Al Masah Capital: MENA Healthcare Sector

April 2014
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MENA Healthcare Sector

EXECUTIVE SUMMARY
It is often said that a healthy body bears a healthy mind. This saying holds great
significance for the MENA region, where several countries are targeting to become
knowledge-driven economies in their bid to sustain/enhance growth. However, in order
to become a knowledge-driven economy, MENA countries need to focus on the health
related aspects of the general populace.

Countries like Hong Kong, Singapore and Japan are perfect examples of how health and
economic prosperity go hand in hand. A Bloomberg survey ranked these countries,
which have firmly marked their place on the developed world map, the top three based
on the efficiency of their healthcare systems. Bloomberg rated the healthcare systems
using three criteria: (1) average life expectancy; (2) relative per capita cost of healthcare
or percentage of GDP per capita; and (3) absolute per capita cost of healthcare.

Basing our case on the above, we construe that if MENA countries wish to be counted
among the leaders of tomorrow, they need to ensure that their healthcare systems
function properly and the healthcare needs of their residents are satisfactorily met.

The MENA region spends about 4.0% of its GDP (or USD329 per person) on healthcare,
compared to 14.3% (USD3,373) by the Americas and 9.3% (USD2,217) by Europe. On an
average, the region allocates 8% of government expenditure toward healthcare, lower
compared to developed countries like the US (20%), Germany (19%), Japan (18%) and
the UK (16%). Within MENA, allocation toward healthcare is high, particularly in Jordan,
Tunisia, Bahrain, and the UAE. Unfortunately, the results so far have not been very
encouraging for most countries, except the UAE, which has been exhibiting good
progress.

In the MENA region, provision of healthcare is generally perceived as the responsibility

of governments, reducing the role of the private sector to a large extent. The WHO data
suggests that governments in MENA bear ~64% of total healthcare costs in the region.

According to our research, MENA is a huge untapped healthcare market.

We forecast the MENA healthcare market to be worth USD144 billion by 2020. The
government/public sector is likely to continue being the dominant force, holding 58% of
the market. The private sector healthcare market is forecasted to be worth USD61 billion
in 2020, more than double the size in 2011. The GCC healthcare market, covering six
countries, is projected to be worth USD69 billion by 2020. The private sectors share is
expected to reach 33% by 2020.

MENA has several positives, particularly its demographic profile. The healthcare needs in
the region are likely to increase significantly, led by a growing and ageing population. As
per the World Bank estimates for the 10-year period 201020, the elderly population
(defined as people over 65 years of age) in the MENA region is likely to witness the
quickest growth of 4.1% per annum, much higher than that in East Asia and Pacific
(3.9%), Southeast Asia (3.6%), Latin America and the Caribbean (3.3%), Sub-Saharan
Africa (3.1%), and Europe and Central Asia (1.4%). The rise in the elderly population
means more business for healthcare providers, as the elderly generally seek more
medical care and have more expensive health profiles than the younger populace.

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MENA Healthcare Sector

Prevalence of lifestyle related problems like diabetes and heart ailments is high in the
region. Incidence of Type 2 diabetes, particularly within GCC, has been found to be
unusually high relative to the rest of the world. According to the WHO, one in three
adults in the UAE is obese, and one out of five people live with diabetes. Additionally,
rising purchasing power in the MENA region, especially GCC, has positively impacted
healthcare spending. Per capita GDP in MENA is projected to grow 5.1% over 201020;
this is likely to further drive healthcare spending in the region.

The MENA healthcare market also has supply side attractiveness in the form of
inadequate healthcare infrastructure. The region lags behind developed countries in
terms of bed count. Taking the US as the benchmark, calculations indicate that the
MENA region would need to add nearly 360,000 beds by 2020. MENA is also far behind
the developed economies such as the UK, Germany, the US and Japan in terms of the
availability of doctors and healthcare professionals. Our calculations indicate that the
region is short of nearly 128,000 physicians, 294,000 dentists, and 1.6 million nurses and
midwifery personnel. By 2020, this shortage would rise to 150,000 physicians, 326,000
dentists and 1.8 million nurses and midwifery personnel.

Moreover, as mentioned earlier, private sector participation in healthcare is low in

MENA. The region has nearly 3,300 hospitals with a capacity of 380,000 beds.
Government-owned hospitals form 64% of the total hospitals and 82% of the bed
capacity, leaving the private sector with 36% of the total number of hospitals and just
18% of the overall bed capacity. Several western healthcare companies have taken note
of the above and are increasing presence in MENA. Within the region, countries like the
UAE and Saudi Arabia already offer world class health facilities through the presence of
brand names like Johns Hopkins, Mayo Clinic, Cleveland Clinic, Harvard Medical
International, Bumrungrad International, Bourn Hall Clinic, Moorfields Eye Hospital,
VAMED and Medical University of Vienna International.

