Ladies and gentlemen, we will welcome you all to Q3 and nine Months FY 2026 earnings conference call of Nephrocare Health Services Limited, hosted by Ambit Capital. This conference call may contain forward-looking statements about the company, which are based on beliefs, opinions and expectations of the company as on date of this call. These statements do not guarantee the future performance of the company and may involve risk and uncertainties that are difficult to predict. As a reminder, all participants' lines will be in listen-only mode, and there will be an opportunity for you to ask questions after the presentation concludes. Should you need assistance during this conference call, please signal an operator by pressing star then zero on your touchtone phone. Please note that this conference is being recorded. I now hand over the call to Mr. Gaurav Tilani from Ambit Capital.
Thank you, and over to you, sir.
Thank you, Pari. Good day, everyone. On behalf of Ambit Capital, I welcome you all to the Q3 and nine-month FY 2026 earnings conference call of Nephrocare Health Services Limited. We are pleased to have with us the management represented by Mr. Vikram Vuppala, the Chairman and Managing Director, Mr. Kamal Shah, the Co-founder, Mr. Rohit Singh, Group Chief Executive Officer, and Mr. Prashant Goenka, Group Chief Financial Officer. We will have the opening remarks from the management, followed by a question and answer session. Thank you, and over to you, sir.
Thank you, Gaurav. Good evening, everyone. Thanks for joining this call. This is our first earnings call. I would also like to thank all our guests, teammates, shareholders, and partners enabling us to list on December 17th on the Indian stock exchanges and for their continued trust and confidence in NephroPlus. Since this is our maiden call, I would want to spend some time on the Indian healthcare industry dialysis market at a macro level and also key insights about our company itself. Later, our senior leadership team will share more details, including the Q3 FY 2026 and nine-month FY 2026 operational and financial highlights. Post that, we'll open the floor for a Q&A session.
Speaking on the India healthcare industry, it operates through a complex interplay between public and private sectors, with service delivery historically dominated by private service providers and financed largely through out-of-pocket expenditure. Good news is that in recent years, government has increased healthcare spending as a percentage of GDP, helping to reduce financial vulnerability among households. Beyond traditional hospitals, the private sector is increasingly driving the evolution of India's healthcare delivery through rapid growth in non-hospital settings such as diagnostic labs, single specialty clinics such as dialysis, IVF, oncology, home healthcare, tele- and telemedicine platforms. This shift reflects a broader move toward more accessible, specialized, and cost-efficient care models. Single specialty providers have evolved from small hospital settings more towards clinic-based models as many high-frequency procedures with low complication risks can effectively be managed outside a tertiary care hospital setting.
The transition from an unorganized to an organized market, coupled with scalable business model and strong unit economics, has significantly accelerated the growth of single specialty providers. Key growth drivers for single specialty include superior clinical expertise, enhanced patient experience, improved affordability, better access, and also rapid adoption of technology. Now, let me spend some time on the dialysis business itself. Rising NCD, non-communicable diseases such as diabetes and hypertension, are causing increasing incidence of chronic kidney disease, which is called CKD globally. If CKD is not managed well, over time it leads to the last stage of CKD which is called stage five, also called end-stage renal disease, which means both the kidneys have failed completely. At that time, you either require a dialysis to survive or a transplant. Dialysis just replicates kidney function. It removes excess fluids from the body and also it removes toxins from the bloodstream.
Dialysis business has many unique characteristics and hence it is needed to understand it separately rather than grouping it among other healthcare service providers. Five distinct characteristics of this business are, firstly, each dialysis session lasts 4.5 hours, including the actual session time of four hours and the pre- and post-treatment time. Dialysis clinics can only offer three sessions per day per machine, morning session, afternoon session, and evening session. Hence, it's a fixed capacity business almost like airlines which have fixed number of seats on a plane. The only major way to grow this business is to keep adding seats or capacity, and that is how all the global dialysis networks have grown across the world. Secondly, dialysis is a life-sustaining chronic treatment that our guests need three times a week.
Hence, proximity to their home is very important and hence it is, it requires a widely distributed network with small to medium clinics to take the treatment closer to patients' homes. As real estate in any clinic is limited, the only major way to increase capacity is to add new clinics to any dialysis network. While airlines will be happy with 100% utilization, dialysis clinics cannot go beyond 85%, as we need to keep some spare capacity for patients coming in breathless and requiring urgent dialysis. Thirdly, globally, dialysis is a reimbursed business as it's very expensive. I think three times a week translates at a $20 price point, translates to roughly INR 2.5 per year for every patient in India, which excludes other hospitalization costs, medication costs, and various laboratory costs for these patients.
India operates at the lowest price point in the world, while middle-income markets operate at 5x-7x our price, and developed world operates at 10x-20x our price. Across the world, hence, dialysis treatment is reimbursed by either insurance or some form of government payment. Even today in India, more than 30% of patients pay out-of-pocket, which becomes quite a significant burden on their families. Fourth, unlike other single specialty businesses, dialysis is a monoline business. For everyone, anyone with kidney failure, it is a standardized single line of treatment that lends itself to scaling in a distributed network fashion. Unlike others, paramedical staff play a much bigger role in dialysis service rather than super specialists like nephrologists, which again lends itself to scaling to tier two, tier three markets where nephrologist availability is very limited.
Fifth, any dialysis network requires massive scale and complete 100% operational focus to achieve sustainable margins in this business. We, in fact, were EBITDA negative for 11 years as we scaled aggressively to reach that critical mass, after which the operating leverage started to kick in. At small scale, no one can make decent margins regardless of price point, as it's a high fixed cost business. Also, there are so many cost items in a dialysis service. If 100% focus is not provided, there will be many leakages which will reduce the margin significantly. Now, let me talk about NephroPlus specifics. NephroPlus was founded 16 years ago by Kamal Shah and me to truly redefine dialysis care in India. As co-founder himself he' s on dialysis for the last 28+ years, we understand customer needs, wants, and wishes better than any other dialysis network in the world.
In 2010, dialysis was almost like a death sentence, wherein nephrologists would just ask patients to settle their financial matters, ask them not to work, ask them not to travel. Average life expectancy was less than one year. Kamal and I, we truly wanted to change the way dialysis was done. We figured out a way to eliminate cross-infections in dialysis, which would otherwise affect 1/3 of the patients on dialysis. These cross-infections were hepatitis C, hepatitis B, or HIV. We also wanted that truly patient-centric care where, based on Kamal's own experiences, was provided in every single NephroPlus clinic. Every clinic was designed with cheerful interiors, Wi-Fi access, certified paramedical staff, and with a staff who genuinely cared for our guests' wellbeing.
