And we see that because hospital growth is in a double digit or a higher teen number, labs will grow at a very higher range, right, the non-Aster business. With that happening, you will not see the growth in the same, growth, because the growth will always get limited over a period of time.
Understood, sir. That's helpful. That's all from myself. Thank you, and all the best.
Thank you, Alankar. We would like to highlight that we will be giving preference to all attendees who have not asked a question before. So in the line, next question is from Sumeet Gill. Sumeet, can you unmute yourself?
Hello?
Yes, Sumit.
Yeah, hi. Thank you for the opportunity. So just want to understand about the medical value tourism, so in Kerala. So, like, what is the differential ARPOB which we get through MVT in Kerala versus the normal domestic business?
Yeah. Thank you, Sumit, for the question. See, MVT business usually are approximately 25%-30% higher than the other, who are cash patients. There are two reasons why the rate it's higher. It's because all these patients who come in, you know, basically come from single room occupancy, whereas the other cash patients is a blended occupancy of a general ward, and you see, you know, twin sharing and single room. That's where it is- looks higher, or around 25%-30%. Second, also, this ARPOB, which you're talking about, also, in, you know, it doesn't net off the referral fees, what we pay. If you do the net off of that, then the nominal increase will be around 10%-15%.
Understood, sir. So, sir, what's the overall trend that you plan to increase the, this contribution from MVT from 5% over the, let's say, next three to four years?
Doctor, you want to add on that?
Yeah. Yeah, as I mentioned earlier, there's a potential to go up . See, certain hospitals of ours are already doing 10%. It's a blended, we are getting 5%. So we are confident of, in the next three, four years to, the MVT alone, can contribute close to 10% of our revenue.
Okay, okay. So, like, so, like, currently, your margin is nearly 17%. So, let's say, all this MVT also increases, increasing in overall payer mix, optimization of basically payer mix. And, your Andhra Telangana margin is subdued, which is, I think, which is dragging the margins. H ow do you plan to increase this margin in Andhra Telangana so that overall margin trajectory also reaches more than 20%?
Go ahead, go ahead.
So we can see Andhra Telangana. If you look at their EBITDA contribution, right, it's almost 5% of your total India contribution. So even if you increase the margin, it is highly unlikely that it's going to move the needle in a very big way. Yes, it can contribute in a you know you know in its own way, but it is not going to impact too much, right? But the major is that 95% of the business or the you know EBITDA is contributed by Karnataka, Kerala, and Maharashtra cluster, and that is what we are looking for the growth to happen. And there, it's very clear that currently you know that operating EBITDA will be closer to 17, and the hospital segment is more than 20, and mature hospitals are 22% +.
We see that, you know, with the continuous ARPOB growth, which is going to happen, which I already guided around 8%-9%, and also with the MVT business increasing and the case mix, because we have been doing a lot of high-end procedures. We did last year, FY 2024, almost more than 1,000 robotic procedures. We did more than 500 transplants, right? And also we're doing more deviate cases, cochlear implant cases. With all these things going to go more and with more of, quaternary care, you know, procedures, which we're going to continue to do in the next two to three years, we can see that margins also will expand at a constant level, near 20% in next two to three years. And hospital segment alone, we should reach 23%-24%.
Okay. Understood, sir. That, that's really helpful. And sir, second part on the overall CapEx side. So basically, out of the over nearly 1,700 beds planned, how much is greenfield or brownfield?
See, out of 1,700 beds, 60% of it is the brownfield. Greenfield projects are only two projects, mainly the Aster Capital project in Trivandrum, which is a 460-odd bed, and another 260 beds from Kasaragod. Right? Kasaragod is expected to operationalize in FY 2026, and Aster Capital is expected to operationalize sometime in FY 2027. So our CapEx requirement for all these 1,700 beds for the next two, three years, that is FY 2025, 2026 and 2027, is approximately INR 1,000 crore.
Understood, sir. And sir, regarding the EBITDA per bed, like it's just want to understand why is it subdued versus the peers, and how do you plan to increase this EBITDA per bed, operating bed, basically?
