BUSINESS PLAN

ZINDAGI AMBULANCE SERVICES PVT. LTD.

Submitted By: (GROUP 5)

Badal Nirwan (07) Himanshu Kumawat (12) Kritika Pal (17) Saurabh Arora (33) ShreyaChatterjee (35) Tanuj Kandpal (39)

INDEX
S.No. TOPIC 1 Business Plan 2 Market Study 3 Technical Study 4 Financial Study 5 Economic Study 6 Management Team & its Vision 7 Conclusion 8 References Page No. 3 5 11 16

BUSINESS PLAN

The healthcare infrastructure in the country is ageing and crumbling. The sheer demand of the healthcare services required outstrips the supply of them. The public agencies are short of funds and there is lack of will in the govt. As such, the govt. agencies are alone not sufficient to meet the demand. Thus there is a huge demand-supply gap to be met. The private sector can help meet this gap on the basis of sound business models generating good rate of return for the equity investors along with a sense of social responsibilities being met. Identifying these problems and seeing the opportunities in the field, the promoter directors have decided to open a private ambulance service. There is no unified ambulance in the state of Maharashtra. The EMRI ambulance service running in the Andhra Pradesh has been hugely successful and has currently expanded to nine states and have added capacity very quickly in the past three years. This has been possible on account of huge demand for the sector services by the public. In the city of Pune, there are no unified ambulance services currently. Our promoter directors believe in providing a secure and safe ambulance service to the city at a reasonable cost. The ambulance industry is as such, you have to be an established player first to start on your own. Thus, the first step is to sign contracts with various hospitals in the city to provide them with the fitted ambulances operating at their premises at a fixed cost covering driver salary, fuel charges, insurance costs, and maintenance charges. Our promoters have got vast experience in the field of healthcare services and they have got a fair number of contacts in the industry enabling us to get our starting contracts. In the initial years we have signed contracts with Inaamdar Hospital, Sancheti Hospital, Oyester and Pearl Hospital, and Shree Hospital enabling us to sustain the initial years and generate our name in the market. The initial years contract with these hospitals will help us market ourselves better and in the future, we would like to see ourselves as a leading unified ambulance services provider on our own in the city of Pune and then the state of the Maharashtra.

MARKET STUDY

OVERVIEW OF THE SERVICE Zindagi Ambulance Service is a special service which is planned to be operating in a certain geographical area of Pune, Maharashtra. This is a private service which will be starting from March, 2013 for the purpose of providing emergency medical services to the citizens within the certain area of Pune city. Our ambulance service has been linked to various hospitals like Inamdar, Sancheti, Oyester & Pearl and Shree Hospital of that region. This service industry is small scale joint-venture of two people, one of them is MBA who is having an industry experience 17 years and the other one is having an experience of 10 to 15 years in Hospital services. INDUSTRY ANALYSIS India, by virtue of statistics, is a country that needs high-quality ambulance services nationwide. One of the most disaster-prone areas in the world, almost 57% of Indias landmass is vulnerable to earthquakes, 68% to drought, 8% to cyclones and 12% to floods. Man-made disasters are also plentiful in India, where the ratio of traffic accidents per 1000 vehicles is around 25 times higher than the world average. A study carried out, revealed that nearly 3 people die in road accidents in Pune every day. Whether the accidents are natural or man-made, 30% accident victims in India die due to delays in transportation to medical facilities after an accident occurs, greater highlighting the need for speedy responses to tragedies. The majority of Pune citizens use auto-rickshaws and taxis for emergency transport due to their low cost, high availability and familiarity. Public ambulances run by hospitals and NGOs are available but not widely used due to the predominantly accurate perception of their unreliability and lack of timeliness. Most private ambulances in Pune act as hearse ambulances, transporting dead bodies rather than saving lives. Basically there are two types of ambulance services: 1) Basic Life Support (BLS) ambulances that are used to transport relatively stable patients and 2) Advanced Life Support (ALS) ambulances that contains all emergency equipment and drugs necessary to manage any kind of patient emergency. Basic Life Support will be provided in our case. BLS is a ground ambulance service with the provision of medically necessary supplies and services, including BLS ambulance services as defined by the state. The ambulance must be staffed

by an individual who is qualified in accordance with state and local laws as an emergency medical technician basic(EMT Basic). These laws may vary from state to state or within a state. For example, only in some jurisdictions is an EMT-Basic permitted to operate limited equipment onboard the vehicle, assist more qualified personnel in performing assessments and interventions and establish a peripheral intravenous line.

MARKET ANALYSIS
Key Drivers: The ambulance market holds huge potential as its niche market with not so much of competition as well. The awareness being created by various ambulance and emergency equipment suppliers, who are making various solutions available for the emergency and disaster management, is one of the major driving forces. Various types of natural and man-made disasters happening frequently in India are also raising concerns amongst emergency care providers leading to more investments in this field. Organizations like NDMA(National Disaster Management Authority) and DGHS(Central Government Health Scheme) are also making consistent efforts to identify suitable methods for emergency management and providing training, education, and setting up suitable guidelines for the management of emergencies and disasters for all the states in India. Necessity for the Service - Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated. Major Manufactures and Product Line

In the initial years we are taking 2 Force Motors Traveler, 2 Force Crusier and six Maruti Suzuki Omni Ambulances and in later years we will be increasing the numbers as per the requirements as well as the returns that we are expecting to receive. Out of six omnis, two are for our personal use.

PRICING STRATEGIES We have initially taken 2 Force Traveler, 2 Force Cruiser and 6 Maruti Suzuki Omnis which takes an initial investment of Rs. 63 lakhs. Insurance of the vehicles for the first year is Rs. 1.8 lakhs. Fuel cost for the first year is Rs. 8 lakhs. Drivers salary is Rs.19.20 lakhs for the first year. Administration costs are Rs. 8.5 lakhs. So, our pricing strategies are: 1. For contracted vehicles: total ambulances Units sales/unit/mth revenue/mth revenue/year omni 1 4 45000 180000 2160000 traveller 2 80000 160000 1920000 cruiser 2 60000 120000 1440000 total 5520000 2. For self-run vehicles: omni 2 2 48000 96000 1152000

With rising cost, pricing will be change in tune with the market rates.

