Hospital sector across EMEA

You've come to the right place to understand Hospital services in Europe and Emerging Markets. Here is how we can help you:
  • Detailed research report on Hospital services with marketshare and growth rates for 31 countries and information on a further 1,360 (HBI Intelligence)
  • Database of 1,360 Hospital 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 Hospital operators (HBI Deals and Insights)
  • Events that cover healthcare services globally including Hospital (HBI 2020)
  • “A key research tool for Fresenius. Nothing else is gives such a broad, yet structured picture of all the players.”
    Wolfgang Hofmann, Senior Vice president, Fresenius Medical Care
  • “Aetna finds the service really useful. Often insightful on business model innovation and help us in our thinking, particularly about Emerging Markets.”
    Dr Sneh Khemka, Managing Director, Population Health, Aetna International
  • “Awesome, always on the money, full of good information, much used internally.”
    CEO of one of the top five international hospital groups
  • “The best source of information for deals and trends in the global healthcare market.”
    Mr. Stefano Ciampolini, CEO & Co-Founder, Renal Services
  • “A really useful tool for investors. Continually digs out interesting stories and casts light on healthcare services internationally.”
    Dr Mark Wadley, Fund Manager, Visio Capital Management
  • “A fascinating ecosystem of data, information, and perspectives on the private healthcare market. My favourite source of information.”
    Andreas Völkl, Global Marketing Manager - Outcome Studies and Collaboration, Siemens Healthineers
  • “I like the team at HBI, their highly focused, analytical work and their ability to bring senior people from different countries in health care together.”
    Dr. Sanjeev Kanoria, Chairman, Advinia Healthcare
  • “May I congratulate you, very interesting and relevant content.”
    Joe Ryan, CFO, Medicover
  • “Unique focus on private healthcare globally. Always learn something useful about sectors, companies and countries where we invest.”
    Kemp Dolliver, Chief Investment Officer, Cherrystone Hill Capital Management LLC
  • “Really useful in keeping track of transactions across Europe and trends in healthcare services.”
    Irina Stamate-Rocha, Principal, Patron Capital Advisors
  • “Extremely useful view of what is happening in European healthcare”
    Laurent Ganem, CEO, G Square Capital
  • “A great site for keeping up with the healthcare sector. Its excellent search facility also means that it is easy to find older but relevant information about a given company or sector.”
    Rune Aresvik, Co-owner, Vardetun
  • “A really valuable initiative that tracks developments across Europe. If it didn't exist, we'd have had to invent it ourselves.”
    Jeremy Tasker, Head of Healthcare, Colliers International
  • “Gives an excellent overview of the European healthcare industry, very perceptive, written with real insight!”
    Nancy Hollendoner, Industry Consultant, Senior Adviser to Hawkpoint Partners

Sector Report
Hospital Sector

Updated: May 2020

Executive Summary

Detailed research overview on private hospitals
 
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
 
Private hospitals across EMEA together had revenue of nearly €100m in 2018. Yet in Western Europe budgets and tariffs from state or statutory payors are often squeezed, normally to favour outpatient treatment.
 
Similar squeezes can be seen in Poland and South Africa and to a lesser extent Turkey. Functional or wholesale privatisation of public sector facilities remains a definite no-no in most countries with the major (possible) exception of Saudi Arabia and to a lesser extent the rest of the GCC and the partial exception of Germany, Poland, Czechia and Slovakia. In these European countries, it tends to be a slow, ad hoc process often involving smaller, loss-making facilities. The potential opportunities are far larger in the GCC.
 
The for-profit sector faces varying degrees of competition from the public sector. Internationally, the for-profit sector also faces competition from the big branded US academic medical centres such as Mayo, Cleveland and MD Anderson. 
 
Yet some large hospital groups in Western Europe continue to enjoy organic growth. We give organic growth rates by country.

Go east for growth. In 2018, we are told the Finnish and Hungarian markets grew around 10% and Bulgaria spectacularly so at 18%. The Italian market is flat due to savage cuts in tariffs and the Greek market is also stagnant, we hear.
 
See market sizes and growth rates in the full report.
 
For context, the number of hospital beds in Europe is falling year-on-year mainly as technological changes allow more treatments to be done in a day surgery setting. Payors are also clamping down on over-treatment. There is also an increased focus on prevention and health screening generally.
 
From 2000 to 2015, the number of hospital beds per 100,000 inhabitants fell on average by 20% in the EU. However, these falls have been mostly seen in the public sector (figures from the WHO and OECD).
 
We will look at international groups in detail, but it is also worth noting here that the region we’ve described is becoming less discrete. In particular, almost all the big Middle East Players, apart from Mediclinic, are building big hospitals in India where they are treating Indian ex-pats and others who were working in the Gulf.
 
