Investment in Healthcare Legal, Regulatory and Tax Overview
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MUMBAI SILICON VALLEY BANGALOR E SINGAPORE MUMBAI BKC NEW DELHI MUNICH N E W Y ORK Investment in Healthcare Legal, Regulatory and Tax Overview May 2020 © Copyright 2020 Nishith Desai Associates www.nishithdesai.com Investment in Healthcare Legal, Regulatory and Tax Overview May 2020 [email protected] DMS Code - 563358,1 © Nishith Desai Associates 2020 Investment in Healthcare Legal, Regulatory and Tax Overview About NDA We are an India Centric Global law firm (www.nishithdesai.com) with four offices in India and the only law firm with license to practice Indian law from our Munich, Singapore, Palo Alto and New York offices. We are a firm of specialists and the go-to firm for companies that want to conduct business in India, navigate its complex business regulations and grow. Over 70% of our clients are foreign multinationals and over 84.5% are repeat clients. Our reputation is well regarded for handling complex high value transactions and cross border litigation; that prestige extends to engaging and mentoring the start-up community that we passionately support and encourage. We also enjoy global recognition for our research with an ability to anticipate and address challenges from a strategic, legal and tax perspective in an integrated way. In fact, the framework and standards for the Asset Management industry within India was pioneered by us in the early 1990s, and we continue to remain respected industry experts. We are a research based law firm and have just set up a first-of-its kind IOT-driven Blue Sky Thinking & Research Campus named Imaginarium AliGunjan (near Mumbai, India), dedicated to exploring the future of law & society. We are consistently ranked at the top as Asia’s most innovative law practice by Financial Times. NDA is renowned for its advanced predictive legal practice and constantly conducts original research into emerging areas of the law such as Blockchain, Artificial Intelligence, Designer Babies, Flying Cars, Autonomous vehicles, IOT, AI & Robotics, Medical Devices, Genetic Engineering amongst others and enjoy high credibility in respect of our independent research and assist number of ministries in their policy and regulatory work. The safety and security of our client’s information and confidentiality is of paramount importance to us. To this end, we are hugely invested in the latest security systems and technology of military grade. We are a socially conscious law firm and do extensive pro-bono and public policy work. We have significant diversity with female employees in the range of about 49% and many in leadership positions. © Nishith Desai Associates 2020 Provided upon request only Accolades A brief chronicle of our firm’s global acclaim for its achievements and prowess through the years – Legal500: Tier 1 for Tax, Investment Funds, Labour & Employment, TMT and Corporate M&A 2020, 2019, 2018, 2017, 2016, 2015, 2014, 2013, 2012 Chambers and Partners Asia Pacific: Band 1 for Employment, Lifesciences, Tax and TMT 2020, 2019, 2018, 2017, 2016, 2015 IFLR1000: Tier 1 for Private Equity and Project Development: Telecommunications Networks. 2020, 2019, 2018, 2017, 2014 AsiaLaw Asia-Pacific Guide 2020: Tier 1 (Outstanding) for TMT, Labour & Employment, Private Equity, Regulatory and Tax FT Innovative Lawyers Asia Pacific 2019 Awards: NDA ranked 2nd in the Most Innovative Law Firm category (Asia-Pacific Headquartered) RSG-Financial Times: India’s Most Innovative Law Firm 2019, 2017, 2016, 2015, 2014 Benchmark Litigation Asia-Pacific: Tier 1 for Government & Regulatory and Tax 2019, 2018 Who’s Who Legal 2019: Nishith Desai, Corporate Tax and Private Funds – Thought Leader Vikram Shroff, HR and Employment Law- Global Thought Leader Vaibhav Parikh, Data Practices - Thought Leader (India) Dr. Milind Antani, Pharma & Healthcare – only Indian Lawyer to be recognized for ‘Life sciences-Regulatory,’ for 5 years consecutively Merger Market 2018: Fastest growing M&A Law Firm in India Asia Mena Counsel’s In-House Community Firms Survey 2018: The only Indian Firm recognized for Life Sciences IDEX Legal Awards 2015: Nishith Desai Associates won the “M&A Deal of the year”, “Best Dispute Management lawyer”, “Best Use of Innovation and Technology in a law firm” and “Best Dispute Management Firm” © Nishith Desai Associates 2020 Investment in Healthcare Legal, Regulatory and Tax Overview Please see the last page of this paper for the most recent research papers by our experts. Disclaimer This report is a copy right of Nishith Desai Associates. No reader should act on the basis of any statement contained herein without seeking professional advice. The authors and the firm expressly disclaim all and any liability to any person who has read this report, or otherwise, in respect of anything, and of consequences of anything done, or omitted to be done by any such person in reliance upon the contents of this report. Contact For any help or assistance please email us on [email protected] or visit us at