We started as a standalone dialysis network in Hyderabad with our first two clinics in 2010, but then realized Indian market was not yet ready for outpatient standalone clinics. We understood that people with kidney failure, while they are severely immunocompromised, the government still did not recognize standalones at that time, and hence, dialysis routinely was almost always performed inside hospital settings in India. While this is not true for the rest of the world, throughout the world, other than India and Indonesia, dialysis is performed in a standalone outpatient setting. Whereas in India, it's slowly, over the next five to 10 years, it will convert into standalone and hopefully so with Indonesia.
When hospitals started asking us to manage their dialysis departments, that's when in 2011 we pivoted to a captive or shop-in-shop model, wherein we started partnering with hospitals in a mutually beneficial revenue share model. Now, historically, hospitals used to run dialysis departments on their own in India. Why would they want to partner with us? As mentioned earlier, you require massive scale in dialysis and 100% focus in dialysis to generate sustainable margins in this business. Massive scale is needed for four reasons. One, to derive synergies from procurement of specialized equipment and consumables. Two, build capacity to recruit large number of specialized paramedical staff like nurses and technicians. Three, to have your own in-house biomedical team to optimize your biomedical costs, which can get very expensive. Four, to develop technology products to monitor quality and overall operations in a widely distributed network setting.
Now, hospitals, due to their very low scale in dialysis service, do not make any margins, and hence it is not their focus. Their profit drivers will be much more acute care departments, like the way we say CONGO, cardiac, ortho, neuro, gastro, onco, rather than dialysis, routine dialysis service. Why do hospitals in India offer dialysis services? Because the nephrologists want a large dialysis unit for their practice, and also because hospitals make good returns from adjacencies of dialysis service, such as transplant, ICU admissions, lab investigations, pharmacy sales, and fistula procedures. Hospitals should ideally be focusing on complex acute care and not a maintenance dialysis care. Now, hospitals can still get these margins from the stated adjacencies if they partner with NephroPlus. As NephroPlus team delivers great clinical outcomes and service levels, and volume grows significantly, the adjacencies value also grows commensurately for the hospital.
Now this model is proven in India with as close as 300 private hospitals, including majority of the large hospital chains having partnered with NephroPlus to run their dialysis departments. Even now, in India, 80% of the dialysis market is unorganized, which means hospitals are running in 80% of the clinics, dialysis departments on their own. This unorganized market is slowly and surely getting converted to organized market, and this trend will continue over the next 10, 20, 30 years. Now, identifying this as a trend, NephroPlus undertook measured expansion across India, with our hospital partners. After our expansion in Hyderabad, we expanded to other cities in South India first and then North India and later in West India and finally in East India.
Now we are catering to with hospital partners across 25 states and more than 290 cities across in a pan-India format. Secondly, we also have forayed into public-private partnership projects, PPPs, across four states, namely Andhra, Bihar, Uttarakhand, and Karnataka. Across all healthcare PPPs, dialysis PPPs have been the most successful projects in India so far. Government has realized that it cannot provide dialysis services very efficiently. Think of Air India just to get the picture. It has realized that they should only be a payer and regulator in this service, wherein private partners bring scale and efficiency along with expertise for the benefit of poor patients. It's a single line of treatment for every single patient, so billing is very straightforward and verifiable. We at NephroPlus are very selective about which PPPs we participate. We did only four PPPs in the last 16 years.
Every few years, we come across a very good PPP, we participate and try to win. Majority of the PPPs we bid, but we lose because our price point is higher, because our quality is better. This has been beneficial for us, too, as we get good volume at good contribution margins, which feeds into our efficiency engine. Came international expansion in 2020. In early 2020 when Kamal and I were thinking about next wave of growth at NephroPlus, we realized that we could either grow vertically into other adjacencies of dialysis or grow horizontally in dialysis into other countries. We realized that we have become very good at dialysis, and we wanted to double down on it as globally it's an $80+ billion market and expand into other geographies.
We explored Southeast Asia, Middle East to begin with, found Philippines to be a decent market, entered it with a small acquisition, and then kept on growing over the last five-plus years. Today, in five years, we have become the third-largest network there, which puts us in a strong leadership position, and we may be getting into number one position in the next few years. In 2022, we won a good dialysis PPP project in Uzbekistan, which the Ministry of Health floated there, which was a global tender, and it has been a good ROCE accretive project for us. Two years ago, we created a JV in Saudi Arabia to set up our operations there. Currently it is in an investment phase, but over the next several quarters, Saudi Arabia will start generating top line and bottom line for us.
With high realizations in these international markets, we have substantially increased our revenue per treatment while maintaining decent margins and accretive ROCEs due to our India platform. Going forward, we'll continue to be 100% focused on dialysis market without any distraction and go deeper into existing geographies via organic and inorganic expansion and explore newer geographies to expand our global presence. Our growth will come from three drivers. First, existing clinics ramp up on little bit of volume, little bit of price wherever possible, and this growth is fairly predictable in nature. Second, roll-ups of clinics in existing countries. This is a lumpy business but is reasonable, reasonably predictable on an annual basis. Third, most importantly, foray into new countries or do large acquisitions or PPP projects for which we cannot put a timeline and hence is not predictable at all.
On this backdrop, speaking of our guidance going forward, we'll want to maintain a revenue CAGR guidance of 15%-20% over a period of 3-4 years. We cannot give any guidance for the short term or on an annual basis. The third growth driver, which I mentioned before, is a big needle mover for us but is quite unpredictable. In a particular year, we may have solid growth from the third growth driver. Next year we may not. Overall, on a steady state basis, we should be growing revenue at a CAGR of 15%-20% over a period of 3-4 years. We hence will not be giving any annual guidance. At this scale, we are gaining operating leverage and will continue expanding over the coming years.
In parallel, we are investing significantly in technology to drive efficiencies across NephroPlus while continuing to unlock deeper synergies from these investments. Despite progress, large proportion of dialysis patients, particularly in emerging markets, still lack access to quality care.