It is also worth noting that in many countries basically any private hospital is referred to as a ‘clinic’ and will have a few beds with most activity done on an outpatient basis. It will also primarily do services not typically done in the hospital setting in the West, like IVF, cosmetic surgery and dentistry.

This is because where you don’t have a developed medical insurance market or co-pay system, private operators will provide services people are more willing to pay cash for, like IVF, dentistry, cosmetic surgery and. Private hospitals in developed, consolidated markets will offer these too, but it will be a much less prominent business segment. 
 
We see this especially in CEE, Southeast Europe and Russia. Facilities tend to be much smaller, with a few beds, and will rarely perform the more complex, capex-intensive areas. Their acute facilities are often centred around maternity and OB/GYN, this being the medical speciality which the average citizen is most likely to be willing and able to pay out-of-pocket for.

The move to outpatient/out of the hospital 

Cost containment in inpatient is hitting margins of all developed market operators, while a move from fee-for-service to DRGs as well as price caps on drugs and implants are affecting those in emerging markets.

Three strategies have emerged:

1) go into new geographies
2) extend the patient pathway
3) position yourself as the quality leader for complex, high-acuity care

But each comes with a unique set of challenges and is yet to prove a winning strategy.
 
See the report for full details on strategies.

Definition: what we mean by hospital/acute care
 
Essentially, we mean any large facility for more complex, acute treatments, typically some form of surgery. (We exclude psychiatry which we include with mental health as a sector). Just about all private hospitals in Europe today still have beds, although this is set to change and a large percentage of revenue for many hospitals today does come from outpatient work. 
  
We also exclude post-acute rehabilitation where it is done in a separate, specialised facility or hospital.
 
Reforms
 
Reforms to increase the role of the private sector in the public healthcare system are usually a long and arduous process, and this is true of developed as well as emerging markets. A payor-provider split in the UK in 2011 has not led to the gains some groups anticipated. Finland’s SOTE reform, which would open up primary care and then acute, was meant to be voted on earl 2019 but has been pushed back after the summer's elections. A move to universal health overage through the introduction of a national health fund has stalled in South Africa, too. But India has moved remarkably quickly on this and its programme launched at the end of September 2018.
 
We can differentiate between hospitals in six main ways:
 
National differences
 
Profitability varies enormously from country to country. Data with numbers on Ebitda margins showing a threefold difference between Portugal and Sweden compared to Russia and GCC.
 
Typically, in NHS countries, for-profit hospitals are viewed as parasites, which can be freely used and abused, whilst in statutory insurance models such as Germany, Netherlands, Switzerland and the GCC, they are much more an integral part of the delivery model.  In Germany, for-profit hospitals are even protected by the constitution and so have to be paid the same tariff as the public sector.
 
National differences then remain the major differentiator when looking at the sector.
 
See the report for full details on national differences, including data.
 
Relationship to doctors
 
In all countries, apart from Germany and named others, the big for-profit hospital groups run some form of hotelier model in which doctors hire the facilities and nursing services to treat their patients. Genolier in Switzerland cites the main advantage of this as “working with several thousand entrepreneurs”.
 
But there are plenty of downsides. The hotelier model means that the ultimate customer for the hospital is the doctor, not the patient. The hotelier model also has the disadvantage that it makes it difficult to control what equipment and consumables use.
 
See the report for full details, including pros and cons, on the hotelier model.
 
Types of procedures
 
In general, for-profit hospitals are elective sausage machines which churn through a series of very similar procedures every day. The exception is Germany where big for-profit groups have large emergency facilities and treat a very wide range of patients.

The elective sausage machine model makes for-profit hospitals far more efficient than a big university hospital, where senior doctors do not know from one hour to the next what patients they will get through the door. However, in emerging markets many hospitals do open training campuses, especially in India. We name the private group opening Dubai’s first university hospital.
 
There has been a strong trend for for-profit hospitals to move into more complex surgery and thus expand what they can offer in the private sector to PMI customers.
 
See the report for full details on the types of procedures in private hospitals, including specific examples and group names.
 
Who pays, who is the customer?
 
Who pays, who is the customer?  There are five possible income streams for hospitals – own country NHS or state payors, statutory insurers, private medical insurers, corporates, private individuals and other state payors.
 
i) State NHS payors are perhaps the least reasonable.
 
ii) Statutory insurers are often engaged in a battle over individual treatment costs.

iii) Private medical insurers, like statutory insurers, are engaged in a constant battle to contain costs and stop over-charging.  
 
iv) The direct corporate market.
 
V) Cash paid by individuals: Typically, these patients pay the most for the least.
 
Vi) Other state payors
 
See the report for full details on who is the payor and the customer, including data and examples from different countries.
 
The local market
 
Hospitals compete internationally for cash patients and other state payors, and they are controlled by national rules and politics. But the decision to buy a hospital is made mainly on local grounds.
 
