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Detailed research report on Dialysis services with marketshare and growth rates for 28 countries and information on a further 36 (HBI Intelligence)
Database of 36 Dialysis service providers, including profile and major external investors (HBI Intelligence)
Merger and acquisition (M&A) intelligence showing likelihood of sale (HBI Intelligence)
News stories and interviews with Dialysis operators (HBI Deals and Insights)
Events that cover healthcare services globally including Dialysis (HBI 2024)
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Sector ReportDialysis Sector
Updated: April 2024
Executive Summary
EXECUTIVE SUMMARY
Impact of Covid-19
We are in the process of analyzing the impact of Covid on the sector and we should have updates for every country’s growth forecasts for 2020 and 2021 by end of May. This is a partially elective sector and there has been a strong short-term impact which we have already reported in news. A serious recession will further hit demand and leave many investors breaking their bank covenants.
Introduction
Kidney failure or end-stage renal disease (ESRD) is a life-or-death situation which requires dialysis to stay alive until a donor kidney for transplantation can be found. The service has been successfully industrialised in most developed healthcare markets and exhibits one of the highest private sector penetration rates of all forms of healthcare.
The dialysis service and the accompanying costs for drugs and management of co-morbidities ends up being one of the largest cost areas for developed healthcare systems, while a lack of provision in the developing world means a tragic loss of life: 180,000 in India and nearly 50,000 in Nigeria each year. Across the world, the figure is probably several million.
Broadly speaking, dialysis technology has not changed very much in the last few decades.
Opportunities and changing nature of dialysis service delivery
Types of dialysis
In-centre haemodialysis (HD) where patients have their blood cleaned in three four-hour sessions each week by large machines remains the bulk of the global market, at 90% or more.
Peritoneal dialysis (PD), which is generally used by 0-10% of chronic dialysis patients - 10-20% in the more forward-thinking countries - is usually self-administered at home. PD is essentially a pharmaceutical sector since patients usually do it at home without any assistance.
Best practice standards are generally consistent internationally in dialysis, hence why it is the most internationalised and industrialised sector. The session number is consistent throughout developed markets while emerging market patients may undergo fewer sessions because of budget constraints.
Ageing population driving kidney failure
With 70-80% of kidney failure caused by diabetes or high blood pressure, demand is growing as populations age. And in developed markets the average age of dialysis patients is also increasing meaning more co-morbidities and higher acuity patients.
This means that providers need to be able to care for more complex, intense cases. They must think more holistically and increase the competencies of the nurses and nephrologists, as well as work more closely with other hospitals and healthcare providers. Centres providing dialysis increasingly require ‘beds’ instead of ‘seats’.
Despite all this, the big international groups claim to have increased life expectancy of dialysis patients. All of our market growth figures in terms of patients are net of transplants and mortality (of those on dialysis). Very few dialysis operators do transplant surgeries; something the private sector shies away from generally because of complexity. One exception is Diaverum in Argentina. If there is a significant private sector activity in organ transplants it will be part of our hospital market size figures.
See the report for full details on opportunities in the dialysis sector. See the table of contents for the titles of each section.
Our market growth forecasts explained
Our market growth forecasts are based on:
- growth in dialysis patient population, net-of-mortality and net-of-transplants
- tariff adjustments, which might mean that one year is an outlier (the case in Hungary, Portugal, Poland and Saudi Arabia)
- if additional outsourcing is expected
How private operators get paid
Dialysis cost structure and ‘global’ versus service-only reimbursement
Tariffs also vary in inclusivity, sometimes only covering the cost of the session, sometimes plus drugs, food and/or transport and, rarely, management of co-morbidities.
Our private market size figures in the rest of this report will sometimes differ on what is covered and might not always be a like-for-like comparison. Generally we aim to provide the services-only market size but we say where our figures are broader.