Let me answer the first part of the question, then Dr. Nitish will add on to it. See, already Dr. Nitish also highlighted that, right? We are 70% of business for us comes from the non-metros, right? EBITDA per bed is relative to your ARPOB. We are not in the metros where the ARPOBs are something like INR 60,000 or INR 70,000, right? But if you look at our own composition, 70% is from the Tier 2 or Tier 1 cities, where our ARPOBs are around INR 40,000, INR 40,000-INR 50,000. And, you look at our own Bangalore market, we are doing more than INR 62,000, INR 63,000 ARPOB. But end of the day, India ARPOB, the consult level is around INR 41,100. That is because majority of our business comes from the Tier 1 cities, right?
Or the other, I would say, non-metros. And considering your ARPOB is at INR 40,000, naturally, your EBITDA per bed will be lower than the peer comparison. But at the same time, we always look for sustainable margins, and also because we are in the non-metros, our ARPOB growth, which can come through, is quite high. Even though, see, for example, in metros, already you've seen, right, 40% is only cash, 60% is your credit business. But for us, in the non-metros, we are still at 60%-65% still cash business, which we have, right? Only because of the metro, our consolidated cash mix has come down to 58%. With that, we have the potential for growth. As compared to metro cities, their potential of ARPOB growth is always limited.
But we are being majority in non-metros, our potential to ARPOB growth is always high. Keeping the trends, what we've done historically in the last five years, we were able to grow at least 8%-9%. We are very confident that ARPOB growth also will be very healthy in future years. And also, along with that, EBITDA per bed also will add to that.
Okay. Understood, sir. That's it from my side. Thank you.
Thanks, Sumit. The next participant who is asking question is Damayanti Kerai. Damayanti, can you please unmute yourself and ask the question?
Hi, good afternoon. Am I audible?
Yes, Damayanti, please.
Okay. Hi, thank you. Thank you for the opportunity. So my first question is on your insurance mix at this point of time, which is around 27%, and you said you have seen good 120 basis point increase compared to last year. And, Dr. Nitish mentioned in his remarks that improving this pie would be critical to improve performance in some segments like AP Telangana, which are right now lagging. So just want to understand, how do you see this 27% pie moving up for next few years? And, what kind of efforts are taken by your side to really push on this part?
Yeah. Damayanti, thanks. So a very important question, because this is something which is going to redefine the healthcare of India. When I talk about insurance, I'm talking about purely with private insurance, because there are others l ike government-sponsored insurance.
But we spoke about the numbers what we shared was about the private insurance. Now, in the bigger cities, the private insurance penetration, like in the hospitals in Bangalore, the insurance, private insurance work is around 60%. 50%-60% is covered by private insurance. Whereas when you go to the other geography, like Tier 2, Tier 3 cities in Kerala, like larger cities like Kochi, it is around close to 50% of patients are covered by private insurance. Whereas in North Kerala, the cash patient is more. It is 80% is cash patient, 20% is insurance. So what this, this is something which is going to change drastically.
At a group level, we have shown more than 1.5% growth, but at a certain unit level, if you really look at it, it might be in the double digits also. The insurance penetration is increasing, because this post-COVID, there's been an awareness among the general population, the importance of the health insurance, and also government is giving a lot of initiatives to improve upon the insurance coverage. So the government has come to a conclusion that universal health insurance is a possibility, but universal health coverage is a challenge. So the only way we can address the industry requirement of comprehensive health coverage is through universal health insurance coverage.
So as an organization, we are best placed to take advantage of that fact because the kind of presence we have, we have major presence in Tier 2, Tier 3 , where insurance penetration is going to happen in a big way. And also we have presence in the metro, where the insurance penetration has happened to the maximum, and it will only I assume that in the future, from 60%, the big metros, the insurance coverage will go up to 80%. That is a possibility. Then I also explained the advantage. We don't see it as a challenge. It is only helps in helping the patient to access the highest care and the highest quality of care, as well as the complex work.