Over the past 16 years, NephroPlus has worked to close this gap through a strong focus on patient-centric care, clinical excellence, and expanded access in Tier 2 and Tier 3 cities. Looking ahead, we remain firmly committed with singular focus to our vision of enabling people on dialysis worldwide to lead long, happy, and productive lives. Our journey has just begun. Now, you must have seen strong results in Q3 FY 2026 and nine months FY 2026 that we published last night. We had few favorable drivers such as Philippines price increase in October 2024 and also few acquisitions we did in Philippines, and the recent CGHS price increase in India also helped. Please do not expect such kind of growth in future results too, and as I said, expect 15%-20% revenue CAGR over 3-4 years time period.
That's the right way to look at our business. I now request our Co-founder, Kamal Shah, for his opening remarks. Over to you, Kamal.
Thanks so much, Vikram, for that good overview of the industry and dialysis ecosystems. Just a little bit about me and what sets NephroPlus apart from the others. I am a dialysis patient, and I've been on dialysis for more than 28 years now. I lead a completely normal life. I work full time, exercise every morning, travel extensively. I've been through all modalities that a patient with kidney failure undergoes. Now, kidney transplant is the ideal solution for kidney failure. Unfortunately, worldwide, there is an acute shortage of organs, and very few people actually end up getting a kidney transplant. The rest have to undergo dialysis. Recognizing this profound need and the significant gap between supply and the need for good quality care, Vikram and I founded NephroPlus, a truly patient-centric dialysis network where patients are placed at the center of our universe.
In India and much of the world, there is a misconception that once somebody gets onto dialysis, it is pretty much the end of life as they know it. Life gets reduced to waiting for dialysis, returning home, and lying on the bed until the next dialysis session. Our belief is somewhat different. If we could deliver high quality dialysis consistently and with empathy, our patients could get their lives back. They would be able to lead normal lives, that is, work, exercise, travel, and have fun. One of the most important decisions we made at that point was to stop calling the people we serve as patients and instead call them guests. The word patient, we felt, had a negative connotation. When you hear the word patient, the image that probably comes to your mind is one of a bedridden sick individual.
Dialysis patients need not be like that. We wanted a more positive word to be brought in, and the word guest tied in beautifully to our Indian culture of Atithi Devo Bhava. When we opened our first center in 2010, the response from our guests was overwhelmingly positive. They felt cared for, respected, and supported, and they deeply appreciated the quality of care we provided and continue to provide. Over the years, NephroPlus has grown and evolved to become Asia's largest dialysis service provider, and we will continue to grow. Yet one thing remains unchanged and will never change, and that is our guest-centric approach. Thank you.
Thank you, Kamal. Good evening, everyone, and welcome to NephroPlus first earnings call. We are pleased to report strong performance with the revenue growing 32% year-on-year in Q3 and 37% in the nine months of financial year 2026. Adjusted profit after tax increased by 71% in Q3 and 103% in nine months this financial year. We are encouraged by our ability to sustain this growth momentum over the years and through the current nine-month period. To begin with, I would like to spend some time on the Indian dialysis industry and key trends. Chronic kidney disease, CKD, prevalence in India is estimated at 8.7%, affecting nearly 12.4 crore people as of 2024. However, diagnoses remain extremely low, with only 7% of the patients identified, highlighting a significant need for greater awareness and screening.
Among diagnosed patients, approximately 42 lakhs had ESRD, end-stage renal disease, in 2024, yet only 3 lakhs received dialysis, indicating a large underserved market. Dialysis demand is growing rapidly. The number of dialysis patients is projected to increase by approximately 3 lakhs in 2024 to 5.2 lakhs by 2029. It's a CAGR of 12.7%. With over 3 lakh new ESRD patients every year and only 5,000 dialysis clinics nationwide, capacity remains inadequate and unevenly distributed. At NephroPlus, we identified these gaps early and have systematically scaled our network through standalone clinics, public-private partnership contracts, and captive clinics within the hospital partnerships. This structured approach has enabled us to address unmet demand and improve access to high-quality dialysis care nationwide. Now, let me share some perspective on how the dialysis segment has evolved in the developed markets.
In developed markets, dialysis evolved from a hospital-based service to predominantly a standalone clinic model in the 1980s, driven by limited hospital real estate, lower setup costs, thus faster scalability, and a dialysis-specific manpower-led delivery model. Today, over 65% of new dialysis patients in developed economies are treated in standalone clinics, supported by insurance coverage and technological advances that enable monitoring of network-level clinical outcomes. The sector has also consolidated, with large players such as DaVita, Fresenius Medical Care acquiring smaller providers. In contrast, dialysis in India remains largely fragmented. As the market matures with rising incidence, deeper insurance penetration, and greater government funding, it is expected to shift towards organized dialysis-focused clinics. NephroPlus is well-positioned to benefit from this transition and the long-term growth through the opportunity.
Speaking of NephroPlus and strategies ahead, we have built a strong brand and leading presence in India and the markets that we operate in. We are approximately 50% of the organized market share in India. Going forward, our strategy is to grow and further cement our leadership position. As Vikram mentioned, our growth will come from three drivers, and allow me to elaborate on them. First, ramp up volumes and capacities at our existing clinics. This growth is relatively predictable as patients require scheduled weekly treatments. By expanding capacity and growing our patient base and by implementing a modest price increase, we can further strengthen our business performance. Second, roll up of our new clinics in our existing markets.
In India, we will deepen our presence by expanding our footprints through the takeover of existing clinics, which we call the brownfield clinics, and selectively setting up new greenfield setup facilities. Internationally, we'll continue to strengthen our presence in markets such as the Philippines and Uzbekistan. In a short span, we have become the third-largest player in Philippines, and we plan to further densify our network through new clinic openings and targeted acquisitions of local providers. In Uzbekistan, due to our strong stakeholder relationships and operational expertise, we have secured approval from the Ministry of Health to expand capacity by opening two new small clinics in Karakalpakstan region. Our ability to replicate a lean cost structure at scale and to deliver operational efficiencies position us well for strong profitability, with operating leverage expected to improve further as revenues grow.
The third big growth lever is acquisition of large network or a sizable PBP or a new market entry. We cannot predict the timeline for these, but NephroPlus has actively engaged in markets and has demonstrated success in this category as well. Our country selection framework is centered on four key criteria, demand, depth, and scale, ensuring sufficient patient volume for operational efficiency and faster break-even. Policy and reimbursement visibility, with a clear preference for markets that have established reimbursement mechanism and government or insurance-supported dialysis program. Third, political and regulatory stability, focusing on regions with predictable healthcare regulations and long-term policy continuity. Fourth, repatriation clarity, ensuring transparent and efficient framework for cash flow repatriation back to India. Lastly, on business continuity and predictability. Our business model provides a good degree of visibility into revenue growth and profitability.
