Who are the biggest health care services companies in EMEA? For the third year running we have compiled a list of the Top 100 companies by revenue from HBI Intelligence’s database, which includes 5,000+ health care services operators across Europe, the Middle East and emerging markets across Asia and Latin America. The Top 100 shows these companies’ sales relating to health care service activities in EMEA only.
This year’s ranking is based on revenue figures for 2022, the year which saw the Covid pandemic and measures to tackle it wind down. In many ways it was back to ‘business as usual’, with elective care activity returning to hospitals as lockdowns ended, labs groups winding down widespread Covid testing and occupancy rates in nursing homes beginning to return to pre-pandemic levels.
But Russia’s invasion of Ukraine and the subsequent increase in inflation and interest rates hit the sector hard. The highest inflation rates in decades meant profit margins were squeezed for many groups, and the highest interest rates since the Great Recession meant big acquisitions came to almost a standstill in the latter part of the year. It was also a year which saw a scandal of unprecedented scale hit the French nursing home sector, centring around pan-European French nursing home giant Orpea.
Despite this, total revenue across the Top 100 was up 7% on the previous year, to €133bn. It remains clear that the for-profit sector plays a crucial role in health care provision across EMEA, one that will likely only strengthen in the years to come.
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The top five groups – Germany-based conglomerate Fresenius (which owns hospital giants Helios and Quirónsalud in Germany and Spain respectively), multinational hospital group Ramsay, German hospital group Asklepios, and French elderly care giants Orpea and Clariane (formerly Korian) – are all in exactly the same positions as last year.
Revenues in the three big hospital groups have remained strong despite the fact Fresenius’ German hospital assets and Ramsay’s French ones took something of a knock in their profitability, due to inflation. However there are some key factors which meant they retained their viability as businesses. In Fresenius’ case, its ownership of Quirónsalud, the largest hospital group in Spain, keeps it profitable, and while Ramsay’s French connection is tricky, it also holds assets in Australia, the Nordics and the UK (the latter was where it acquired mental health specialists Elysium and will see much more outsourcing in 2023 and beyond as the government attempts to tackle the backlog).
The fact that the two French elderly care giants Orpea and Clariane remain firmly in the top five is notable given the scandal that shook the sector throughout 2022, in the wake of which both companies saw massive drops in their share prices. Orpea was at the centre of this, and began divesting away from multiple geographies as a result. Rival French nursing home operators Domus Vi and Colisee also seem to have done well in spite of the scandal, having jumped from 17th to 13th and 33rd to 23rd respectively. Both have been busy acquiring since 2021.
Most of the biggest movers are companies that have been busy acquiring or doing big sell-offs. French hospital group Vivalto Sante is up 23 places, to number 12, having doubled its revenue, to €2.2bn, in 2022. This was due to its significant international expansion through big acquisitions: it bought Spanish hospital chain Ribera Salud from US managed care giant Centene (incidentally Centene is down 15 places, to 27, because of this) and Portuguese hospital chain Lusiadas Saúde, as well as Swiss outpatient group Clinique CIC. German post-acute rehab provider Median Kliniken is up 25 places to number 16, having almost doubled its revenue, to €1.9bn, after its owner Waterland Private Equity merged it with UK rehab company Priory Group.
Other big hospital players such as Portugal’s Luz Saúde, Italy’s San Donato, and Asian hospital giant IHH, dropped several places. Greater emphasis on outpatient care, the end of Covid, staffing issues, and the growth of other health care markets, may have contributed to this.
Some of the changes are down to HBI refining its revenue estimates. UK elderly care group HC-One and German homecare group B. Braun Avitum are up 37 and 32 places respectively. It’s also worth noting that Nordic group Aleris’ drop of 16 places, to 71, is purely due to the fact that the Swedish Krona lost a significant amount of its value against the Euro in 2022.
The share of revenue by sub-sector is broadly similar to last year, with hospitals, elderly care and labs dominating. But some of the smaller sub sectors have seen significant changes, largely due to new entrants. Medicalised homecare saw the biggest increase, more than doubling its total revenue. This is due in part to Deutsche Fachpflege, in at 73 with revenue of €620m. Imaging services saw its revenue grow by 86% because of French network Groupe Vidi, in at 38 with revenue of €1.1bn. As well as being part owned by the radiologists in the network, Groupe Vidi is also part owned by private equity firm Kartesia.
Primary care and ophthalmology also saw significant increases, of 60% and 29% respectively. This isn’t too surprising given that PE investors have become increasingly interested in primary care and that demand for ophthalmology has been steadily growing due to an ageing population.
Labs saw a slight decrease, of 6%, due to reduced Covid testing in 2022 (expect a much bigger decrease for 2023!)
When looking at revenue by country of origin, Germany and France account for more than half of the total revenue of all 100 companies. This doesn’t mean that more than half the revenue was generated in Germany and France of course, as big French and German companies like Orpea and Fresenius have significant operations in other countries. But it does highlight the dominance of the two biggest EU countries in the pan-European health care services market (Spain accounted for just 1.3% of the total revenue).We would welcome your thoughts on this story. Email your views to David Farbrother or call 0207 183 3779.