Some markets have only been entered by the supplier-service providers (Fresenius, B. Braun, Baxter) and not the service-only ones (Diaverum, Davita) indicating the standard model of reimbursement is one covering services and drugs, making that the right way to measure the market. While in others, like the UK, services and medication are procured separately making a service-only market size figure appropriate. We say when it is which. Even so, aside from a few countries there should not be a massive difference between a service-only figure and one that includes drugs. The cost structure of haemodialysis is typically 82-90% for the service with 10-18% for the drugs.
See the report for full details. See the table of contents for the titles of each section.
Private sector market share and major operators
Private for-profit penetration varies by country. Currently it sits at a third in France and the UK, 25% in Italy and Switzerland, 11-12% in Germany and the Nordic countries and 40% in Saudi Arabia while the private sector treats all but the most complex patients (so 90-95%) in Romania, Hungary, Spain and Portugal.
The big international groups are Davita, which is in 12 countries including the USA; Fresenius Medical Care is in around 40 spanning all continents; supplier B. Braun provides services in 30; Diaverum is smaller than all three but the most internationally diversified; Baxter supplies its products in over 100 countries.
Generally speaking, the dialysis service sector in developed markets covered in this report is dominated by 2-4 of the above groups. In peritoneal dialysis, the private sector is usually a two-horse race between Fresenius Medical Care and Baxter, although a large portion is also done in public hospitals.
See the report for EBITDA figures on the above groups.
Threats to the sector
More peritoneal dialysis
Near-term, more peritoneal dialysis or home haemodialysis could mean less revenue for operators as it has a lower reimbursement per session. But attempts to increase the amount of these treatment modalities have not gone very far outside of small markets like Hong Kong, New Zealand, Finland and cities like Seattle, US. PD penetration generally is a maximum of 15-20% as older, frailer or higher acuity patients find it difficult to follow all the steps to perform PD, which is done several times a week for a shorter period of time. PD patients inevitably go onto HD if they don’t get a transplant as they get older, frailer and develop co-morbidities.
New, smaller sleeker devices like Singapore-based AWAK’s PD device hope to increase peritoneal penetration but operators are sceptical of how far you can go considering that mean age and co-morbidities of patients are both on the up. And in some emerging markets like India, PD is actually more expensive than HD because of the lower economies of scale accrued and the fluid needed is more expensive than for HD. Salaries, the single biggest cost portion of haemodialysis services, are also very low in India and many public patients are often prescribed fewer than three sessions per week.
PD might not be appropriate for the obese, whose larger abdomen makes inserting the catheter more difficult, those with recent abdominal surgeries, or patients with co-morbidities for whom an infection in a non-medicalised setting might be disastrous.
The liquid for PD is classed as a pharmaceutical device making it harder to scale internationally than for equipment, without the right structures in place, as regulations on drugs are often more onerous than on the latter. Hence why the private supply of peritoneal dialysis supplies and service provision is often a two-horse race between Baxter and Fresenius Medical Care.
See the report for full details on threats to the dialysis sector. See the table of contents for the titles of each section.
Sample report pages and data
What we offer
- Instant overview of the EMEA dialysis market and players This report gives you visibility of this important, fast-growing market across 25 countries with market data on all as well as detailed profiles of the Top 50 players.
- Ever green! Updated throughout your subscription As part of our HBI intelligence platform this report is updated throughout the period of your subscription. You will also receive additional news stories and interviews on dialysis throughout the period.
- Insights on business models The report is based on in-depth interviews with many operators. The report also looks at how dialysis players can best build customer loyalty.
- Identify national opportunities We assess opportunities at national level based on the regulatory environment and proposed reforms.
