Financial Resilience of Listed Hospital Companies in India Across Pre-COVID-19, COVID-19-Affected and Recovery Periods: A Longitudinal Ratio-Based Study.

BACKGROUND: COVID-19 created operational and financial pressure for hospitals. Financial resilience became important because hospitals require stable profitability, liquidity, debt-servicing capacity and market confidence to maintain services. Limited evidence is available on the financial resilience of listed hospital companies in India across pre-COVID-19, COVID-19-affected, and post-COVID-19 recovery periods. This study assessed period-wise differences in selected financial ratios, using a repeated-measures design that accounts for company-level clustering, to identify indicator-based evidence of financial resilience among selected listed hospital companies in India.

MATERIALS AND METHODS: This retrospective longitudinal secondary-data study used publicly available financial ratio data. Seven listed hospital companies with 10 years or more of comparable ratio data were included, out of an initial universe of 21 candidate companies. Final analysis covered 77 company-year observations from FY2015-16 to FY2025-26, classified as pre-COVID-19, COVID-19-affected, and post-COVID-19 recovery. Twenty-one non-redundant financial ratios covering profitability, liquidity, solvency, efficiency, market valuation, and per-share performance were analyzed (one originally planned outcome, market capitalization/net operating revenue, was excluded as mathematically identical to price/net operating revenue for a given company). Because the same seven companies were measured repeatedly across all three periods, each company's period-level mean was used as the unit of comparison, and the Friedman test (with company as a repeated-measures block) was used for period-wise comparison, with Wilcoxon signed-rank post hoc tests for significant ratios. Holm correction was applied across all 21 omnibus tests.

RESULTS: The Friedman test showed significant period-wise differences in 5 of 21 financial ratios after Holm correction. Market valuation indicators (enterprise value (EV)/net operating revenue, price/net operating revenue) and per-share/earnings indicators (basic earnings per share (EPS), cash EPS, book value per share) showed significant improvement, concentrated mainly in the post-COVID-19 recovery period. Profitability ratios (profit before depreciation (PBDIT), profit before interest and tax (PBIT), profit before tax (PBT) and net profit margins, return on equity (ROE), return on capital employed (ROCE), return on assets (ROA)), liquidity ratios, interest coverage, debt-equity, asset turnover, EV/earnings before interest (EBITDA) and earnings yield did not show statistically significant period-wise differences once company-level clustering was properly accounted for.

CONCLUSIONS: Once repeated measurements from the same seven companies are treated as non-independent, listed hospital companies in India showed significant strengthening only in market valuation and per-share/earnings indicators during the post-COVID-19 recovery period, not in profitability or liquidity. Financial resilience, as measured through selected financial ratios, was concentrated in market-facing measures rather than operating performance. Findings should be interpreted as period-wise associations based on publicly available company-level data, not as causal effects of COVID-19, and should not be read as evidence about staffing, access, or clinical quality of care.