MARKETING STRATEGIES Although the healthcare industry is booming, running a profitable ambulance service business is no small feat. To market an ambulance service, its important to look at the niche market with attractive revenue streams. We will be aggressively marketing and will also track our records. We will be finding out the attractive revenue sources. We will be trying to have government contract later in the future, this will be great source of revenues. Our marketing plan will be to reach out more and more nursing homes as well as hospitals of Pune so as to spread our services in the city. Through our contacts, we will be looking for revenue opportunities from events like sports, parades, festivals and other gatherings by hiring them our ambulance in case of medical emergency. A robust measurement and evaluation process will be there, that will include metrics that can be monitored on a monthly, weekly or even daily basis. These are designed to monitor marketing efforts on a campaign-bycampaign basis; these metrics can be used as a baseline for strategic planning. For e.g. Simple quantitative tools can be a good start. We will be consulting professional marketers for assessment tools and strategic insights. Signage also plays as important part as signage can be used to communicate the companys value to its customers. Print advertising can be used to market ambulance services. Use of Internet will be done. We will be making website for our ambulance services so as to give more and more information to the customers about our services, etc.

SERVICE AREA

Initially, our ambulance services will be provide in the NIBM region covering INAMDAR HOSPITAL, Shivajinagar region covering SANCHETI HOSPITAL and OYESTER AND PEARL HOSPITAL and Nagar Road covering SHREE HOSPITAL. Later we will expand our services in more regions of Pune and in various states of Maharashtra, too.

TECHNICAL STUDY

Technical Study:
1.Details of Capacity/Capacity Utilisation Vehicle Maruti Omni Year 1 2 3 Force Cruiser 1 2 3 Force Traveller 1 2 3 Capacity 7 9 10 2 3 4 2 3 4 Capacity Utilisation 6 8 10 2 3 4 2 3 4

2. Flowchart of Activities:
Setting Up of Company ;Administration Set-Up
Sign contracts with the hospitals Ordering Of Ambulance Vehicles

Delivery of Ambulance Vehicles

Training of Drivers Retrofitting of ambulances

Delivery of the Ambulances to the Hospital Premises

Monitoring Of Ambulances and Drivers;Maintenance of Vehicles Looking for new business opportunities

FOLLOWING ARE THE ESTIMATION FOR THE FIRST YEAR:

SALES sales ambulances omni 1 omni 2 traveller cruiser

units 4 2 2 2

sales/unit/mth revenue/mth 45000 48000 80000 60000 180000 96000 160000 120000 total

total revenue/year 2160000 1152000 1920000 1440000 6672000

FUEL EXPENDITURE fuel expenditure ambulance

units

expected run

fuel total fuel expense/unit/month expence/ mth 5550 4440 10000 7500 22200 8880 20000 15000 total

total feul expense/year 266400 106560 240000 180000 792960

omni 1 omni 2 travelar cruzer

4 2 2 2

1000 800 1000 1000

DRIVERS SALARY drivers` salary 20 shifts 2 salary/driver/mth total salary expense/year 8000 1920000

SELLING AND ADMINISTRATIVE EXPENDITURE selling & per administrative month expenses rent telephone bills electricity bills admin salary stationery misc 15000 1500 1500 35000 500 8000 total per year 2nd Year

180000 18000 18000 420000 6000 96000 738000

198000 19800 19800 420000 6000 50000 713600

OFFICE EQUIPMENT

Office Equipment PC X 2 50000 Printer 3500 Furniture 10000 misc 8000 71500

INVENTORY INVENTORY gas cylinders stretchers medical supply cost/unit 7000 2000 2000 units 5 5 5 total 35000 10000 10000 55000

INSURANCE Cost per Vehicle 250000 600000 1150000 Fitting 100000 150000 200000 Total/Veh 350000 750000 1350000 units 6 2 2 total 2100000 1500000 2700000 6300000 Insurance(1st year) 60000 40000 80000 180000

FINANCIAL STUDY

FINANCIAL ANALYSIS SOURCES OF FUNDS YEAR 1 EQUITY TERM LOAN SUBORDINATE DEBT YEAR 2 TERM LOAN REINVESTMENT YEAR 3 TERM LOAN REINVESTMENT AMT(RS LAKH) 10.5 42.5 10 UTILISATION AMT(RS LAKH) 63

ASSETS PURCHASED

25.71 4.54

ASSETS PURCHASED

30.25

28.28 4.99

ASSETS PURCHASED

33.27

In future the accumulated reserves of the project would be utilized to finance further expansion plans. REASONS FOR THE FINANCIAL PLAN Huge investment involved No access to capital market Debt provide discipline Cost of debt is low Tax shield

COST OF CAPITAL Cost of debt 15.5% charged on the bank loan. Which reduces to 10.85% after taking the effect of tax shield. Cost Of Equity For the purpose of calculating the cost of equity the risk free rate is taken from 10 yrs government bond which stands at 8.24%. the risk premium for the medical service sector stands at 7.39%. The beta for the sector is 0.91. Thus the cost of equity is calculated as 14.965% . The cost of capital is computed using WACC which comes to 11.78%.

TERM LOAN The loan from the bank consists of auto finance scheme of the bank and personal loan whose cost is taken from OBC bank. The term loan provide discipline to the project. It also provide tax shield and cost of debt is less than cast of equity. The margin is 15%. This is provided by the partners from their personal savings. LEGAL AND MARKETING EXPENSES YEAR 1 2 3 LEGAL 30000 75000 150000 MARKETING 100000 120000 180000

The legal expenses are taken in exceptional items in income statement. It take care of the expenses incurred in getting the licenses and clearance. The marketing expenditure includes advertisement and other additional cost. IMPORTANT RATIOS YEAR1 NPV BREAKEVEN IRR ICR DSCR LLCR YEAR2 YEAR3 10941665 7 YRS 26% 2.140542191 1.005607714 2.527441937 1.037266324 2.882233293 1.043635083 1.736772238

TAXES The taxes are calculated on PBT at 30%. DEPRICIATION The depreciation is calculated using WDV method at 20%.

