Kamla Nehru Memorial Hospital: Which Way Forward? Net Present Value (NPV) / MBA Resources

Introduction to Net Present Value (NPV) - What is Net Present Value (NPV) ? How it impacts financial decisions regarding project management?

NPV solution for Kamla Nehru Memorial Hospital: Which Way Forward? case study

At Oak Spring University, we provide corporate level professional Net Present Value (NPV) case study solution. Kamla Nehru Memorial Hospital: Which Way Forward? case study is a Harvard Business School (HBR) case study written by Naga Lakshmi Damaraju, Prafulla Rawal, Bavneet Singh, Himanshu Jain. The Kamla Nehru Memorial Hospital: Which Way Forward? (referred as “Hospital Nehru” from here on) case study provides evaluation & decision scenario in field of Strategy & Execution. It also touches upon business topics such as - Value proposition, Organizational structure.

The net present value (NPV) of an investment proposal is the present value of the proposal’s net cash flows less the proposal’s initial cash outflow. If a project’s NPV is greater than or equal to zero, the project should be accepted.

NPV = Present Value of Future Cash Flows LESS Project’s Initial Investment

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Case Description of Kamla Nehru Memorial Hospital: Which Way Forward? Case Study

Kamla Nehru Memorial Hospital (KNMH) is a non-profit, non-government trust organization that is managed by the Gandhi-Nehru family, India's premier political family which gave the country three generations of prime ministers. Members of the family continue to be at the helm of the board. The hospital specializes in the areas of Obstetrics and Gynecology (O&G) and Oncology and has several supporting departments. It is a very reputed hospital in Allahabad, in the highly populated state of Uttar Pradesh in Northern India, and draws patients from nearby states, primarily from the Eastern part of India where infrastructure is largely underdeveloped, and from other developing countries such as Nepal and Bhutan. The hospital is endowed by the Trust. Due to its reach, it attracts funds from governmental and non-governmental agencies as an implementing agency for several of their health schemes and initiatives. The hospital operated independently and without a formal administrative structure for many years. Consequently, the governance as well as the efficiency of hospital operations had been going downhill for some time, with the result that patients were choosing other hospitals and nursing homes over KNMH. Decreasing revenues and inefficient operations led to operational losses. After the next generation of the Gandhi-Nehru family joined the governing board, there was some rethinking at the top about the way forward for the hospital. They decided that the time had come to manage the hospital professionally in order to be able to serve patients in a more efficient and effective manner. It was in this setting that Dr. Madhu Chandra, a pathologist and PhD, who had served at a corporate hospital (Yashoda Hospitals, Hyderabad), was appointed Chief Executive Officer of KNMH. Her goal was to streamline hospital operations and put it back on a growth trajectory.

Case Authors : Naga Lakshmi Damaraju, Prafulla Rawal, Bavneet Singh, Himanshu Jain

Topic : Strategy & Execution

Related Areas : Organizational structure

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Calculating Net Present Value (NPV) at 6% for Kamla Nehru Memorial Hospital: Which Way Forward? Case Study

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 6 %	Discounted Cash Flows
Year 0	(10016084)	-10016084	-	-
Year 1	3469499	-6546585	3469499	0.9434	3273112
Year 2	3954967	-2591618	7424466	0.89	3519907
Year 3	3959307	1367689	11383773	0.8396	3324311
Year 4	3236333	4604022	14620106	0.7921	2563479
TOTAL			14620106		12680808

The Net Present Value at 6% discount rate is 2664724

In isolation the NPV number doesn't mean much but put in right context then it is one of the best method to evaluate project returns. In this article we will cover -

Different methods of capital budgeting

What is NPV & Formula of NPV,
How it is calculated,
How to use NPV number for project evaluation, and
Scenario Planning given risks and management priorities.

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Capital Budgeting Approaches

Methods of Capital Budgeting

There are four types of capital budgeting techniques that are widely used in the corporate world –

1. Net Present Value
2. Internal Rate of Return
3. Payback Period
4. Profitability Index

Apart from the Payback period method which is an additive method, rest of the methods are based on Discounted Cash Flow technique. Even though cash flow can be calculated based on the nature of the project, for the simplicity of the article we are assuming that all the expected cash flows are realized at the end of the year.

Discounted Cash Flow approaches provide a more objective basis for evaluating and selecting investment projects. They take into consideration both –

1. Magnitude of both incoming and outgoing cash flows – Projects can be capital intensive, time intensive, or both. Hospital Nehru shareholders have preference for diversified projects investment rather than prospective high income from a single capital intensive project.
2. Timing of the expected cash flows – stockholders of Hospital Nehru have higher preference for cash returns over 4-5 years rather than 10-15 years given the nature of the volatility in the industry.

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Formula and Steps to Calculate Net Present Value (NPV) of Kamla Nehru Memorial Hospital: Which Way Forward?