Based on our existing bed capacity, patient pool, and rising treatment volumes across the current network, we can forecast next quarter's revenue with reasonable certainty. The primary source of visibility stems from the timing of new capacity additions. However, once these assets are part of the network, our historical experience indicates strong performance. That said, while we have clear annual targets, confidence in the clinic roll-up strategy, planned capacity additions, visibility at the quarter level still remains limited. As a result, there can be spillovers in execution from one quarter to the next. Therefore, it is prudent to view our performance on annualized basis rather than a quarterly basis. As stated, the most uncertain aspect of our growth is acquiring a large network, securing sizable PBP, or entering a new geography, given regulatory constraint and market understanding.
However, once we acquire or establish operations, we are highly confident in our ability to transition, scale, and achieve profitability over time, an outcome we have demonstrated in Philippines and Uzbekistan. International revenues now contribute approximately 41% of the total revenue in the nine-month period of FY 2026, up from 12% in FY 2023. This growth underscores our ability to leverage India platform in higher priced geographies. With this, I hand over the call to Mr. Prashant Goenka, Group Chief Financial Officer, who will take you through the operational and financial performance before we move on to the question and answer round. Thank you.
Thank you, Rohit. A very warm welcome to everyone. I will now take you through our performance and our journey over the years, explained through key operational and financial metrics. On the operational front, in a dialysis business, the most critical metric to track is patient volumes. Patient volumes are the single most important driver of scale, operating leverage, and ultimately return on capital employed for the business. If you look at our historical trajectory, patient volumes have demonstrated healthy and consistent growth. Between FY 2023 and FY 2025, patient volumes grew at a healthy CAGR of around 20%, increasing from 22,890 patients to 33,076 patients. This momentum has continued into the current year.
On a nine-month FY 2026 basis, patient volumes stood at over 36,055, compared to 31,657 in nine-month FY 2025, reflecting a year-on-year growth of 15%. Moving to treatment volumes, which represent the total number of dialysis sessions performed during a period, we have seen a similar upward trend. Treatments increased from 2.3 million in FY 2023 to 3.3 million in FY 2025, reflecting our expanding networks and higher utilization. During Q3 FY 2026, treatment volumes stood at 0.98 million compared to 0.84 million in Q3 FY 2025, a growth of 17.7%. On a nine-month FY 2026 basis, treatments reached 2.85 million, up from 2.43 million in nine months 2025, registering a 17% year [audio distortion]. Now coming to revenue per treatment or RPT.
This metric has been a key value driver for us. The primary factor influencing RPT growth has been our increasing penetration into international markets, which typically operates at significantly higher price points compared to India. Over the years, as we have added new geographies and scaled existing operation, this has translated into a steady improvement in RPT. RPT increased from INR 1,912 in FY 2023 to INR 2,275 in FY 2025, representing a 9% growth over the period. This trend has further strengthened in FY 2026. In Q3 FY 2026, RPT stood at INR 2,642, marking a 12% growth over the corresponding quarter last year. On a nine-month FY 2026 basis, RPT improved to INR 2,574, reflecting a strong 17% year-over-year increase.
Overall, the combination of these three operating metrics, which is steady patient additions, higher treatment volume, and improved revenue per treatment, continues to strengthen and reinforces our confidence in the long-term scalability and the returns profile of the business. Now, coming to the financial performance of the company. Over the years, we have steadily scaled our operations across multiple formats and geographies. This has meaningfully improved our market penetration and is clearly reflected in our financials. If you look at our historical performance, the growth has been consistent. Between FY 2023 and FY 2025, our revenues increased 1.8x , rising from INR 437 crore to INR 733 crore. This scale-up has enabled significant operating leverage, resulting in a healthy improvement in profitability. EBITDA grew 3.5x from INR 49 crore in FY 2023 to INR 167 crore in FY 2025.
Expansion from 11.1% to 22%. On the bottom line, the improvement has been equally noteworthy. Profit after tax improved from a loss of INR 12 crore in FY 2023 to a profit of INR 67 crore in FY 2025, marking a clear turnaround in the business and beginning of an inflection point. Overall, this financial trajectory reflects the benefits of scale, operating discipline, and our diversified operating model. It provides a strong foundation for the next phase of the growth. Speaking of our Q3 and nine-month FY 2026 performance, we delivered healthy growth across all key financial metrics. Revenues continued to scale meaningfully. In Q3 FY 2026, revenue increased to INR 258 crore from INR 197 crore in Q3 FY 2025, reflecting a 32% year-on-year growth.
For the nine months ended FY 2026, revenue grew to INR 733 crore compared to INR 537 crore, registering a healthy 37% growth. EBITDA performance also remained robust, driven by operating leverage and improved scale. On a Q3 basis, our adjusted EBITDA, which excludes the expenses related to Saudi operation, stood at INR 63 crore in Q3 FY 2026 compared to INR 44 crore in Q3 FY 2025, representing a 43.1% year-on-year growth. The adjusted EBITDA margin also expanded to 24.3%, up from 22.4% in the same period last year. For the nine-month period, adjusted EBITDA, excluding Saudi expenses, increased to INR 175 crore from INR 115 crore, reflecting a 52% growth. The margins also improved from 23.9% to 21.5%. Profitability at the bottom line also showed improvement.
In Q3 FY 2026, adjusted PAT INR 4 crore with a margin of 13% compared to INR 20 crore and 10% margin in Q3 FY 2025. For the nine months, adjusted PAT increased to INR 85 crore with a margin of 12% compared to INR 46 crore and 8.5% margin in nine months 2025, representing a strong 86% year-on-year growth. One thing to note here, the adjusted PAT in nine-month FY 2026 includes two things. First, we have excluded a INR 37.2 crore finance cost which came due to a CCPS conversion done before the IPO. This conversion is a non-cash item, notional in nature and one time. We have also excluded INR 2.2 crore of Saudi expenses, which is currently in the set-up phase and does not contribute to the operating income.