Income Statement:
1 Revenues(Ambulance Service Fees) Other Income less: raw material consumed(refilling of oxygen cylinder) Insurance Fuel manpower expenses Office Equipment Maintenance 55,20,000.00 1152000 66,72,000.00 2 77,40,000.00 1728000 94,68,000.00 3 1,11,86,400.00 2304000 1,34,90,400.00 4 1,28,64,360.00 26,49,600.00 1,55,13,960.00 5 1,40,22,152.40 28,88,064.00 1,69,10,216.40

19200 180000 792960 1920000 71500 1,20,000.00

29568 224000 1235124 3024000 10000 1,68,000.00

41817 259200

50180.4 298080

60216.48 342792

1597992 20,18,439.37 25,49,510.56 4752000 5702400 6557760 50000 50000 50000 259200 5,87,770.00 10,00,000.00 -

less: selling and administration expenses Marketing Expenditure EBDIT/PBDIT less: depreciation & amortisation EBIT/PBIT less: Interest EBT/PBT Add: exceptional items EBT/PBT Tax @ 30% EAT/PAT

738000 100000 27,30,340.00

763600 120000 38,93,708.00

1270410 15,22,555.33

18,24,745.35

180000 2,25,000.00 2,81,250.00 50,79,781.00 50,59,534.90 42,43,942.02

1260000 14,70,340.00 686900.733 7,83,439.27 -30000 7,53,439.27 226031.78 5,27,407.49

1613000 22,80,708.00 902378 13,78,330.00 -75000 13,03,330.00 390999.00 9,12,331.00

1955900 31,23,881.00 1083840.44 20,40,040.56 -150000 18,90,040.56 567012.17 13,23,028.39

1805064 32,54,470.90 780994.6 24,73,476.30 -200000 22,73,476.30 682042.89 15,91,433.41

1731848.64 25,12,093.38 500745.9 20,11,347.48 -200000 18,11,347.48 543404.24 12,67,943.23

Balance Sheet
LIABILITIES SOURCES OF FUNDS EQUITY TERM LOAN SUB DEBT less principal payments RESERVES total ASSETS FIXED ASSETS less depri net block CA inventory receivables bank/cash less CL accruals 6300000 8065000 9477000 9021100 9216036 1731848.64 7484187.36 3100044.398 96195.34375 1232834.5 1771014.554 616196.22 616196.22 1 2 3 4 5

1050000 1050000 1050000

1050000

1050000 4304768.224 278503

4250000 6193675 7866492 6157064.349 1000000 852335 678503 478503

775240 1296390 1909429

2189676.1

2496193 46,72,760.65 7809838.87

527400 989481 1813384 34,04,817.41 6052160 7789101 9498950 8900708.661

1260000 1613000 1955900 1805064 5040000 6452000 7521100 7216036 1207160 1628261 2424369 3306675.385 55000 460000 692160 195000 195000 63250 645000 72737.5 932200 83648.125 1072030 2150997.26 535822.8 535822.8

920011 1419432 291160 291160 446519 446519

net assets total

1012160 1337101 1977850 2770852.585 6052160 7789101 9498950 9986888.585

2483848.178 9968035.538

CASH FLOW STATEMENT

CASH FLOW STATEMENT CASH FLOW OPERATING ACTIVITIES Cash received from customersand users Total Outflows Net Cash inFlow from Operating Activities CASH FLOWS FROM INVESTING ACTIVITIES Purchase of Assets Net Cash outflowFrom Investing Activities CASH FLOWS FROM CAPITAL AND RELATED FINANCING ACTIVITIES Equity and Reserves Loan Loan Repayment Net Cash From Capital and Related Financing Activities 1050000 5250000 1462141 0 2571250 2198768 0 2828375 2993269 0 0 2970671 0 0 2996939

62,12,000 3972692

94,68,000 5674131

1,34,90,400 8531112

1,55,13,960 10600645

1,69,10,216 12593482

22,39,308

37,93,869

49,59,288

49,13,315

43,16,734

6300000

3025000

3025000

1500000

2000000

-6300000

-3025000

-3025000

-1500000

-2000000

4837859

372482

-164894

-2970671

-2996939

NET INCREASE IN CASH AND CASH EQUIVALENTS CASH AND CASH EQUIVALENTS, BEGINNING OF YEAR CASH AND CASH EQUIVALENTS, END OF YEAR

777167

1141351

1769393

442644

-680205

692160

920011

1419432

2150997

692160

920011

1419432

2150997

1771015

RATIOS:
1 INTEREST COVERAGE RATIO 2 3 4 5

2.141

2.527

2.882

4.167

5.017

DSCR LLCR

1.006 1.737

1.037

1.044

1.096

0.838

NPV IRR
EBiT ebit(1-t) add depriciation less capex less nwc cf kd ke Rf 1 2 3 4 5 14,70,340.00 22,80,708.00 31,23,881.00 32,54,470.90 25,12,093.38 10,29,238.00 15,96,495.60 21,86,716.70 22,78,129.63 17,58,465.36 1260000 0 320000 2410340 0.1085 0.149649 premium debt 0.0824 0.0739 beta 0.155 0.91 growth normal 0.055 1613000 3025000 417090 451618 1955900 1805064 1731848.64 3025000 1500000 2000000 558418.5 619855.325 712833.6238 1496362.5 2939679.579 1531108.394

6300000

wacc discount factor d cf tv npv irr

0.117763133 0 1

1 0.894643928 0.800387758 0.716062047 0.640620563 0.573127296 6300000 2156396.045 361469.5183 1071488.395 1883219.185 877520.0142 19003757 10891572 10941665 26%