Now, if you-- Sunil mentioned about how we have doubled the robotic surgery from 400 to 1,000 to close to 1,200 robotic surgeries. This has primarily happened because of the insurance has started covering the robotic surgeries. Same way, oncology is another case. In our group, we do close to 8%-10% of oncology work, but I see that might go up to 25% in the coming future, and that is primarily enabled by the insurance penetration, because oncology treatment is very complex, very expensive, and long-term treatment is a must. And there are specialized insurance package only available for oncology patients. So a lot is being played out.
As an organization, I think we are definitely placed, very well placed to take advantage of the fact that insurance penetration is going to only go up. And, that's why we are so that much focused on the tertiary and quaternary care delivery, which is a challenge, especially in Tier 2, Tier 3 cities to deliver, because acquisition of the talent and creating infrastructure is a big challenge. But, we have been fortunate, and we have been capable enough to demonstrate that, this kind of high-end work can be also done at, Tier 2, Tier 3 cities. I hope I answered it.
Yeah, understood. But it seems like in most cities in, say, Kerala, where you have most of the presence, cash will likely remain the biggest component, and maybe gradually we'll see a pickup on the insurance side. But in markets like Bangalore, obviously, I guess, it's the fastest- growing pie to understand.
The biggest cities, metros, the insurance penetration is happening by a much faster pace compared to Tier 2, Tier 3 , but it's just a matter of time. It is also going to change because insurance penetration is not happening to that extent like in metro, because the high-end work is not happening in Tier 2 cities. But wherever it is happening, the insurance penetration is improving.
Understood. My second question is on your 0 to 3 years category hospital, where you have 6 units. So, can you just update us, like, which hospitals have really achieved cost break even and then moving up further in terms of margin improvement, and which are the units which have slightly longer way before they can turn around at the EBITDA level?
Yeah. Yeah, yeah. Thank you, Damayanti, for the question. So the six hospitals basically include four owned and satellite hospitals. That basically includes our Aster Mother Hospital in Kozhikode, Aster PMF Hospital in Kollam, Aster G Madegowda Hospital in Mandya, Aster Narayanadri Hospital in Tirupati. In addition to these four, we have got a new facility we added for handling the scheme patients, called as Aster Ramesh Hospitals in Vijayawada. That's just a 50-bed hospital. In addition to all these small hospitals, the biggest one is the Aster Whitefield Hospital. So when you look at, when you say cash burn, I would say, your Narayanadri has done really well. We talked about it previously also. It broke even in the first quarter itself. Even today, they are turning out, you know, lower double-digit margins.
Similar is the case of Aster PMF Hospital. Our Aster Mother Hospital, I report, you know, the losses have really reduced to hardly, small losses, which is there. That's where I've talked about that Aster owned and hospitals, basically, owned and satellite hospital. Last two quarters, out of blended four hospitals, we are able to consistently maintain the positive, even though 1 or 2 hospitals are in the loss, but positive margin is there in the all 4 hospitals together from the last 2 quarters. And Aster Whitefield Hospital also specifically called out in the speech of DMT and Nitish, wherein you know, we were the fastest break even, right? In third month itself, we broke even. For example, full year number would be less than INR 4 crore-INR 5 crore.
So that's where you can see 0-3 years, even the 6 hospitals contributing INR 275 crore revenue, the operating EBITDA loss is just INR 7 crore negative, and that is a very considerable decrease from the previous year. And I hope that is outlook.
Yeah. Thank you. And my last question is clarity. So in terms of margin outlook, did you mention at the consolidated level, 20% is something which you are targeting, and then it will be higher, say, 23% or so for the core hospital segment?
That's right.
Okay. Thank you. I'll get back in touch.
Thanks, Damayanti. So the next question is from Mr. Rajkumar. Mr. Rajkumar, can you please unmute yourself and ask the question?
Yeah. Good afternoon. Can you hear me?
Yeah, we can hear you.
Yeah. So I'm looking at slide number 19 of the presentation. This question is for Mr. Sunil, Sir, I just want to know, I saw the note on the tax part, that due to the deferred tax liability of INR 52 crore, the tax looks very high for this quarter. So I just want to know what is the steady state, or rather the projected tax rate for the upcoming quarters? So should we work with 25%, given that you have now moved to the, whatever, the normal range?