NPV = Net Cash In Flowt1 / (1+r)t1 + Net Cash In Flowt2 / (1+r)t2 + … Net Cash In Flowtn / (1+r)tn
Less Net Cash Out Flowt0 / (1+r)t0

Where t = time period, in this case year 1, year 2 and so on.
r = discount rate or return that could be earned using other safe proposition such as fixed deposit or treasury bond rate. Net Cash In Flow – What the firm will get each year.
Net Cash Out Flow – What the firm needs to invest initially in the project.

Step 1 – Understand the nature of the project and calculate cash flow for each year.
Step 2 – Discount those cash flow based on the discount rate.
Step 3 – Add all the discounted cash flow.
Step 4 – Selection of the project

Why Strategy & Execution Managers need to know Financial Tools such as Net Present Value (NPV)?

In our daily workplace we often come across people and colleagues who are just focused on their core competency and targets they have to deliver. For example marketing managers at Hospital Nehru often design programs whose objective is to drive brand awareness and customer reach. But how that 30 point increase in brand awareness or 10 point increase in customer touch points will result into shareholders’ value is not specified.

To overcome such scenarios managers at Hospital Nehru needs to not only know the financial aspect of project management but also needs to have tools to integrate them into part of the project development and monitoring plan.

Calculating Net Present Value (NPV) at 15%

After working through various assumptions we reached a conclusion that risk is far higher than 6%. In a reasonably stable industry with weak competition - 15% discount rate can be a good benchmark.

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 15 %	Discounted Cash Flows
Year 0	(10016084)	-10016084	-	-
Year 1	3469499	-6546585	3469499	0.8696	3016956
Year 2	3954967	-2591618	7424466	0.7561	2990523
Year 3	3959307	1367689	11383773	0.6575	2603309
Year 4	3236333	4604022	14620106	0.5718	1850384
TOTAL					10461171

The Net NPV after 4 years is 445087

(10461171 - 10016084 )

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Calculating Net Present Value (NPV) at 20%

If the risk component is high in the industry then we should go for a higher hurdle rate / discount rate of 20%.

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 20 %	Discounted Cash Flows
Year 0	(10016084)	-10016084	-	-
Year 1	3469499	-6546585	3469499	0.8333	2891249
Year 2	3954967	-2591618	7424466	0.6944	2746505
Year 3	3959307	1367689	11383773	0.5787	2291266
Year 4	3236333	4604022	14620106	0.4823	1560732
TOTAL					9489751

The Net NPV after 4 years is -526333

At 20% discount rate the NPV is negative (9489751 - 10016084 ) so ideally we can't select the project if macro and micro factors don't allow financial managers of Hospital Nehru to discount cash flow at lower discount rates such as 15%.

Acceptance Criteria of a Project based on NPV

Simplest Approach – If the investment project of Hospital Nehru has a NPV value higher than Zero then finance managers at Hospital Nehru can ACCEPT the project, otherwise they can reject the project. This means that project will deliver higher returns over the period of time than any alternate investment strategy.

In theory if the required rate of return or discount rate is chosen correctly by finance managers at Hospital Nehru, then the stock price of the Hospital Nehru should change by same amount of the NPV. In real world we know that share price also reflects various other factors that can be related to both macro and micro environment.

In the same vein – accepting the project with zero NPV should result in stagnant share price. Finance managers use discount rates as a measure of risk components in the project execution process.

Sensitivity Analysis

Project selection is often a far more complex decision than just choosing it based on the NPV number. Finance managers at Hospital Nehru should conduct a sensitivity analysis to better understand not only the inherent risk of the projects but also how those risks can be either factored in or mitigated during the project execution. Sensitivity analysis helps in –

What will be a multi year spillover effect of various taxation regulations.

What are the key aspects of the projects that need to be monitored, refined, and retuned for continuous delivery of projected cash flows.

What are the uncertainties surrounding the project Initial Cash Outlay (ICO’s). ICO’s often have several different components such as land, machinery, building, and other equipment.

What can impact the cash flow of the project.

Understanding of risks involved in the project.

Some of the assumptions while using the Discounted Cash Flow Methods –

Projects are assumed to be Mutually Exclusive – This is seldom the came in modern day giant organizations where projects are often inter-related and rejecting a project solely based on NPV can result in sunk cost from a related project.

Independent projects have independent cash flows – As explained in the marketing project – though the project may look independent but in reality it is not as the brand awareness project can be closely associated with the spending on sales promotions and product specific advertising.

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Negotiation Strategy of Kamla Nehru Memorial Hospital: Which Way Forward?

References & Further Readings

Naga Lakshmi Damaraju, Prafulla Rawal, Bavneet Singh, Himanshu Jain (2018), "Kamla Nehru Memorial Hospital: Which Way Forward? Harvard Business Review Case Study. Published by HBR Publications.