SENSITIVITY ANALYSIS:
Sales PAT TO SALES 0.8 0.9 0.95 1 1.05 1.1 1.2 pat

527407.5 3941660 5337600 -806993 6004800 -139793 6338400 193807.5 6672000 527407.5 7005600 861007.5 7339200 1194607 8006400 1861807

0.8 0.9 0.95 1 1.05 1.1 1.2

Ebit 1.005608 1176272 1323306 1396823 1470340 1543857 1617374 1764408

Dscr 1462141 0.804486 0.905047 0.955327 1.005608 1.055888 1.106168 1.206729

cost pat to cost

pat

527407.5 6672000 0.8 4915674 1756326 0.9 5530133 1141867 0.95 5837363 834637.1

1 1.05 1.1 1.2

6144593 527407.5 6451822 220177.9 6759052 -87051.8 7373511 -701511

0.8 0.9 0.95 1 1.05 1.1 1.2

Ebit 2.140542 1176272 1323306 1396823 1470340 1543857 1617374 1764408

Iscr 686900.7 1.712434 1.926488 2.033515 2.140542 2.247569 2.354596 2.568651

ECONOMIC STUDY

MACROECONOMIC CONDITIONS: A GROWING HEALTHCARE SECTOR

Healthcare is one of Indias largest sectors, in terms of revenue and employment, and the sector is expanding rapidly. During the 1990s, Indian healthcare grew at a compound annual rate of 16%. Today the total value of the sector is more than $34 billion. This translates to $34 per capita, or roughly 6% of GDP. By the end of 2012, Indias healthcare sector is projected to grow to nearly $40 billion. The private sector accounts for more than 80% of total healthcare spending in India. Unless there is a decline in the combined federal and state government deficit, which currently stands at roughly 9%, the opportunity for significantly higher public health spending will be limited. GROWING POPULATION AND ECONOMY

One driver of growth in the healthcare sector is Indias booming population, currently around 1.21 billion (according to population cencus 2011) and increasing at around 1.5% annual rate. By 2030, India is expected to surpass China as the worlds most populous nation. By 2050, the population is projected to reach 1.6 billion. This population increase is due in part to a decline in infant mortality,the result of better healthcare facilities and the governments emphasis on eradicating diseases such as hepatitis and polio among infants. In addition, life expectancy is rapidly approaching the levels of the western world. By 2025, an estimated 189 million Indians will be at least 60 year of agetriple the number in 2004, thanks to greater affluence and better hygiene. The growing elderly population will place an enormous burden on Indias healthcare infrastructure.The Indian economy, estimated at roughly $1.8 trillion, is growing in tandem with the population. However, Indias thriving economy is driving urbanization and creating an expanding middle class, with more disposable income to spend on healthcare. While per capita income was Rs 53,331 in 2005, over 150 million Indians have annual incomes of more than $1,000, and many who work in the business services sector earn as much as $20,000 a year. While this is a fraction of the income that their US peers earn, it is the equivalent of more than $100,000 per year when adjusted for purchasing power parity. More women are entering the workforce as well, further boosting the purchasing power of Indian households. Between 2001 and 2011, the

percentage of women increased from 26% to around 35% of the workforce. Many of these women are highly educated: the ratio of women to men who have a college degree or higher level of education is 40:60. Thanks to rising income, today at least 100 million Indians can afford to buy Western medicinesa market only 20% smaller than that of the UK. If the economy continues to grow faster than the economies of the developed world, and the literacy rate keeps rising, much of western and southern India will be middle class by 2020. RISE OF DISEASE

Another factor driving the growth of Indias healthcare sector is a rise in both infectious and chronic degenerative diseases. While ailments such as poliomyelitis, leprosy, and neonatal tetanus will soon be eliminated, some communicable diseases once thought to be under control, such as dengue fever, viral hepatitis, tuberculosis, malaria, and pneumonia, have returned in force or have developed a stubborn resistance to drugs. This troubling trend can be attributed in part to substandard housing, inadequate water, sewage and waste management systems, a crumbling public health infrastructure, and increased air travel. In addition to battling infectious diseases, India is grappling with the emergence of diseases such as AIDS as well as food- and water-borne illnesses. And as Indians live more affluent lives and adopt unhealthy western diets that are high in fat and sugar, the country is experiencing a rise in lifestyle diseases such as hypertension, cancer, and diabetes, which is reaching epidemic proportions. Over the next 5-10 years, lifestyle diseases are expected to grow at a faster rate than infectious diseases in India, and to result in an increase in cost per treatment. Wellness programs targeted at the workplace, where many sedentary jobs are contributing to an erosion of employees health, could help to reduce the rising incidence of lifestyle diseases. DETERIORATING INFRASTRUCTURE

Indias healthcare infrastructure has not kept pace with the economys growth. The physical infrastructure is woefully inadequate to meet todays healthcare demands, much less tomorrows. While India has several centers of excellence in healthcare delivery, these facilities are limited in their ability to drive healthcare standards because of the poor condition of the infrastructure in the vast majority of the country. Of the around 25,000 hospitals in India in 2010, roughly two-thirds were public.

After years of under-funding, most public health facilities provide only

basic care. With a few exceptions, such as the All India Institute of Medical Studies (AIIMS), public health facilities are inefficient, inadequately managed and staffed, and have poorly maintained medical equipment. The number of public health facilities also is inadequate. For instance, India needs 74,150 community health centers per million population but has less than half that number. In addition, at least 11 Indian states do not have laboratories for testing drugs, and more than half of existing laboratories are not properly equipped or staffed. The principal responsibility for public health funding lies with the state governments, which provide about 80% of public funding. The federal government contributes another 15%, mostly through national health programs. However, the total healthcare financing by the public sector is dwarfed by private sector spending. In 2003, fee-charging private companies accounted for 82% of Indias $30.5 billion expenditure on healthcare. This is an extremely high proportion by international standards.Private firms are now thought to provide about 60% of all outpatient care in India and as much as 40% of all in-patient care. HEALTHCARE INFRASTRUCTURE EXPANSION