Now, coming to the balance sheet side of things. Return on capital employed is the most relevant metric for evaluating our business, as it captures both operating performance and the capital intensity of the model, including account receivables, which are structurally higher in our business. Therefore, ROCE serves as our primary filter for all capital allocation decisions. This disciplined capital allocation has already translated into a meaningful improvement in ROCE from 10% in FY 2024 to 18.7% in FY 2025.
Building on this trajectory, annualized ROCE, supported by continued discipline and capital deployment, is expected to be 24.7% in FY 2026, improving from 18.7% in FY 2025. Coming to the cash and the debt side of things, net debt remained negative at INR 283.6 crore as of nine months FY 2026, reflecting a healthy surplus cash position. That positions us well to fund our expansion strategy. We maintain a very strong owners mindset with a consistent focus on cash conversion. This is reflected in our cash flow to EBITDA conversion of operating cash flow of INR 153 crores. Overall, if you look at our result, it reflects disciplined execution and capital allocation. With meaningful headroom in the global dialysis market, we remain focused on scaling responsibly, maintaining cash discipline, and supporting sustainable long-term growth. With this, I'll open the floor for Q&A.
Thank you very much. We will now begin the question and answer session. Anyone who wishes to ask a question may press star and one on their touch-tone telephone. If you wish to remove yourself from the question queue, you may press star and two. Participants are requested to use handsets while asking a question. Ladies and gentlemen, we will wait for a moment while the question queue assembles. The first question is from the line of Sakshi Pratap from Wise Investment. Please proceed.
Hi, sir. Congratulations on a great set of numbers. I truly appreciate the company you have built in the healthcare space. My question is that you're present in the international markets, and I assume we have been able to generate healthier margins compared to the local players in that geography. If you could throw some light on what edge does NephroPlus have over the local players to generate such heavy margins?
Yeah, thanks for the question. I think this reflects the platform that we have built in India over the last 16 years, right, Sakshi, wherein, when we operated a $20 price point in India, which is the world's lowest, we did not have any luxury of any inefficiency in the way we operate. We have looked at each and every single cost item and optimized it very well, and with scale it further continues to be optimized. There are four levers, I would say, that help us create this India platform play. First lever is efficient cost structure for the consumables. In the emerging markets, consumables is the biggest cost item in dialysis service. We have done multiple things, such as, negotiating with the global suppliers directly instead of distributors.
We have figured out how to optimally consume material in each of these line items. Thirdly, we have also started doing contract manufacturing of some of the low complexity consumables. That's lever number one. Lever number two is we have figured out the optimal human resource staffing strategy, wherein we have set up training academies in every country that we operate. For example, in India, we have 10 academies across the country, which constantly create fresh paramedical staff that gets absorbed in our own network. Now, with this efficient inflow of junior therapists, we manage the pyramid in each of our dialysis clinics optimally, wherein people who do not get promoted over a long period of time will move to the other players, other dialysis networks, while the pyramid is optimally maintained.
Thirdly, the biomedical team that we have built in-house has significantly helped us reduce the biomedical cost. Compared to taking CMC and AMC from the manufacturers who are aligned towards larger repairs, more expensive repairs, we invest in preventive maintenance of our equipment. We figure out what is the most optimal repair that we need to do. We're using the spare parts we have in our warehouses. Thirdly, we also figured out how to revamp the machines to extend the life of the machines by another 3-4 years compared to the market. The fourth lever in the India platform story is the optimal usage of technology to reduce the overheads to manage a distributed network, be it overseeing quality, overseeing operations, overseeing financial audits. All these levers we have optimized to have the much lesser overhead compared to other networks.
These are the four levers, Sakshi. I hope this is helpful for your understanding.
Yeah. Thank you so much for your detailed answer.
Thank you. The next question is from the line of Madhav Mada from FIL Industries. Please proceed.
Hi. Good evening. Thank you so much for your time. My first question was on the Saudi business. You know, great to see that, you know, I think we've already got a contract there or about to win a contract. Could you give some sense in terms of how that adds up for us and, you know, how that business will shape up in the next two to three years?
Thank you, Madhav. Saudi, we entered Saudi market two years ago in a joint venture with a publicly listed company, Tibbiyah. Over the time period, we have formed the company, we have established a team there, and then now as we speak, we are at a stage we have also signed up a captive unit with a partner hospital called Riyadh Hospital. At the moment, as we speak, we are in the license acquiring stage for that unit.
Once we acquire the license, we would be demonstrating our capabilities in that country and then eventually you would expect the business to grow. Saudi to me is a couple of quarters from now, we would see this investment that we have done for the past two years will start translating into some revenue.
Okay. That's quite positive. Any sort of broad sense in terms of the next, you know, couple of years, how many, you know, patients, how many guests that you could target in the Saudi market? Any broad sense would be helpful.
Madhav, as I said that we are at a stage of first establishing and starting our operations there.
Okay, okay.
Once we have established our service there, then only we would have a visibility of any other aspect there.
Understood. The other question I had was in terms of the growth guidance that you've given. T he new guidance is well received 15%-20%. On the margin side, next couple of years, you know, I think we're already at 24.3%, like you said, adjusted for the costs for Saudi. Can margins directionally move higher, even if you're not giving a quantitative guidance yet, like should we assume some improvement in margins over the next couple of years?
Yeah, Madhav, this is Vikram. Essentially the margins will be in that kind of level, right? If you open a new geography, then the first year of that new geography may pull down the margin by 1% or 150 basis points. As the volume increases in existing geographies, the operating leverage kicks in. Reasonably healthy in that range is what I would say.
You think with this, current margins that we have, we should stay in that range given we'll be making some investments for new geographies as well?
Yeah, I mean, roughly in that range, I would say. Depending on how many, how much new geography pans out, the initial investments or the initial time period that we need to invest there to get to steady state. In that ballpark is a good way to look at it.
Got it. Just last question from my side, like, in terms of the incremental growth that we expect in the next, you know, few years of 15%-20%, how much do we expect more of the incremental growth to come from the international markets or the India market, or do they grow at a similar pace in the next 2-3 years?
Madhav, Rohit here. As you mentioned that you have seen the trend that in financial year 2023, our international business contributed close to 12%, and now for these nine months of FY 2026 it is already 41%. We expect this to be inching up slowly again, depending on the geography and the quantum that we do. It would be hard to kind of look at the ratio, but I think we have already kind of had a decent increase in this trend. The next is a factor of any other geography that we open up. We are positive of increasing our footprints in the existing places that we are already operating on.
