Narayana Health’s development of Health City Cayman Islands is a case study on how NH was able to successfully build its first venture in the global healthcare space. Health City Cayman Islands (HCCI) is a tertiary-care hospital complex on Grand Cayman, founded by Dr. Devi Shetty and Narayana Health (NH) in partnership with local and international stakeholders. Narayana’s strategic entry into the Cayman Islands – a British overseas territory near the US – was motivated by medical‐tourism potential and a chance to export its high‐quality, low‐cost care model outside India.
Over time NH built and expanded HCCI, transitioned from a joint venture to full ownership, and has integrated it into its global network. Below are the details Narayana’s rationale, the chronology of partnerships and acquisitions, deal size and financing, the hospital’s scale and services, current performance, synergies with NH’s Indian operations, leadership perspectives, and future plans.
Acquisition Rationale
Narayana’s push into Cayman was driven by strategic and operational factors. The Cayman location lies just outside U.S. regulatory jurisdiction, allowing Narayana to serve American and Caribbean patients at much lower prices than U.S. hospitals.
Dr. Shetty explicitly noted that “a big advantage of the Cayman Islands facility is its location: near the American shore, but off the stringent US regulations,” allowing the venture to offer ~30% discounts to U.S. healthcare rate. The project’s vision was vast – a 2,000-bed “Health City” campus with medical university and retirement living over 10 years (total investment ~$2 billion) – positioning Cayman as a Caribbean healthcare hub. Crucially, the Cayman government recognized Indian medical degrees, letting Narayana staff the hospital with its experienced Indian specialists. This combination of U.S. market access, regulatory flexibility, and workforce strategy aligned with Narayana’s mission: demonstrate its high-volume, low-cost model to the developed world.
Secondary motives included general global expansion and risk diversification. The project fit Narayana’s growth plan – aiming to add one-fourth of new beds overseas – and provided a showcase for its practices (e.g. telemedicine, efficient supply chains) on an international stage. For example, Narayana planned remote staffing from its Bangalore facilities (initially 70 Indian physicians) to ensure continuity of care. The venture also aligned with the broader goal of medical tourism: attracting patients from the U.S., Caribbean and Central America who seek high-quality tertiary care (cardiac, orthopedic, oncology, etc.) at more affordable prices.
Timeline: Entry, Partnerships, and Ownership Changes
The HCCI project unfolded over a decade. Key milestones include:
- 2009–2012 – Concept & JV Formation. Dr. Shetty first met Cayman officials in 2009, leading to an MOU in Oct 2009. A partnership was announced in April 2012 between Narayana, the Cayman government and Ascension Health (a large U.S. health system) to co-develop HCCI. Land was acquired (Oct 2011) and construction progressed through 2013.
- 2014 – Hospital Opening. HCCI’s first phase opened Feb 25, 2014 as a 104-bed multispecialty hospital. (Local reports sometimes cite 105–140 beds; Narayana’s filings confirm a 105-bed facility.) Specialty services initially focused on cardiac and orthopedic surgery, with pediatric cardiology, neurosurgery, and others added soon after.
- 2017–2018 – Narayana Takes Full Control. In November 2017 Ascension announced its intent to exit the JV, transitioning HCCI to “full ownership by Narayana Health”. In Jan 2018 Narayana’s Cayman unit (Narayana Cayman Holdings) completed a share buyback of Ascension’s 71.4% stake for US$32.26 million, making HCCI 100% owned by NH. (At that time Narayana itself held 28.6% via its Cayman subsidiary, so post-buyout it held 100%.) Following regulatory approvals, HCCI became a direct subsidiary of Narayana (via a merger of holding companies) as of Apr 1, 2021.
- 2018–Present – Expansion and Affiliations. Post-acquisition, Narayana reinvested in HCCI’s growth. A notable expansion was the addition of the Gene Thompson Radiotherapy Centre (opened 2023) and a new second hospital (“Health City at Camana Bay”) inaugurated in 2024 with obstetrics, NICU and other services.