Yeah, Rajkumar. Yeah, thanks for the question. See, this INR 52 crore is a one-time non-cash liability, deferred tax liability hit. See, basically what happened is that now we had a major income, right? From the GCC sale, which is upstream from Affinity to a listed entity. There is certain higher profit has been generated in the quarter one. And going forward, we will not be able to continue with our current, you know, old tax regime. We had to move to new tax regime to become more tax efficient. That is the reason why the deferred tax liability has been coming in, right? So and this is a one-time hit.
So if you look at the next year onwards, you don't expect that such a hit coming through, because already the deferred liabilities are already created as a one-time hit for the future benefits, right? Now, we are going to see the deferred liability only going to unwind over a period of time. When, which your next question is that what is the tax which you can take it? So because in the new regime, we'll come down tax to 22%, plus the surcharge and cess. You can look at, and that is only for the profit-making entities, and also where the subsidiaries, where our revenue is more, less than INR 400 crore, we, we have a lesser rate of 25%, right?
But you take up, because also we are also making the new assets that are coming into picture, new greenfield projects in FY 2026 and FY 2027, and also the Whitefield hospital, which we recently started. Even though EBITDA breakeven has happened under the PAT, it will have some stress, right? So with all this put together, you can take a effective tax rate on the PBT of something around 14%-15%.
14%-15%, right? That's what you mentioned.
That's right.
Okay. Okay, yeah, just continuing on this, the same, I have just a couple of more housekeeping question. The next one is, there is a movement of, the fair value, contingent consideration payable of INR 6 crore. So just wanted to know, you know, this is just a one-off, right? So this will not again come in the subsequent-
Yeah, see, movement in fair value of contingent consideration payable is a non-cash item again, right? See, what happens is that because we have got multiple subsidiaries where we have holding investment, correct. So and also all these investments, for example, Ramesh Hospitals or Prerana Hospitals, they do have a certain put option. And when you have a put option and they have a time period, they are, they have the right to put the shares, and I have the obligation to buy those shares. During that period, as per the accounting norms and the Ind AS, you are supposed to recognize a gross obligation of that liability in the consolidated financial statements. So that is what we recognize when we, when we first take the investment.
After that, what happens that every financial year end, you assess or reassess what is the gross obligation based on the future, cash flow, or I would say, you know, based on the DCF method. Now, if the performance is really good, that means to say the valuation will go higher. That means to say our, when they put the shares, my investment will be on a higher cent, right? In that case, what happens? The liability goes up, and that any increase or decrease in liability comes through PNL. So INR 6 crore is basically a decrease in liability because we have seen the Ramesh Hospitals performance, right? It's not so great. Because of it, the liability has come down, and that is where it is getting unwinded as a, you know, income, or I would say negative liability under INR 6 crores.
Okay. Okay, got it. And lastly, on this NCI of INR 9 crore that you have shown, is it coming from your Malabar acquisition?
Yeah, I would say majority would be coming from there. See, we have three major subsidiaries, or I would say major material subsidiaries of MIMS, where we hold 79.6% or so. And the balance we hold is the Prerana Hospital, that is, Aster Aadhar Kolhapur, that's where we hold 87%, and the Ramesh Hospitals, where we hold 57.5. And considering all these subsidiaries, major performance is happening in MIMS, one of the very good cash flows. So you can say NCI, whatever INR 9 crore we have recognized, 80% would be coming from the MIMS Limited itself.
Okay. So just to labor on the same point, given that you are looking at acquisitions, would it not make more sense to go 100% on this, the NCIs wherever the NCIs are happening? Because that will immediately give you a 25%, close to 25% upside on your PAT. That's more like a low-hanging fruit for you, right?
Correct. No, no, your point is very right, Rajkumar. That's exactly what we have tried to do in last one year. If you know, one year back, our stake in MIMS, right, it was at 74%, and we increased almost by 5%. So, from the very clear strategic point of view, we are very clear that wherever possible, we will always increase the stake, and that too, such a unit where the performance is quite good. But at the same time, right, we don't have a specific shareholders agreement for them to, you know, put on a call option to buy those shares. And also, this is MIMS Limited, where the number of shareholders are very high, but we'll always keep that effort open, and but it will always take certain time to get into the 100% or even near 90%.