The only reason I ask is if the international mix for us, you know, naturally moves higher in the next couple of years, that should immediately be margin accretive for the business, right? Because, international is a higher margin business, so that should help the blended margin profiles for the business, right?
Yes, we would want to believe so. Again, that's a factor which market we enter into, what is the cost structure and how things are. It's very hard to predict as of now. As we take each step, we'll kind of be able to give more light to that. Having said so, as Prashant has mentioned, all our decisions would be based on the ROCE factor, that any investment that we do would be ROCE accretive and we will be conscious of that fact.
Got it. Can I ask one last question on the capital allocation, you know, maybe next one year or two years, how much do we expect to invest, organically and on the inorganic side as well, if there's any framework that you could share. Thank you.
Yeah. Hi, Madhav, this is Prashant Goenka here. I think as Vikram and Rohit mentioned, we are very focused on one metric, which is ROCE, because ROCE account for all the capital that gets allocated and along with that working capital and AR cycle. When we look at the projects, we very closely look at the ROCE profile and at a portfolio level, at a platform level, we try to get into projects which are ROCE accretive in nature. That has been the nature of our focus for the last many years, and that will remain the focus going forward. In terms of the capital expenditure, we typically invest anywhere between INR 100 crore-INR 125 crore historically. Like Vikram and Rohit mentioned, it's difficult to predict the future, but that's the historical number.
Got it. Thank you so much, and congratulations on the start to the ROCE journey. Thank you.
Thank you.
Thank you. The next question is from the line of Devang Patel from Sameeksha Capital. Please proceed.
Hi, sir. Thank you for your extensive comments initially. My first question was on the 13% growth in revenue per treatment that you had in Q3 YoY. Could you break that down into how much of that comes from price hikes you got in different geographies and how much of that has come because of mix change?
Devang, Rohit here. Thanks for the question. As we said that we have had an increase in the proportion of international revenue to 41% here, that has translated to higher RPTs. But at the same time, India also, we have been very conscious in selecting projects where the RPTs are at a company average range. At NephroPlus, we look at a blended RPTs because that's the approach, it's the platform play. We don't break it as per geography or the regions. Probably in a short to medium term, one lever would break. In a second phase could be another lever breaking, but largely the balance will be maintained. Hence, we would look at a platform level.
Could you give guidance on what kind of growth one can expect over three years within the 15%-20% revenue growth that you mentioned?
RPT typically, it would be very hard to kind of comment because dialysis as a business has a very lumpy price increases in whatever geographies that we operate in. Once the price is increased, it stays there for some time, insurances or government as a payer. Only cash area is where we have leverage of increasing. It's a lumpy price increase, and it's difficult for us to predict what the RPT change will be in the coming years. As I said, typically, we would be conscious of any new geographies that we open up, and that would also have an impact on the overall network level RPT.
Okay. Secondly, for Georgia level, you mentioned average treatment cost is $300. But it's also a shop-in-shop model with a revenue share. Both things considered, is the geography going to be margin accretive for us versus what our other international geographies make on a steady-state?
Good question. Again, any geography that we enter to, the basic fundamentals remain in place, right? If we have decided to go, or partner with any hospital, it has obviously cleared the internal thresholds to be starting operations there. I can give that comfort that it has cleared internal thresholds. H aving said so, given it's our first center and there are significant amount of investments in the team building that we have done there. The real play that we will see would be few quarters ahead, and we will get more clarity as we demonstrate our operations there.
Okay. Lastly, you mentioned operating cash flow of, I think, INR 153 crores. Could you just clarify nine-month OCF because first half was about INR 38 crores, and what kind of steady-state OCF to EBITDA conversion one can expect?
Yeah. As you rightly mentioned, nine-month OCF is INR 153 crore. Our OCF by EBITDA ratio for the nine-month is 65%. I think it has been fairly healthy. I think in our business it's difficult to predict the OCF or give any guidance on the OCF by EBITDA ratio. We have a very strong focus. On a daily basis we maintain a very, very strong intensity on converting all our earnings into cash, and it is reflected in our OCF number as well as the ratio number. We will continue to focus on maintaining a healthy number as we have currently.
Thank you so much. That's all from my side.
Thank you. Ladies and gentlemen, in order to ensure that the management is able to address questions from the participants in this conference, please restrict your questions to two per participant. Should you have a follow-up question, please rejoin the queue. The next question is from the line of Abdulkader from ICICI Securities. Please proceed.
Yeah, hi, sir. Thank you for the opportunity and, congratulations on good set of numbers. My first question is with regards to your expansion. You know, this is on the disclosure what we had done on the RHP. You know, where are we in terms of expansion at the end of this quarter in India and in Philippines? Second would be in terms of acquisitions. Sir, I mean, what is the space exactly you would be more keen on acquiring assets, whether it would be in India on your, you know, private clinic side or it would be in Philippines. You know, that would be of utmost importance to you.
Hi, hello, Abdul. This is Rohit . Thanks for the question. To address the first part of it, that are we in line on the expansion piece with our RHP. I think we are in line with our expansion. A good way to look at our business would always be to look at the session count, because ultimately the revenues are multiplier of session and the RPT. To answer your piece, I think we are in line with the RHP that we, the numbers that we had mentioned in the RHP. Second part on the acquisition front. I think we voiced it out in our strategy as well, that we want to increase our footprints in our existing geographies.
If there is any interesting acquisition opportunity that is coming, either in India or Philippines or any other place that we operate in, we would be very keen on. If you're looking at any other new geography opening, we are absolutely flexible in all modes of growth, whether it is acquisition, whether it is partnering with government or partnering, taking participation in any of the project. NephroPlus has capabilities of that piece as well. I think we'll be fairly flexible. To answer your piece, we'll be keen in our existing geographies as well.
Got it. Would it be possible for you to share what was your India region RPT growth for the quarter or for nine months?
Abdul, the right way to look at it is that we keep it at the platform level, so that, because we have growth complementing from both areas. We always observe it at the platform level. I think consolidated is already shared.
Okay. All right. I'll get back in the queue. Thanks for the answers.
Thank you. The next question is from the line of Vivek from Emkay Global. Please proceed.
Hi. Thanks for the opportunity. Congratulations, sir, on a good set of numbers. I just wanted to get a deeper understanding of this business model. In that context, I have a two-part question. Firstly, with regards to the revenue mix and unit economics, could you break down the revenue contribution across captive, PPP and standalone models, and, within that, how do the economics look? In particular, the revenue sharing mechanics for the captive business and the rental expense, both as a percentage of sales for the standalone clinics. Add to that, also if you could briefly explain how revenues are recognized for the captive, and the PPP models, and, are any major, captive contracts, up for renewal, in the near term? That's my first question.