- Size markets This report enables you to swiftly see market sizes and market shares
- Save time and money This report will save you weeks researching these opaque markets and enable you to swiftly identify investment opportunities, new partners and markets.0
Table of Contents
Table of Contents
EMEA overview
Datasets Size of EMEA market 2018 Marketshare of major EMEA players 2018 Comparison of market sizes 2018 Comparison of market growth rates 2016-2020
Introduction
Opportunities and changing nature of dialysis service delivery - Types of dialysis
- Ageing population driving kidney failure - Emerging markets playing catch-up
- Consolidation opportunities - Moving into prevention
- More outsourcing
Our market growth forecasts explained
How private operators get paid - A public payor-private provider market - Outsourced tender contracts
- Standalone clinics - Dialysis cost structure and ‘global’ versus service-only reimbursement - Supply price erodes while services stable or growing
- Being more than “blood-washers” - Tariff variation
Private sector market share and major operators
- EBITDA margins
Threats to the sector - More peritoneal dialysis - More kidney transplants - An artificial kidney/tech disruptors - Exposure to public payor and currency risk - Providers digging their own grave
Albania
Data sets For-profit /private market size and growth rates 2016-2020
Market description and trends.
Bulgaria
Data sets For-profit /private market size and growth rates 2016-2020
Market description and trends.
Croatia
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Czech Republic
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Denmark
Market description and trends.
Finland
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
France
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Germany
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Greece
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Hungary
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Italy
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Netherlands
Data sets Marketshare of major players 2018
Market description and trends.
Norway
Market description and trends.
Poland
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Portugal
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Sweden
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Romania
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Russia
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Saudi Arabia
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
South Africa
Data sets Marketshare of major players 2018
Market description and trends.
Spain
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Sweden
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Switzerland
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Turkey
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
United Arab Emirates
Data sets For-profit /private market size and growth rates 2016-2020
Market description and trends.
United Kingdom
Data sets For-profit /private market size and growth rates 2016-2020 Marketshare of major players 2018
Market description and trends.
Dialysis News & Interviews
Our indepth stories dig deep and cover profit multiples, revenue, EBITDA and CEO thinking.
Indian dialysis group NephroPlus has solidified its position in the Philippines with the acquisition of Renal Therapy Solutions, a six-clinic provider....
Multinational dialysis giant Diaverum has entered the Greek market with the acquisition of six clinics. HBI hears the group has plans to consolidate more of the market and become the country’s best quality provider....
The deconsolidation of multinational dialysis giant Fresenius Medical Care (FMC) from German health care conglomerate Fresenius Group has been completed. This means FMC is now a regular limited liability stock corporation; Fresenius Group still holds the large...
In a rapidly opening up Saudi market full of opportunities, how attractive is the dialysis sector? HBI hears the answer is less straightforward than you might expect....
Germany-based healthcare conglomerate Fresenius SE is trading at its highest share price in over a year – and three high-profile investment banks predict things will get even better....
Investors had a mixed reaction to Fresenius’ half-year results, which saw the firm perform poorly on a group-level, but the core businesses highlighted by the restructuring plan perform well. The company did not confirm rumours of divestments....
The UK NHS was once globally revered, but cracks are showing as it marks seventy-five years and a question mark hangs over its future. HBI asks half a dozen experts what role for-profits have in its future - and whether it will it last another 75 years....
Database of 36 Dialysis service providers
HBI has built a unique database of the Top 4,000 operators globally in health care services. As part of this, we have identified the top 36 Dialysis operators in Europe and will soon add the major players in Emerging Markets.
Profiles include revenue/sales data as well as EBITDA and other profit margins where known. They also cover private equity ownership with dates and mergers and acquisitions.
Mergers & Acquisition (M&A) Intelligence
Our deal pipeline shows how likely all private equity and some privately companies are to sell based on algorithms and journalistic know-how.
HBI 2024 – the only CEO-level conference to cover healthcare services globally
HBI 2020 – the only CEO-level conference to cover healthcare services globally
In 2019 this event brought together 700 delegates from over 40 countries. Over 60% are CEO level and they included 150 specialist investors in health care services. HBI 2020 includes a session on AI, Big Data and Operations, in which the CEO of Diaverum will talk freely about how they are deploying AI and big data to improve efficiency and achieve care standardization.
Other sessions look at trends in the investment and merger and acquisition, digital health and telehealth.
Contact us in the UK on 0207 183 3779 for more information.
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