An enormous amount of private capital will be required in the coming years to enhance and expand Indias healthcare infrastructure to meet the needs of a growing population and an influx of medical tourists. Currently India has approximately 860 beds per million population. This is only one-fifth of the world average, which is 3,960, according to the World Health Organization. It is estimated that 450,000 additional hospital beds will be required by 2015 an investment estimated at $25.7 billion. The government is expected to contribute only 15-20% of the total, providing an enormous opportunity for private players to fill the gap. CONCLUSION The Indian healthcare sector can be viewed as a glass half empty or a glass half full. The challenges the sector faces are substantial, from the need to improve physical infrastructure to the necessity of providing health insurance and ensuring the availability of trained medical personnel. But the opportunities are equally compelling, from developing new infrastructure and providing medical equipment to delivering telemedicine solutions and conducting cost-effective clinical trials. For companies that view the Indian healthcare sector as a glass half full, the potential is enormous.

Porters five forces analysis:

Porter's five forces analysis is a framework for industry analysis and business strategy development formed by Michael E. Porter of Harvard Business School in 1979. It draws upon industrial organization (IO) economics to derive five forces that determine the competitive intensity and therefore attractiveness of a market. Attractiveness in this context refers to the overall industry profitability. An "unattractive" industry is one in which the combination of these five forces acts to drive down overall profitability. A very unattractive industry would be one approaching "pure competition", in which available profits for all firms are driven to normal profit. Three of Porter's five forces refer to competition from external sources. The remainder are internal threats. Porter referred to these forces as the micro environment, to contrast it with the more general term macro environment. They consist of those forces close to a company that affect its ability to serve its customers and make a profit. A change in any of the forces normally requires a business unit to re-assess the marketplace given the overall change in industry information. The overall industry attractiveness does not imply that every firm in the industry will return the same profitability. Firms are able to apply their core competencies, business model or network to achieve a profit above the industry average. A clear example of this is the airline industry. As an industry, profitability is low and yet individual companies, by applying unique business models, have been able to make a return in excess of the industry average. Porter's five forces include - three forces from 'horizontal' competition: threat of substitute products, the threat of established rivals, and the threat of new entrants; and two forces from 'vertical' competition: the bargaining power of suppliers and the bargaining power of customers.

Five forces in our Company:-

1. Threat of new competition Profitable markets that yield high returns will attract new firms. This results in many new entrants, which eventually will decrease profitability for all firms in the industry. Unless the entry of new firms can be blocked by incumbents, the abnormal profit rate will tend towards zero (perfect competition).

The existence of barriers to entry (patents, rights, etc.): The ambulance industry is highly regulated and require several state permits. Health is a state subject and is subject to many regulations.The industry requires knowledge of internal processes and knowledge of the practices in the industry,therefore,the entry barriers are quite high.The exit barriers are low because ambulances can be sold off as vehicles to recover a part of the cost anytime and investors can make an exit. Brand equity: The brand equity of the hospital being served by us automatically gets attached to our company resulting in high brand equity for our ambulance company. Capital requirements: Capital requirements are only for the vehicles being purchased and the retrofitting being done to convert them into ambulances. There are no other capital requirements in the start-up. Absolute cost: The absolute cost is low; comprises of operating cost in terms of fuel, maintenance and salaries whereas capital cost is mainly through the bank debt. Industry profitability; the more profitable the industry the more attractive it will be to new competitors: Industry profitability is high, but even as the profitability is high, due to high entry barriers, it requires deep knowledge of the industry to make an entry. 2. Threat of substitute products or services The existence of substitute products increases the propensity of customers to switch to alternatives. The buyer propensity to substitute is low. The relative price performance would be of low consideration to the patient in an emergency situation. The switching costs would be high because customer would be changing his preferred hospital which can escalate his costs.The perceived level of product differentiation is low and the number of substitutes available are high. 3. Bargaining power of customers (buyers) The bargaining power of customers is also described as the market of outputs: the ability of customers to put the firm under pressure, which also affects the customer's sensitivity to price changes. The customers sensitivity to the price changes is very low because the health market is seldom affected by price changes. The ambulances can be run for the hospitals in the initial years at a low return but eventually can be turned into a full fledged ambulance care provider of its own due to the experience gained in the field. The customers have high

bargaining power in the initial years, but that risk has been mitigated by signing long term offtake contracts. 4.Bargaining power of suppliers The bargaining power of suppliers is also described as the market of inputs. Suppliers of raw materials, components, labor, and services (such as expertise) to the firm can be a source of power over the firm, when there are few substitutes. Suppliers may refuse to work with the firm, or, e.g., charge excessively high prices for unique resources. Suppliers have low bargaining power because a number of companies are producing ambulance vehicles and also retrofitting them. The fuel prices are controlled by the government,but also their hike has been taken into account for the next years in the agreement signed.The degree of differentiation of inputs is low.The impact of crucial inputs such as fuel prices has already been taken into account.The drivers are being paid the current market price and thus no problem is seen in their services.The employee solidarity is high which can be lowered through giving ample chances to the employees to grow in the organization.The suppliers have been competitors for the past many years and they are unlikely to form a cartel so as to cut out a buyer. 5.Intensity of competitive rivalry For most industries, the intensity of competitive rivalry is the major determinant of the competitiveness of the industry.The industry has ample growth opportunities today due to low presence of healthcare providers in India.The competitive advantage can be made through making use of high technology and usage of innovative supply chain practices incorporated in the company.The company has a flexible strategy to scale up in the future years through newer contracts or even going for acquistions of established companies.