I can go for the second question, or you can answer this, and then we can go to the section.
I think in terms of the question around unit economics and other details, I think the right way to look at our business is at the consolidated level. As Vikram and Rohit mentioned, it's a platform play. It's the fact that we have been operating in India for the last 16 years at $22 price point in India. That has given us a platform that when we take it to international markets, we are able to generate higher margins than the local competition and also create a ROCE accretive returns for the company as a whole.
From a modeling point of view, if you're looking to model our company, I think the right way to look at the business would be to understand all the unit economics at the console level, and the details for which can be easily obtained from the financial statements that are uploaded on our website as well as the exchanges. I think we had a second question around realization, the renewal rate of the captive clinics. In terms of the renewal rate of captive clinics, as Vikram mentioned, we have more than 300 hospital partners. We have four PPP contracts. Our renewal track record over the last 16 years has been very good in the high 90% range.
We anticipate to keep the renewal rate healthy as we move forward.
Yeah. Just to add to Prashant's point on the renewal, we have had fairly high renewal rate, close to 95%+ in the captive and close to 100% in PPP. That's the past, right? I think in general, what we need to understand is outsourcing. The hospitals realize that they don't make enough margins in dialysis, and NephroPlus is putting in the CapEx, taking care of operational hazard costs, delivering better net margins for them. That theme continues. The logic continues, right? There were a few instances where we did not renew a few contracts wherein the hospital partners were not good paymasters. Ultimately, the quality of earnings is also important for NephroPlus. Every quarter, every few quarters, we ourselves terminate few hospital partners, captive partners.
Again, the onus always at NephroPlus is long-term focus, good quality of earnings, good sustainable relationships. We do not do anything for the short-term, optimization. It's always for the long-term, sustainable, better financials and healthy financials.
Understood. Just on the renewal part, if you could help me explain in the revenue share for the captive model, how does that revenue sharing model work? Like, what is the percentage of our income that we share with the hospital, given that you said, you know, that we set up the clinic in the captive on the captive side of things as well. If you could throw some light on that.
Yeah. Hi, Vivek. Rohit here. To answer piece on the revenue, as we mentioned, we work on the revenue share piece, so we have no rent obligations in the captive model. The revenue share is also a factor of the price point in that geography and also the scope of each partner. Every partnership is a little nuanced there. To give you a range, typically it varies anything between 10% to 15% to 15%-18%, depending on the hospital partner, price point, location, volume, and the scope of each partner, because there is a little variability in the scope. Typically it ranges in that. Yes. These are typically long-term contracts, anything from 14-15, 12-14 years of tenure is the contract period.
Got it. Thank you. My second question was on the line of your expansion strategy. Just wanted to understand, are you more inclined towards doing expansion in the nature of greenfield? Or, are you looking more towards the acquisition side of things to expand your presence, given that your focus is on, you know, maintaining a ROCE accretive profile whenever you look to add a clinic to your portfolio?
Vivek, if you look at our present portfolio also, we have 300+ partnerships which are captive, and then we have other PPPs in India, scaling up. Largely, we have been focused around rolling up captive units, and that has been our strategy for over 10 years now or from the beginning. Then we take up PPP selectively, depending on the various filters, internal filters that we have. I think we would still stick on the same strategy that we will keep doubling or keep focusing on rolling up centers in the captive center. Then, as we mentioned, look at acquisitions or larger PPP project on the opportunity basis as and when they come, and we evaluate them on their merit.
Just a final question on the clinic side of things. On the standalone clinic side of things versus if you compare it with the captive, how does the margin profile look like?
Yeah. If you look across all our three model, whether it is standalone, captive or PPP, the margin profile is very similar. The bed economics are also very similar. We invest around INR 9 lakhs- INR 11 lakhs per bed irrespective of the model. The margin profile, the return profile are fairly similar across all the three models. Different parts of the unit economics modulates and ultimate result is a very similar margin profile.
Got it. Just one last question if I could squeeze in. In one clinic, how many beds are there approximately? If you could give us an idea.
Within India-wide, our average is 11 beds per clinic. That's the companywide average we have.
Okay. Thank you. Thank you for taking my questions.
Thank you. The next question is from the line of Jinesh Gandhi from Oaklane Capital. Please proceed.
Yeah. Hi. Am I audible?
Yes. Yeah, you are.
Yes, you are audible.
My question pertains to your comment that RPT change for India on the new business is similar to the company average. Can you elaborate on that a bit because if India's realization is close to $20 per treatment, how is incremental or the new business coming at a much higher rate than $20? How one should think about that?
Jinesh, sorry to again interrupt you. You're not very audible. The voice is not very clear. So if you could please repeat the question.
Better now?
Yes, please go ahead.
Yeah. There's comment from management with respect to that RPT on new business in India is similar to the company average for the new business in India. How should one think about why that trend is playing out? Because if average cost of dialysis or realization for dialysis in India is $20, the new business is coming at much higher rate to have it to be in line with the blended at the company level?
Yeah. Hi, this is Prashant. I'll take this question. I think if you look at our RPT, of course, India is, as Vikram mentioned in the beginning, India is at the lowest price point in across the current world. The other markets like Philippines and Uzbekistan are at a much higher RPT. Philippines is at around $110 RPT and Uzbekistan is around $55 RPT. When you see the number at the consolidated level, it's basically accounting for the favorable international mix.
Okay. Sorry. I thought during the call we had mentioned that the new business in India, RPT is closer to the company average. Is that understanding right or that is misunderstood at my end?
Jinesh, let me add to that. The idea was that India new business is equivalent to the India existing average.
O kay. Got it. Great. Second question is with respect to the international business. Given that, the market outside India is also very large and our capabilities and the cost structure enables us to have better competitive advantages in the international market, how should we as investor think about your strategy of entering into new market, given very wide variety of markets available in the global market? What is your strategy of selecting new markets in the global scenario?