Okay. Thank you so much for answering my question. Just, just last bit, on the cost components, I see there's a significant shift between the employee costs and other costs when you look at, Q4, FY 24 and FY 23. So is there anything, I mean, any significant change in strategy, like the employee costs come down, whereas the other costs have doubled?
No, it's related to reclassification, Rajkumar. I can give you more insights, offline on the bit of it.
Okay, no problem. Yeah. Thanks a lot. Thank you so much for answering this.
Thanks, Rajkumar. So the next question is coming from Dr. Vinu. Dr. Vinu, can you please unmute yourself to ask the question?
Yeah, hi, good morning or good afternoon. Dr. Nitish, just a question on nursing and other technical talent. You know, nowadays we have seen a lot of corporate hospitals coming up across both yours as well as competitors. Is there any shortage of nursing and other technical talent that you are coming across? And are the costs or the manpower costs in that regard going up?
Yeah. Thanks. Thanks, Vinu. Nursing attrition, nursing shortage of nursing is an industry problem. We all are aware of it. So we have to address this challenge, we have certain inherent advantage and certain strategies we have put in place to address this challenge. Inherent advantage is, most of the hospitals are in Kerala, and, you know, majority of the nurses come from Kerala, so we have the distinct advantage of getting the nurses, access to the nurses and paramedical staff. 60% of the paramedical and nursing staffs are from Kerala, so that is we come from, we are based off Kerala. That is one fact that is helpful. But at the same time, we have a cluster approach.
When we have a cluster approach, when we are dominant in a micro market, like we are by far the number one in Kerala compared to the competition, it's much easier to retain the clinical talent because everybody wants to associate with the organization which is growing and which is focusing on the high-end work. Because the value of the nurses in getting trained in the high-end work. So since all the hospitals are enabled to do high-end work and we have a cluster approach, we are able to retain and train them, and cross-train them also.
And also we have kind of focus. We accept the fact that nursing is the core of our existence, so that in terms of you would have seen our nursing award, and we take a lot of initiatives to encourage the nurses to not only work as nurses, but after a certain phase in their career, we also encourage them to take up managerial role, and we also encourage them to get into administration in other areas. So there's a clear-cut path, growth path. But then also we have presence in GCC, which helps in kind of giving a career path than to go to.
If they have aspiration to go abroad, but they can kind of join us and grow in India and then go to GCC if required, or if in the GCC, some of the lot of nurses beyond certain years would like to come back to their hometown. That also it, this, this, we having presence in GCC and India helps them into kind of closing their career path. So that also is one more aspect. So we do have challenges, but compared to the competition, we have lesser challenges because of the cluster approach and also dominant presence in Kerala, and also the kind of strategies we have taken. We are able, to large extent, able to mitigate this challenge.
Understood. Actually, my question was more like, you know, in the last six months, have you seen anything incrementally on that front?
Not much, but there has been a general, because what I don't see a major attrition rate going up compared to the previous years, but it's been consistent. It has not gone down, but not, it has, has not gone up also drastically.
Understood. Just, from a housekeeping perspective, Sunil, what would be the CapEx number for FY 25?
FY 25, it could be something like INR 450.
INR 450 crore. Okay. And just to confirm, when you give this cluster-wise revenue and EBITDA reporting, that also captures the, the pharmacy and diagnostics revenue, and EBITDA of those particular geographies. Is that right?
No, no, no. See, when we give cluster, it's very clearly hospitals, what we cover, hospital and clinics, but it doesn't include the labs and pharmacies.
Okay. So that, those are the separately reported numbers.
Yes.
Okay, understood. Thank you.
Thanks, Dr. Vinu. So the next, next question is coming from Mr. Devanshu. Devanshu, can you please unmute yourself and ask the question?
Hi, good afternoon. Can you hear me?
Yeah, we can hear you.
Just two questions. Just to follow up on the previous participant. CapEx for FY 2025 is INR 450. Do you, can you give us a number for the next year after as well, projected for FY 2026?