See the report for full details on the local market, including UK examples.
 
International players versus national players
 
The hospital market is becoming increasingly international.
 
We can differentiate here between different types of international player.

i. Genuinely Multinational players – large operators with significant market share in more than one market.

ii. Academic Medical Centres – Historically big US not-for-profit groups have struck JVs with foreign operators or governments to either run hospitals or to transfer knowledge.

iii. Wannabe internationals – Increasingly, national players are active in other markets. Excluding the multinationals, just over a third of the 25 groups with 2017 hospital sales of above €300m have got, or have announced, plans for international expansion.
 
 iv. Insurers - Owning hospital chains enables insurers to control costs.

Sample report pages and data
 
What we offer
 
-       Instant overview of the EMEA private hospital market and players This report gives you visibility of this important, fast-growing market across 30 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 private hospitals throughout the period.
 
-       Insights on business models The report is based on in-depth interviews with many operators. It divides players by type: pure play, imaging providers, academic hospitals, verticalised medtech. The report also looks at how hospital 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.

Table of Contents

EMEA overview
 
Dataset  
Size of EMEA market 2018
Marketshare of major EMEA players 2018
Comparison of market sizes 2018
Comparison of market growth rates 2016-2020
 
Global outlook
 
The move to outpatient/out of the hospital
 
Definition: what we mean by hospital/acute care
 
Reforms
 
National differences
 
Relationship to doctors
 
Types of procedures
 
Who pays, who is the customer?
 
The local market
 
International players versus national players
-       Genuinely Multinational players
-       International presence is not core
-       Academic Medical Centres
-       Wannabe Internationals
-       Insurers
Albania
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Bulgaria
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
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
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
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.
 
Ireland
 
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.
 
Morocco
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Netherlands
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Norway
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
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.
 
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.
 
Serbia
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Slovakia
 
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
For-profit /private market size and growth rates 2016-2020
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.
 
Ukraine
 
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
Marketshare of major players 2018
 
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.

Hospital News & Interviews

Our indepth stories dig deep and cover profit multiples, revenue, EBITDA and CEO thinking.

2,068 news stories on Hospital.

Spanish for-profits demand COVID compensation 44h ago

For-profit hospitals and clinics in Spain are facing bankruptcy and closure unless urgent payment is made for work done and financial difficulties faced during the coronavirus pandemic over the last three months, according to The Spanish Private Health Allianc...

LATAM operators told 'agree COVID fees or face nationalisation' 44h ago

For-profits in Peru were told to agree fees for treating pandemic patients or face effective nationalisation - the taking over of their administration and caseload for the duration of the COVID crisis....

COVID takes shine of Apollo's Q4 results 44h ago

The Q4 results of India's largest hospital group by revenue, Apollo Hospitals, show the effect of a falling footfall, deferred electives and the loss of medical tourism will make for a troubling start to FY21....

COVID crisis will present rollup opportunities in Greece 44h ago

Greece has never been the most buoyant of markets for healthcare services operators, with limited PMI penetration and problems in the Greek economy limiting out-of-pocket spending. We speak to a Greece-based consultant to find out more about how COVID is affec...

HBI Exclusive interview: NMC Health's acting CEO Michael Davis on the future of the business 3d ago

NMC acting CEO Michael Davis speaks publicly for the first time about the future of under-fire NMC Health. In this exclusive interview, we ask about a possible sale of all or part of the business, and whether and how NMC might recover from its present position...

Health care values look high 5d ago

Analyst forecasts suggest that healthcare sector valuations have been largely unaffected by the crisis, with EMEA hospitals and medtech stocks now being more expensive than before the Covid outbreak, both on an EBITDA and PE multiples basis....

Exclusive: Steward’s International CEO on its future in Malta 5d ago

Now that Steward Health Care has been bought by its doctors, what future does it face in Malta where the deal it inherited to run almost half the country’s public hospitals had attracted scrutiny? HBI talks exclusively to Dr Armin Ernst, CEO and President of...

Aster shows Covid impact on India and GCC 1w ago

Thanks to Covid, Aster DM, the GCC to India clinic, hospital and pharmacy chain, saw a 25% drop in revenue across both geographies in April. May and June have seen improvements with a return to normal expected in the autumn, providing there is no second wave. ...

From homecare to hotels 2w ago

In Argentina a domiciliary homecare group has taken over three hotels to offer accommodation to Covid-symptomatic patients. What does this say about the wider links between hotels and care homes in Emerging Markets?...

Database of 1,360 Hospital service providers

HBI has built a unique database of the Top 3,700 operators globally in health care services. As part of this, we have identified the top 40 hospital 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 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 digital and outpatient transformation in private hospitals and internationalization and the balance of power with payors.
 
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.