www.nishithdesai.com Acknowledgements Dr. Milind Antani [email protected] Harshita Srivastava [email protected] Afaan Arshad [email protected] Darren Punnen [email protected] Shreya Shenolikar [email protected] © Nishith Desai Associates 2020 Investment in Healthcare Legal, Regulatory and Tax Overview Contents 1. INTRODUCTION 01 2. OPPORTUNITIES 02 I. Hospitals and Infrastructure 02 II. Technology Driven Services 03 III. Medical Devices and Equipment 03 IV. Diagnostics 04 V. Health Insurance 04 3. EMERGING TRENDS 05 I. Consolidation of Hospitals – a Fast Emerging Trend 05 II. Emerging Tier 2 and Tier 3 Cities 05 III. Inclination of Doctors Towards Debt Funding 05 4. INVESTMENT IN HEALTHCARE SECTOR 06 I. Foreign Direct Investment 06 II. Foreign Venture Capital Investment 06 III. Transactional Issues for Investments in Healthcare 07 5. LEGAL AND REGULATORY ASPECTS 08 I. Authorities 08 II. Hospitals 08 III. Medical Devices 09 6. TAXATION IN INDIA 11 I. Direct Taxes 11 II. Incentives under the ITA 13 III. Potential Permanent Establishment Issues 14 IV. Taxation as an Association of Persons 16 V. Structuring Investments in India – Use of Intermediate Jurisdictions 16 VI. Indian Transfer Pricing Restrictions 17 VII. Disallowance of Deductions Incurred in Unethical Promotion 18 VIII. Indirect Taxes 18 IX. Customs Duty 19 7. ISSUES AND CONCERNS 20 © Nishith Desai Associates 2020 Investment in Healthcare Legal, Regulatory and Tax Overview 8. CONCLUSION 21 ANNEXURE A 22 Schematic Representation of Various Business Models 22 ANNEXURE B 26 ANNEXURE C 27 List of Notified Medical Devices 27 © Nishith Desai Associates 2020 Investment in Healthcare Legal, Regulatory and Tax Overview 1. Introduction India, one of the biggest emerging markets, is con fined to a specified area with limited currently an important destination for foreign infrastructure and services are now expanding, direct investment (“FDI”). Despite India’s mainly due to the foreign investment being potential to become one of the most dominant received by the sector. economies in the world, its economic progress Further, the Government of India also aims to since gaining independence in 1947 has increase its healthcare spending to up to three generally been masked by a perception of India percent of the Gross Domestic Product (GDP) being a closed, developing country. However, by 2022.2 This will lead to organic and inorganic this perception has changed in the recent past expansion of existing hospitals in India. India and India is today accepted as one of the most has witnessed the emergence of various multi- stable and robust economies. specialty, single -specialty and super-specialty The healthcare sector as an industry is hospitals in Tier 1 and Tier 2 cities. These expanding rapidly in India. It comprises of hospitals are predominantly managed by hospital and diagnostic services, diagnostic corporates. products, medical devices, medical technology, Foreign investors are playing a significant e-health service, clinical trial services, and role in the development of the hospital and clinical research organizations. This sector is diagnostic sector. Under the Union Budget 2020- predominantly privatized with almost 75 to 80 2021, the allocation to the Ministry of Health percent of hospitals being run and managed by and Family Welfare was INR 69,000 crore out of the private sector. which INR 6,400 crore was allocated to India’s Indian healthcare sector was expected and flagship healthcare program the Prime Minister continues to record a threefold rise, at a CAGR Jan Arogya Yojana, popularly known as of 22 per cent during 2016-2022 to reach Ayushman Bharat.3 The budget also proposed a US$ 372 billion by 2022.1 It is undergoing a cess of 5% on the import of medical devices the metamorphosis by broadening the focus of its funds from which would be used to set up more services using technology, deliverables, and hospitals in public-private partnership models.4 newer applications. Hospitals that were 2. Ibid. 3. https://www.indiabudget.gov.in/doc/Budget_Speech.pdf 1. https://www.ibef.org/download/healthcare-jan-2019.pdf 4. Ibid. © Nishith Desai Associates 2020 1 Provided upon request only 2. Opportunities The Indian healthcare sector is ripe for the government or local municipal body on expansion and significant growth. a long lease and constructs a hospital on this land. The trust may then manage the hospital I. Hospitals and Infrastructure itself or if it does not have the management capability, it may engage professional service providers to run and manage the hospital. There is tremendous demand for tertiary care Regarding profit sharing, several commercial hospitals and specialty hospitals in India and models have evolved. The challenges in this there is a gap between the availability of beds model are the restrictions imposed in the lease and required beds. The Indian medical tourism by the government body, such as restrictions industry is expected to reach USD 9 billion on expansion and requirements of rendering (around INR 68,000 crore) by 2020.5 Due to services to poor patients.