MANAGEMENT TEAM

Management Team:
1. Himanshu Kumawat: Promoter Director, has experience of handling ambulance services in a large private hospital in Pune for the past 14 years. As the manager of emergency services, Inamdaar Hospital,Pune has handled several pressure situations and responded effectively to them. He knows the procedures, processes and the various rules and regulations of the industry. He holds B.Com degree from Gujarat University and a diploma in health care management from Pune University. He also holds LLB from Pune University. 2. Badal Nirwan: Promoter Director, holds MBA in Hospital Adminstration from MIMS, Chennai. He has extensive interests in the healthcare industry. He is currently working with Sasoon Hospital,Pune as in capacity of Head, Administration Deptt for the past 3 yrs.Holds total experience of 17 yrs in healthcare industry. 3. Saurabh Arora: Business Operations Manager, 7 yrs experience in a large ambulance company based out of Kolkata. Holds MBA in marketing from IISBWM,Kolkata. Holds equity in the company to the tune of 20 %. 4. Tanuj Kandpal: Product Lead Manager, IT & Supply Chain Management, Holds 5 yrs extensive experience in various verticals across different industries in the domain of supply chain management. He holds MCA from Delhi University and PGP-SCM from SCDL,Pune. 5. Dr.Kritika Pal: Equity Promoter Director, holds 10 % equity,practicing Cardiologist in Inaamdar Hospital, Pune. She holds extensive experience of 8 yrs in healthcare industry. 6. Dr.Shreya Chatterjee : Equity Promoter Director,holds 10 % equity,practicing general physician, Sasoon Hospital, Pune. She holds extensive experience of 6 yrs practicing medicine in Pune. Resourcefulness of the management team: The management team comprises of seasoned professionals of the healthcare industry having immense knowledge of the inside out of the industry.The management team has good financial resources for the capital investment in the initial years and to also take the exposure. The management team can easily reinvest the profits generated back into the company and also reinvest in case of losses in the initial years.

Vision of the management:

The City of Pune needs a secure and safe Ambulance service at a reasonable cost to the patients delivering quality healthcare and fast service.

Mission of the management:

To save lives, reduce suffering and enhance quality of life, through accessible and responsive quality patient care and transport.

Our Target: Reach patient site within 15-20 minutes and shift patients to the contracted or
nearest hospital.

Analysis of the organization through Mckinseys 7S model:1. Strategy: Quickly scaling up in the next 3 years on getting hospitals contracts as fast as
possible. Strength of the organization lies in its management team having extensive experience in the healthcare industry across all domains ranging from first point of contact to the medical expertise providers. As there are negligible unified ambulance services in India, the industry is expected to grow at a very fast rate initially in the coming years. The opportunities lie in the very fact that the country is under equipped in the area of the health care industry and it is the immense demand that will drive the growth in this segment. The threat is of the similar services being started in the competition but as the management team is comprised of healthcare specialists, this risk is mitigated. The contracts are expected to come easily due to the promoters network in the domain and the sheer demand of the ambulance services in the city. The long term strategy is to move out from the city of Pune to the other parts of the Maharashtra namely Satara, Kolhapur, Jalgaon etc(namely tier-II cities comprising population greater than 10,00,000 and inadequate health infrastructure).The long term strategy also encompasses running mobile hospitals in tier-III cities and rural areas.

2. Structure of the organization:-

Himanshu Kumawat,CEO

Badal Nirwan, AVP,Marketing and Customer Satisfaction Tanuj Kandpal,Product Lead Manager,IT & supply chian management

Saurabh Arora, Business Operations Manager

Ms.Bhanupriya,Secretary

Ms.Kanupriya,Secretary to the CEO

Mr.Prem Kumar,Office Executive

Ms.Sonali,Customer Care Executive

3. Systems:Systems are routine processes and procedures followed within an organisation

to implement the strategy and to run day-to-day affairs. These processes are mainly designed to achieve maximum effectiveness. Traditionally, the higher management makes the most decisions. Increasingly, the organisation are using innovation and new technology to make decision-making processes quicker. Ours is a leaner organization following flat structures. The decision making is quick and prompt. The faster the decisions taken at the spot, the higher is the probability that they can be wrong. So, accordingly the BDM can take decisions concerning business growth at his own judgment and later take CEO in confidence in the vertical assigned to him. The marketing vice president can take routine marketing decisions without any delay if the budget is in within the limits assigned to him by the CEO, and supply chain manager has to ensure that the business doesnt suffer due to lower inventory levels or delay in ambulance delivery dates to the clients.

4.Staff : As the organization is a start-up the key employees are the promoter directors of
the company and are highly competent professionals of the healthcare industry and are highly motivated and keen to see that this project works well. As for the driving staff, the drivers of the ambulance will be trained through an agreement signed by us with the Motor Learners Institute through a module specially designed by them for ambulance drivers. The focus is on hiring good quality local drivers with knowledge of local roads and ways. The selection criteria is a pass in Xth class and 6/6 both eyes and good physical and mental condition. The drivers have a good opportunity to grow with the organization. The drivers are entitled for their own vehicle loan after 5 years of continuous service and also to hold common equity in the company so as to have a high retention ratio with our company. As the company will grow in the coming years we will require huge supply of trained good quality drivers

5.Skills: Management team has adequate skills to start this project due to previous industry
exposure.The team comprises of 2 MBAs, and an healthcare experience of more than fifty years combined in the healthcare industry comprising of ambulance services specialists to the medical practitioners.

6. Style: - Open management style, focus more on team work. Lateral organization. 7. Shared Values: Common Equity participation and the experience of the healthcare
industry helps the team have shared beliefs and expectations from this service. The team is highly motivated and keen to see the success of this project.

Mckinsey 7S framework for Ambulance Company

The whole of the 7S creates synergy for our organization to help it achieve excellence and grow in the field. We can also add 8S that is surroundings, whose contribution we have taken into account on the fact that ambulance lease providers are niche service providers and we can establish ourselves easily due to prior industry knowledge and the contacts in the industry.This 7S model for the our company differs from the regular 7S models,instead of keeping Shared Values in the middle,we have kept synergy in the middle because Shared Values are boundary conditions,if we have shared values of the management intact then the company can keep bay with the outside elements.The company creates synergy through the interaction of all the elements with each other in an effective manner.