In parallel, HCCI acquired a local ENT practice (100% acquisition on Mar 3, 2023) and launched an affiliated Cayman insurance venture (Cayman Integrated Healthcare Ltd.) in 2024. Throughout, Narayana’s global push continued: in Nov 2025 it announced its parent’s acquisition of UK’s Practice Plus Group (13-hospital network) to complement its Cayman presence.
Timeline of Health City Cayman Islands
| Year | Event |
| 2009 | MOU signed (Oct) between Cayman govt and Dr. Shetty for 2,000-bed hospital vision. |
| 2010 | Cayman government formally partners with Narayana (signed agreement Apr 2010). |
| 2012 | Narayana–Ascension joint venture announced (Apr). Government amends regs to recognize Indian doctors. |
| 2014 | HCCI East End 104-bed hospital opens (Feb 25). |
| 2017 | Ascension announces transition; HCCI to be fully owned by Narayana. |
| 2018 | HCCI (Cayman) buys back Ascension’s 71.4% share (Jan 2018) for US$32.26M; Narayana holds 100%. |
| 2021 | Holding company merge makes HCCI a direct Narayana subsidiary (Apr 2021). |
| 2023 | HCCI opens Gene Thompson Radiotherapy Centre; partners with Dana-Farber (Oct). |
| 2024 | Health City at Camana Bay hospital opens (July) with maternity, pediatric ICU, etc.. |
| 2025 | Narayana (via HCCI) acquires UK’s Practice Plus Group; continues Caribbean expansion (e.g. Doctors Hospital Bahamas stake). |
Deal Size and Ownership Structure
Narayana’s acquisition of HCCI’s remaining equity was executed via its wholly owned subsidiary Narayana Cayman Holdings. Prior to 2018, Narayana held 28.6% of HCCI (through Narayana Cayman Holdings) while Ascension Health Ventures held 71.4%. In late 2017 NH’s board approved funding a buyback of Ascension’s shares; by January 2018 HCCI completed the buyback of the 71.4% stake for US$32.26 million. This made HCCI a 100%-owned step-down subsidiary of Narayana Health (via Narayana Cayman Holdings). (Business press reported the price, and Narayana’s regulatory filing confirmed the $32.26M value. In 2018 terms, $32.26M equated to roughly ₹230–250 crore.)
Afterwards Narayana reorganized the holding structure: by April 2021, Narayana Cayman Holdings (NCHL) was merged into HCCI, making HCCI a direct subsidiary of Narayana Hrudayalaya Limited. In sum, before the buyout the ownership was NH (28.6%) + Ascension (71.4%); after 2018 Narayana (via NCHL) owned 100%. NH funded the acquisition internally (no separate fundraising was reported) and then consolidated HCCI fully into its group. No other private equity or bank financing was involved – the deal was a straightforward corporate share purchase from Ascension.
Facility Profile and Evolution
Scale and Infrastructure. HCCI’s flagship facility (East End) is a two-floor tertiary hospital. Narayana’s filings and website cite it as a “105-bed capacity” hospital. In practice, sources vary (initial plans said 104–140 beds), but 105 operating beds is confirmed by the latest reports. In 2024 Narayana opened a second facility (“Health City Camana Bay”), adding new operating theatres, maternity suites, and a 24/7 ER in George Town. Together, Narayana now operates two hospitals in Cayman (East End and Camana Bay) and a radiotherapy center, per its 2025 report.
Clinical Capabilities & Services. HCCI offers a full range of inpatient and outpatient services. Core specialties include Cardiology (adult and pediatric, including cardiac surgery and cath labs), Orthopedics (joint replacement, sports medicine), Oncology, Neurosciences, Gastroenterology, Pulmonology, and General Surgery. The hospital added Pediatric Cardiology, NICU, and Obstetrics/Gynecology over time. It also provides 24/7 Emergency care, imaging, laboratories, pharmacy and rehabilitation services. Technology is advanced: HCCI was the first hospital in the English-speaking Caribbean to deploy robotic-assisted orthopaedic navigation and implant artificial (VAD) hearts. In 2023 the Group opened a Gene Thompson Radiotherapy Centre, making HCCI the largest joint JCI-accredited hospital in the region.