It is very early, Devanshu, to give it, because this 450, what I've given is because we have the budgets, and there is a very clarity on the what is the project CapEx. Because, see, when we say CapEx, we've got a project CapEx of INR 1,000 crores, which I talked about. Plus it also includes a, a little bit of a growth for the additional medical equipments we need to do and also replacement CapEx, right? So it all includes around INR 450 crores is what we have. But going forward, usually what we can say is that, project CapEx of anyway INR 1,000 crores will be allocated in 2026 and 2027. In addition to that, you can take 1.5%-2% on the top line as a growth under the replacement CapEx.
Got it. And, just one clarification-
Just to clarify, Sunil, you said project CapEx will get allocated in 2026, 2027. I think from 2025 to 2027, right? The INR 1,000 crore, that's all for the three years.
So, I mean, Nitish, what I told is that totally we have INR 1,000 crore to be spent on the project CapEx for 1,700 beds. Out of that, already given the highlight about INR 450 crore, which includes the project CapEx plus the growth and replacement CapEx.
Sure, sure. Noted, noted. And second, clarification I had was on this residual amount of INR 1,500 crores that we have net of the dividends, what would be the net amount retained by the company post or transaction costs and, you know, any other costs, if any?
We basically, out of $907 million, $20 million approximately was retained in the Affinity level for the transaction cost. Post that, it was upstreamed around $87 million to Indian listed entity in terms of dividend and the redemption of preference shares. That is basically in INR, we are talking about around INR 7,400 crore. So out of INR 7,000 crore, INR 7,400 crore, we have already released a special dividend of INR 180 per share, which amounts to INR 5,900 crore. That's where you're seeing the balance amount, which is excluding any transaction cost. We have a cash of around INR 1,500 crore in the listed entity.
Will there be any amount that will be netted off from this?
No, no. There's no further amount netted off from this.
So, this is a net amount retained by Aster in India now?
Yes. Correct.
Okay, noted. Thank you. Thank you, thank you. That's it from my side.
Thanks, Devanshu. Yeah, I can see the raised hand from Mr. Nithin. Mr. Nithin, can you please unmute yourself and ask the question?
Hello? Hello.
Yeah, Mr. Nithin.
Yeah, yeah. Thanks for the opportunity.
Can you be please little more louder?
Yeah. Am I audible now?
Yeah. Yes.
So most of my questions have been answered. I have only one question left. What will be our peak debt post all the CapEx we are spending for next three years?
Nithin, can you come again on the question?
My question is on the debt. As we are in the CapEx cycle for next three years, what will be our peak debt? Out of the INR 1,000 crore which we are going to spend in three years, can you give the breakup or what will be our internal approval and debt we are going to borrow?
So, let me put it this way, if you keep the INR 1,500 crore apart, right? Even keeping that apart, we are talking about currently a gross rate of INR 669 crore, right? So out of that, we have got 1,700 beds to be expanded in the next three years, which will be again a combination of the debt and the internal accruals. And what we are already seeing is that we should hit the peak debt only in FY 2025. B ecause that's when the majority of the CapEx on the greenfield is going to incur in FY 2025. With that happening, from FY 2026 onwards, you should see the debt, per se, coming down.
That means to say, net debt to EBITDA ratio, today what we have, around 1.1, may a little bit slightly increase in FY 2025. And again, after that, it should come down in such a way that by FY 2027, 2028, we should go into net cash. Unless we add another, you know, many more beds, which is already in plan. But I'm giving the visibility based on the CapEx which we have in sight.
Anyway, the net debt to EBITDA will remain below 2.1, right?
Yeah, all, yeah, very much.
Okay. Okay. Yeah, that was my only question. Thank you.
Thank you.
Thanks, Nithin. If any of other attendees would like to ask a question, can raise their hand. Okay, I don't see any, you know, raises hands. Okay, so I think there is no more question to the management. Thank you all. Concludes the earnings call of this quarter for Aster DM Healthcare. I thank the management and all the attendees for joining us today. If you have any further queries or questions, please get in touch with us. Thank you.
Thank you.
Bye-bye.