LEGAL AND TECHNICAL ASPECTS FOR OPERATING AMBULANCE SERVICE

LEGAL ASPECTS TO BE CONSIDERED WHILE OPERATING AN AMBULANCE SERVICE:

Introduction: Over the past 20 years, the field of prehospital medicine has undergone impressive growth. As the body of knowledge continues to grow, as more technology is introduced, and as research defines and refines the uniqueness of prehospital medical care, the challenges of the prehospital setting are becoming more than operational and medical. Efficient response, appropriate care, and safe, expeditious transport are the expectant fundamental components of prehospital care. However, more and more prehospital providers are facing challenging ethical dilemmas. There are three fundamental ethical premises that guide prehospital medical care. The principle of justice implies that the system be fair and equitable. The principle of beneficence requires that actions and intentions are in the best interest of the patient. Respect for patient autonomy dictates that the requests of the patient are honored and nothing is done which is contrary to the wishes of the patient.

The Relationship Between Ethics And Law: Ambulance services must look to the law for guidance when developing methods to honor advance directives to limit resuscitation or to implement policy regarding involuntary transport of serious patients. However, legal guidance does not provide the answer to every difficulty that may arise. There are many situations in the prehospital setting that have not been addressed by statute or case law. In addition, statutes may vary substantially between states. Ethical theory should set a universally applicable standard. Also, the law may be ambiguous, so no clear guidance is offered, or it might be very specific, applying only to cases with substantially similar circumstances. The law also does not address the breadth of ethical imperatives which obligate ambulance services. Finally, the law may not reflect ethical behavior. For example, case law has stated that a person who knows how to swim has no legal obligation to rescue a drowning child. While the law is limited in its ability to provide universal guidance and direction, ethical analysis should provide a frame work for determining moral duty, obligation and conduct. Similarly, ethical analysis does not substitute for appropriate legal guidance. When dealing with dilemmas, when initiating policy and protocols, or when updating existing procedures, informed legal advice is mandatory.

The Ambulance services` Ethical Obligation: When an ambulance service system holds itself out to the community as an emergency response network, it is assuming an important ethical obligation. It has the duty to respond regardless of the patient's income or social position. Care must not be limited unfairly to any specific group or class of people. Financial concerns do dictate the resources available, and often set the community level of prehospital care. Financial limitations do not necessarily present an ethical dilemma. The duty of the system is to uphold those standards that it sets for itself; whether the services are basic or advanced, they must be medically acceptable. Ambulance services often set priorities of care or classify certain calls as "nonemergencies." Patients with minimal illnesses may not be transported, or may have transport delayed. This rationale or triage of care must be based only upon medical indication and well-defined protocols. These efforts are appropriate because they allow the system to be fluid and accessible to critically ill or injured patients. These allocation decisions must not be arbitrary, and must not penalize any group unfairly. When planned appropriately, Ambulance services might be regarded as one of the most fair of health care institutions. Ambulance service policies must remain equitable and just. Informed Consent: Patients will express preferences and voice demands regarding interventions and hospital destination. They will refuse care, refuse elements of care, prefer transport without interventions, or prefer interventions without transport.The provider must be trained to deal with these difficult circumstances, while respecting both the patient's autonomy and the obligation of beneficence. The prehospital care provider operates, as does the paramedic, only at the request and with the consent of the patient. This is complicated particularly in the prehospital setting when the patient may not have been the one to call for assistance, but is confronted with providers who are eager to intervene. Prehospital care practitioners must respect patient autonomy. Nothing can be done to a patient without the patient's consent, whether this consent is explicit or implied. Prehospital care providers comfortably operate under implied consent when patients request and cooperate in the care. The emergency rule, or consent applied by law, presumes that consent is offered if the patient is unable to express it because of illness or injury. In these cases, treatment must proceed when prompt intervention is necessary to prevent loss of life or disability. True informed consent requires that

the patient participate in the decision-making with a full understanding of the risks and benefits of treatment as well as the risks of lack of treatment. The ideal of informed consent is difficult to achieve in the typical prehospital setting. Nevertheless, in the routine of prehospital emergency medicine, when appropriate care is provided in the best interests of the patient without patient objection, no ethical dilemma is present. A dilemma may arise when a patient refuses to consent to care. The competent patient's wishes must be honored: it only is with the patient's permission that care is rendered. However, patients in acute medical crisis might lack the ability to make reasoned judgments regarding their care. Withholding care based on a patient's impulsive refusal would not serve the patient's interests. Patients with intracranial injury, drug or alcohol intoxication, metabolic derangements, or mental illness might offer unreasoned refusals of care. Conversely, patients with dementia, mental retardation, or drug or alcohol intoxication may offer valid, autonomous decisions (i.e., a decision made with an appropriate understanding of the facts, risks, and benefits that are consistent with their personal values). Sometimes, it is difficult to know when a prehospital patient's refusal represents an informed decision. A patient may refuse care despite a serious illness. In this circumstance, if the patient was declared by law to be temporarily incompetent to make such decisions, care could be instituted. However, such decisions require a judicial determination. Only the rare ambulance service system can obtain rapid judicial determinations of competence. Most ambulance services are challenged to determine which patient refusals are acceptable, At a minimum, a patient must demonstrate an understanding of his or her illness, recognition of the risks of refusing care, be able to manipulate the information rationally, and freely and voluntarily refuse intervention. Further intervention should be carried out on any patient who cannot meet these criteria. In daily operations, the provider is confronted with the reluctant patient, the agitated patient, the impulsive, the incoherent patient, or the intoxicated patient who refuses transport to an emergency department. CIVIL LIABILITY ACTIONS: Because patients may be entitled to monetary compensation for injuries caused by careless acts of ambulance service providers, a paramedic may become a defendant in a civil suit. Two terms must be defined with regards to this type of action STANDARD OF CARE The standard of care is the basis for evaluating a claim of negligence. The standard of care is determined by what a reasonable, prudent ambulance service provider of similar training, skills, and experience would do in like circumstances.