Accreditations and Quality. From inception Narayana emphasized high standards. In July 2015 HCCI earned Joint Commission International (JCI) accreditation across all services (Gold Seal of Approval) – notably the first such “Enterprise” accreditation in the Caribbean. It maintains continuous JCI certification and, as of 2023, is “the largest hospital in the Caribbean to have earned the prestigious Gold Seal”. These attest to HCCI’s quality matching Narayana’s benchmarks.
Growth and Upgrades. Since opening, the hospital has steadily expanded. Key upgrades include: advanced imaging (CT/MRI), robotic surgical suites, a dedicated cancer center (with linear accelerator), and IT systems imported from Narayana’s network. Telehealth links with India ensure 24/7 specialist support – e.g. the initial plan deployed 17 Bangalore consultants for round-the-clock consults.
Narayana’s annual report notes continued capacity growth: “HCCI expanded capacity with a new facility at Camana Bay”. In essence, HCCI evolved from a single 104-bed hospital to a small campus of two hospitals and specialty centers, mirroring Narayana’s multi-campus Indian model on a Caribbean scale.
Operational & Financial Performance
Since opening in 2014, HCCI has ramped up volumes and moved into profitability. Narayana’s management reports that HCCI broke even at the EBITDA level within ~24 months of opening and achieved net profit by the 11th quarter. For instance, HCCI’s published accounts show revenue of ~US$61.1 million in FY2019-20 (≈₹4,580 million) and net profit of about US$8.1 million (≈₹61 crore) for that year. (In FY2018-19, revenue was ~US$54.6M with a smaller profit.) This indicates a rising gross margin as patient volumes grew. Narayana’s executives have confirmed year-over-year growth: one report notes a 32% revenue increase “due to consolidation of [HCCI] and growth”. (Precise modern figures are disclosed only consolidated; however, Narayana notes that Cayman operations have delivered “return of capital” and an export income stream.)
Occupancy has historically been modest. Independent analyses reported that HCCI’s occupancy was about 27% in 2018, reflecting soft initial demand. Narayana continues marketing to the U.S. and Latin American markets to boost volume. Narayana’s CEO commented that the facility’s “differentiated business model” has been validated in new markets, suggesting performance roughly met or slightly exceeded early projections. Cost structure-wise, Narayana leverages its India-based procurement to keep input costs lower, but Cayman is still more expensive per-patient than India. Market commentary noted procedure pricing (e.g. bypass surgery ~$32K) well above Narayana’s Indian tariffs – appropriate to the Caribbean context and insurance reimbursements.
The venture has thus become a profitable overseas unit. EBITDA margins are not published specifically for HCCI, but management’s statements imply healthy margins once scale was reached. Narayana’s rating agencies cite the venture’s contribution to group profitability. Overall, HCCI’s success is seen positively: “the commendable performance… underpins [Narayana’s] success”, and the hospital has achieved most of its early goals (market reach, accreditation, break-even timeline).
Synergies with Narayana’s India Operations
HCCI benefits from and contributes to Narayana’s global network in several ways:
- Clinical and Staff Exchange. Narayana dispatched its own specialists and nurses to Cayman: e.g. the launch team included 70 Indian clinicians. Ongoing, Narayana hospitals in India provide tele-consultation and second opinions to Cayman doctors (and vice versa). Notably, in 2016 Ascension and Narayana exchanged teams for cross-training: Ascension sent cardiology/orthopedic experts to HCCI, while HCCI staff had trained in Ascension centers. NH also rotates talent such as Indian cardiac surgeons participating in Cayman’s programs.
- Technology and Protocols. HCCI adopted many of Narayana’s low-cost high-volume innovations – from surgical protocols to patient-record IT (e.g. iKare apps on every bed). Conversely, Narayana has adapted lessons from HCCI: for instance, Ascension noted learning facility design and construction techniques from HCCI’s build. Both networks share clinical decision-support and management systems, aligning quality standards.
- Brand and Referrals. The Narayana/Shetty brand helps attract patients to HCCI who seek Indian-trained experts. Likewise, HCCI’s international accreditation and English-speaking Caribbean location bolster Narayana’s global reputation. In practice, “world-class healthcare” branding allows cross-promotion: U.S. insurers may refer cases to HCCI as a low-cost option, and vice versa Cuban or Latin American patients might come to NH India through these connections. Narayana’s insurance subsidiary in Cayman (CIHL) further integrates local patient channels.