Yeah. Good question, Jinesh. We are constantly evaluating new markets, right? We have a team which is continuously evaluating the new markets. Rohit and I spend significant time on that as well. It all depends on the factors, right? We mentioned about large volume of patients, good reimbursement by the government, the political and economic stability, the repatriation of cash flows or profits to India. These are the filters. Now, beyond that filter, do we, when we evaluate, as Prashant mentioned earlier, every project, every entry has to be ROCE accretive, right? Once you put all these filters, few bubble up, and then we figure out from our expansion perspective, does it make sense to enter it this time or does it make sense to enter next year? It all depends on these factors, right?
Every one to two years we would enter one to two geographies. Just because four, five markets are attractive, we wouldn't jump in in one year because ultimately we are in healthcare delivery, right? If you do a certain project, you need to give it adequate bandwidth, deliver the right level of clinical quality and make sure the brand equity is continuously built. The way you should look at it is every year, maybe a new market, as a foray and the RPT that you are seeing, you have the data on RPT. You know the contributions from international market that Rohit mentioned about 41% already slowly inching up. That's the way to build the model. We are not in a rush. This is a marathon. We will do it, in a measured manner, slow and steady.
We are not in a rush at all.
Effectively, say five years down, would international business be close to 50%-20% for us, given that 41% is without Saudi? Over the [audio distortion] markets, or should it be close to 60%, 30% of revenue? That's the trajectory we should be looking at.
We cannot estimate that. I think India would continue to be the majority for the foreseeable future. Again, it all depends on various levers, right? Depending on how much business we get from Saudi, depending on how many big projects we launch in India. It's all. These are some things that we cannot predict, but slow inch up of international contribution to revenue, definitely, you should estimate.
Okay. Great. Thanks, and all the best.
Sure.
Thank you. The next question is from the line of [Surjan Jawa] from Opportune Wealth Advisors. Please go ahead.
Hello, am I audible, sir?
Yes, you're audible.
Yes.
First of all, congratulations on your good set of numbers. My question is regarding the revenue mix between the captive model standalone clinics and the PPP. I want to understand. Is there any change of mix happening in upcoming years? This is my first question. My second question is, for every clinic, every kind of clinic, how much cost borne by you and in upcoming years, how many clinics are you looking to open? That is my two questions.
Yeah. I think I'll take that question. While we wouldn't want to give, you know, too much specifics here, but I think just to help you understand the business and model it out, captive is our bread and butter, right? That is predominantly the biggest composition of our business in India. Standalone is a very, very small component, less than 5%, because, as Vikram mentioned in his opening, it's something that will happen over the next five, 10 years. That model is not the primary model currently. PPP is basically something that we do on a very opportunistic basis when the quality, cost, and other ROCE factors make sense. That is the second-biggest component after the captive model.
Can you answer my second question about how many clinics are you looking to open in next few years, and what could be the cost per clinic?
Yeah. I think, you know, clinics is not the right way to model our business. I think the best way to model our business would be to look at the treatment volume, patient volume, primarily the treatment volume. If you look at our, as Vikram said, the growth rate that Vikram talked about, I think at the revenue level, the treatment will more or less follow a similar pattern. I think you can model it on the basis of that.
Okay. Thank you, sir.
Thank you. The next question is from the line of Aman Goyal from Axis Securities. Please proceed.
Yeah. Thank you for the opportunity, and congratulations for the set of number. Sir, I just want to know on the margin side, could you please help me to understand what is the margin contribution from the international business? Let's say we have a 41% from the international market, and how much, I mean, we on the nine months, we have almost INR 175 crore. So how much is attributed from the international business? Or you can say the how much international business margins are higher than our consolidated margin.
Yeah. I think our business is more of a platform play, right? I think we don't look at even internally, we don't look at countries separately. The right way to look at our business is to look at the entire platform and understand the entire platform play. To that extent, the consolidated numbers that we have given in terms of the patient volume, treatment volume, revenue per treatment, I think those are the right ways to model the business. The margins that are happening in respective countries has a lot of element of India platform basically driving synergies in the international platform, international markets. If you compare us to a local competition, our margins are much higher than the local competition, mainly because of the India platform play.
Both elements are quite intertwined with each other, and therefore, it will not make sense to look at the margins of each country individually. As Vikram mentioned, we will continue to expand into international markets every one or two years. You know, sort of homing in on one country or two countries will get more and more complicated as we continue to open new markets.
Okay. My next question is, could you throw some light how much net patient added during the year? I mean, and what is the target mix over the medium term between domestic and international business? Like, we are entering into Saudi and all that.
Yeah. Between the last nine months, FY 2025 to this nine-month FY 2026, our guest count has increased from 11,657 to 36,560. That's about 15.5% increase.
I mean, we have done 2.8 million treatments in the FY 2026 so far. Can you break down what is the Indian patient base and versus international patient base, if you have some data points on that?
No, we don't have the data.
Okay.
It would be to look at the consolidated number. Looking at the overall consolidated treatment volume and RPT at the consolidated level, and that will help you model out the business.
On the last, I just want to know your input from the CGHS side. Since the new CGHS guideline, the dialysis revised prices also has been revised by the government. Will it kick from the Q1 FY 2027 or it has been already started in your business?
Aman, Rohit here. CGHS prices, price increase has already kicked in or is already there in the quarter three. We have started realizing that already, from quarter three onwards. That's already part of the numbers that we speak.
If you could throw some light how much realization will improve over the year. I mean, we last had a $20 realization in India. It's like, I mean, $20, $22 in the DRHP. How will it improve over the year?
Aman, the way to look at it is that CGHS volume is less than 5% in our network. If that volume is increasing by 30% price point, it does not really increase the RPT because the base will continue growing in India and with the limited present volume of CGHS, I think the RPT will not have that significant impact at the network level.
Okay. Thank you, sir. I will join back the queue.
Thank you. Ladies and gentlemen, due to time constraints, that was the last question for today. I now hand over the conference to management for closing comments. Over to you, sir.
Yeah. Thanks everybody for joining the call. I think it's a maiden earnings call and we appreciate all of you joining this call. I think we may have answered most of your questions, but I think there are still few queries remaining. We'll continue to keep participants informed of any updates, and you can also reach out to us for any urgent questions or queries. Also feel free to reach out to SGA, our investor relations partner as well. Look forward to continued engagement and this market. This dialysis business is a new business with very unique characteristics. I would urge all of you to spend some time, understand the nuances and work with us as we move forward. Thank you so much for joining the call. I appreciate it.
Thank you. On behalf of Ambit Capital Private Limited, that concludes this conference. Thank you for joining us, and you may now disconnect your lines.