MALPRACTICE Malpractice usually refers to negligent conduct by a professional in the performance of duty. To win a case alleging malpractice, the patient must prove each of the following four elements by a preponderance (more than 50%) of the evidence: 1. The defendant had a duty to act according to the standard of Care. 2. A breach of that duty occurred; 3. The breach of duty caused the injury; and 4. The patients injury can be assessed monetarily. Another common basis for civil cases against ambulance service providers is abandonment which is the unilateral termination of a provider/patient relationship when the patient still needs care, but provision is not made for that care and an injury results. Refusal to transport a patient or talking a patient out of being transported to a hospital is an invitation for an abandonment claim. LIABILITY PROTECTION: LIABILITY INSURANCE Liability insurance is not a means to avoid liability itself. Rather, it provides payment for legal representation and damage awards entered against the policy holder. Because the provision of ambulance service is unique and considered a specialized aspect of medical care, paramedics may consider seeking malpractice coverage with an insurance company familiar with ambulance service procedures. RISK MANAGEMENT There are various ways that ambulance service providers can reduce their exposure to lawsuits. First, ambulance service providers must pay strict attention to patient run report documentation. A properly documented run report can diffuse potential lawsuits. In addition, preparation and prevention may provide some liability protection. Training records must be up to date and skills must meet, at a minimum, current guidelines and practices in the industry. GUIDELINES FOR NON EMERGENCY AMBULANCE SERVICE: Definition: A Non-Emergency Ambulance Service is one that provides ambulances for ferrying non-emergency patients e.g.a. Patients requesting for ambulance for regular outpatient clinic attendance. b. Patients requesting for ambulance for transport to hospital with medical problems.

c. Inter-hospital transfers of non-critically ill patients. d. Patients discharged from hospital to home. In spite of the above, it must be remembered that such non-emergency patients may occasionally develop acute emergency problems while en-route in the ambulance. Non-Emergency Ambulance Agency: The Agency that intends to provide the service must be a company or a business entity registered with the Registry of Companies & Businesses or a bona fide registered voluntary or charitable organisation. The Agency must have the following: a. A qualified person (either a doctor or a paramedic) employed by the Agency who sets protocols of care for patients transported and organises training and supervision for medical care provided by ambulance crew. Voluntary organisations must also provide for a qualified person to supervise the service. b. A programme for training and monitoring performance levels of ambulance crew and records of such performance monitoring. c. Acceptable scales of ambulance equipment and ambulance medical supplies. d. A system for activation of the ambulances of the Agency. Non-Emergency Ambulance Crew: A) Each Non-Emergency Ambulance should be staffed by at least a two member crew, one of whom is a driver, and the other the Ambulance Officer who may be either a Registered Nurse or trained Paramedic. B) The Driver should have the following minimum qualifications/ experience:a). Possess a valid licence to drive the ambulance. b). Understand the usage of ambulance stretchers. c). Undergone training in Standard First Aid. d). Trained in defensive driving and be well aware of the use of sirens and flashing lights for conveying emergency patients to hospital. C) The Ambulance Officer should be able to :a). Measure vital signs eg pulse rate, respiratory rate, blood pressure.

b). Perform Basic Cardiac Life Support (BCLS) and be currently certified in BCLS. c). Use airway adjuncts such as oropharyngeal airway, nasopharyngeal airway, suction devices and basic oxygen delivery devices such as bag valve mask. d). Use various types of stretchers and body immobilisation devices. e). Perform basic emergency procedures such as:i). Control of external bleeding ii). Application of dressings, bandages, slings and splints. f). Monitor peripheral lines of stable patients. g). Transfer and maintain patients with nasogastric tubes and urinary catheters. h). Establish contact with a receiving hospital if the need arises. . Various State Clearances:The various state clearances will be taken by the hospital. We will supply all the other clearances required with the vehicle such as pollution certificate, insurance certificate, maintenance certificate, and driver credentials. The majority of the clearances required would be borne by hospital and we would reimburse them the cost associated with it.

TECHNICAL ASPECTS TO BE CONSIDERED WHILE OPERATING AN AMBULANCE SERVICE:

NON-EMERGENCY AMBULANCE SERVICE: AMBULANCE EQUIPMENT AND MEDICAL SUPPLIES A) VEHICLE EQUIPMENT 1. Siren and Wail Sound Horn or Two-Tone Horn. 2. Red Beacon Light. 3. Fire Extinguisher. 4. Street Directory. 5. Bench Seat and Safety Belts. 6. Water Tank and Sink. 7. Frosted or Tinted Side and Rear Window Glass (excluding the front side windows). 8. Radio Network Communication or Mobile Phone or other Ambulance-Hospital Communication Equipment

9. Adequate rear (including roof mounted) warning lights B) MEDICAL EQUIPMENT 1. Main Stretcher with Mattress, Firm Base and Patient Restraints. 2. First Aid Box (standard)/Ambulance Bag. 3. Blanket. 4. Trolley Sheet. 5. Pillow. 6. Hand Carried Stretcher. 7. Wheel Chair with Restrainers. 8. Receiver for Vomits (kidney dish). 9. Bed Pan. 10. Urinal. 11. Pocket Mask with One-Way Valve (for CPR). 12. Bag-valve Mask. 13. Vital Signs Equipment eg Blood Pressure Set and Thermometer. 14. Stethoscope. 15. Hand Torch. 16. Portable oxygen including Spare Cylinder. 17. Tubing and Mask for Oxygen. 18. Portable Suction Unit. 19. Detachable Drip Stand for use with Stretcher.

CONCLUSION: Above studies have been done with the best of our efforts and we hope that the project would reap benefits.

REFERENCES 1) EMRI ambulance services website www.emri.com 2) Apollo Hospitals Annual Report 2012 3) Andhra Pradesh Govt Website 4) Google Maps www.maps.google.com 5) ZVH Ambulance suppliers, New Delhi Quotations 6) SAI ambulances Pune 7) Inamdaar Hospital Pune 8) Ministry of Healthcare,India,website