- Financial/Scale Synergies. Narayana’s group purchasing and financing clout likely lower HCCI’s supply costs. Shared capital planning (e.g. group bond issuances fund global projects) helps finance expansions. Also, consolidating HCCI in Narayana’s consolidated accounts provides working-capital flexibility.
In short, Narayana India and HCCI operate as a single enterprise spanning continents, leveraging shared know-how, personnel, and branding to mutual benefit.
Leadership Commentary
Narayana Executives: NH’s leadership has consistently touted the Cayman venture’s importance. At the 2014 opening, Dr. Shetty proclaimed his “dream that … when you Google the best heart hospital in the world, it will be Health City Cayman Islands”. After taking full ownership, Shetty remarked in 2017 that HCCI’s “commendable performance… underpins the success” of their model in a new market, and he remained “confident about [attracting] international patients”. NH’s CFO/Vice-Chairman Ashutosh Raghuvanshi later summarized that HCCI “broke even at the EBITDA level by the 24th month of opening and made a net profit by the 11th quarter” – emphasizing that the venture achieved its business targets. NH leadership also highlights how HCCI exemplifies their scalable low-cost care approach: “our differentiated business model” has succeeded even in “unexplored international territories”.
Cayman Partners: Local partner Dr. Gene Thompson (CEO of HCCI) and government officials initially emphasized healthcare capacity-building and economic diversification. Government leaders called the hospital a transformative project for Cayman (e.g. Premier McLaughlin hailed it as a “transformative moment” for diversifying the economy). Ascension’s CEO, Anthony Tersigni, praised HCCI’s outcomes, noting it had treated 46,000+ patients by 2016 and pioneered several Caribbean “firsts” in care. Ascension highlighted the partnership’s bidirectional learning: “two Ascension cardiology experts traveled to HCCI” for knowledge exchange, and Ascension affiliates explored research collaborations in orthopedic care.
New Collaborations: In 2023 HCCI’s Chief Business Officer Shomari Scott emphasized the ongoing ambition: partnering with Dana-Farber “underpins our commitment to operational excellence” and advancing cancer care. She described entering an “era of hope” for cancer patients after opening a radiotherapy center and building this collaboration. Dana-Farber’s CMO, Craig Bunnell, noted this is Dana-Farber’s first Caribbean collaboration and expressed excitement to “share our expertise” to enhance regional cancer care. These comments from both sides confirm Narayana’s intent to keep HCCI at the cutting edge of specialized care and to leverage global partnerships.
Future Outlook
Narayana plans to continue growing its Cayman operations and integrating them globally. The immediate roadmap includes fully ramping up the Camana Bay Hospital’s services (maternity, NICU, pediatrics), and leveraging the Dana-Farber tie-up to attract more oncology cases. Narayana has also stated a CapEx plan (₹3,000 crore group-wide) partly aimed at strengthening its international footprint. Locally, the government’s 20-year tax exemption on HCCI helps free capital for reinvestment (as noted in financial filings).
Beyond Cayman, Narayana’s expanding international strategy (e.g. recent UK acquisitions) suggests Health City will be a central hub for both Caribbean and U.S. referral networks. Narayana executives have publicly discussed scouting further expansions. For example, Dr. Shetty noted ongoing talks with other countries (Europe, Africa) for similar ventures – likely applying lessons from Cayman.
In summary, Health City Cayman Islands is envisioned as a springboard for Narayana’s global vision. Its early success and ongoing upgrades (new hospital, new centre) position it as a regional leader. While occupancy and patient-mix continue to grow, Narayana’s integrated approach – combining brand, technology and talent – aims to realize the original vision: a low-cost, world-class healthcare destination for the Western hemisphere.
The revenue being generated from the business is close to 1200 crores with an EBITDA margin > 40%. This speaks a lot about the management of NH which was able to execute this business performance despite many changes in its plans from not being able to capture USA medical tourism to changes in partners to strategy. With another 100 beds coming up and acquisition of UK hospital chain, its ability to execute will be tested further.