Healthcare opportunities have attracted private equity firms to the region. Over 2004
13, the MENA healthcare sector witnessed 44 private equity buys worth USD1.59 billion
(disclosed value) at the rate of about 45 deals each year. During the period, Al Masah
Capital and Abraaj Group were the most active private equity firms in terms of the
number of buy deals. Al Masah Capital reported eight deals, while Abraaj completed six.
The UAE was the hub of private equity deal activity in the healthcare sector. Nearly 40%
of all deals announced in the MENA during 200413 were with companies based in the
UAE. The pharmaceuticals and diagnostics segments garnered the maximum number of
private equity deals during the period.

Given the favorable demographics, rising government support, higher per capita income,
we feel the MENA healthcare sector would witness higher private equity interest, going
forward.

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MENA Healthcare Sector

MENA ECONOMY
Overview of last years performance
The MENA region is estimated to have grown 2.1% in 2013 compared to 4.6% in 2012, as
The MENA region
grew 2.1% in 2013 lower-than-expected performance of oil exporting countries weighed on the regions
compared to 4.6% in economic growth. These countries were affected by weak global demand for oil amid an
2012 increase in non-conventional oil production in the US and relatively little change in the
price of oil despite supply disruptions in some parts of the MENA region.

The oil-rich GCC region grew 3.7% in 2013 compared to 5.2% in 2012. GDP growth of
non-GCC oil exporting countries also slowed down to 0.2% in 2013 vis--vis 5.6% in 2012.

Oil importing Increasing political uncertainties and delays in reforms affected the oil importing MENA
economies were economies. Despite this, oil importing economies are expected to have registered a GDP
affected by rising growth of 2.8% in 2013 on small improvements in tourism activity (especially in the first
political uncertainty
and delays in reforms quarter) and a recovery in exports in some countries.

Expectations for 2014

Despite significant headwinds due to a fragile political scenario in some of the major
regional economies like Egypt and Tunisia, the IMF projects the MENA regions GDP to
grow 3.8% in 2014, higher than the 2.1% growth experienced in 2013.

Exhibit 1: GDP growth across some of the MENA countries (%)

Jordan
2.8 3.3 3.5
2.6 Kuwait
6.2 Bahrain
6.3
0.8 2.6 4.8 4.4 3.3
11 12 13 14E 2.1

11 12 13 14E
11 12 13 14E
Algeria
2.6 3.3 3.1 3.7 Qatar
13.0
6.2 5.1 5.0
11 12 13 14E
11 12 13 14E

UAE
3.9 4.4 4.0 3.9

Morocco
Saudi Arabia 11 12 13 14E
5.0 2.7 5.1 3.8 8.6
Egypt 5.1 3.6 4.4

11 12 13 14E 1.8 2.2 1.8 2.8

11 12 13 14E
Oman
11 12 13 14E 5.1
4.5 5.0 3.4

11 12 13 14E

Source: IMF, Al Masah Capital Research

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MENA Healthcare Sector

GDP growth in 2014 would largely be driven by the oil exporting countries, including the
2014 looks promising
due to high oil prices GCC nations, which are likely to witness higher GDP growth of 4.1% in 2014 on high oil
and a steady flow of prices and a steady flow of government spending on development. Growth in non-GCC
government spending oil exporting countries is estimated to be 3.9% versus 0.2% over the same period.
on development
Saudi Arabia, the largest economy in MENA, is projected to grow 4.4% in 2014, led by an
increase in oil production as well as growth in its non-oil sectors. This indicates a
significant increase from the 3.6% growth projected by the IMF for 2013. Continued
government spending is likely to lend impetus to the non-hydrocarbon sector, which is
slated to contribute ~17% to total export earnings in 2015.

The UAE is expected to report a GDP growth of 3.9% in 2014, mainly driven by increased
The UAE is basking in
the glory of winning investments, a favorable demographic profile (rapidly growing population base), stable
the hosting rights for political environment, and improved trade relations with neighboring GCC states.
EXPO 2020, among Hospitality, manufacturing, trade, and logistics would be the primary drivers of growth in
others
the non-hydrocarbon sector during 2014. Preparations for the Dubai EXPO 2020 are also
expected to accelerate growth.

Egypts economy is expected to grow 2.8% in 2014 versus 1.8% in 2013. The countrys
economy has been projected to recover, following relative stability on the political front.
Economic assistance from Saudi Arabia, Kuwait, and the UAE helped ease pressure on
the economys fiscal position. The three GCC countries have pledged a total aid of USD12
billion to boost Egypts economy.

GDP growth in Qatar is Qatar is expected to report GDP growth of 5.0% in 2014, almost unchanged from 5.1% in
expected to remain 2013. Despite saturation in the hydrocarbon sector, growth is likely to be strong in
stable even in 2014 cement and metal production, driven by increasing construction activity and the rapidly
growing manufacturing sector. Moreover, the USD140 billion spend on infrastructure
projects, including construction of airports, roads and stadiums, partly in preparation to
host the World Cup in 2022, would facilitate growth.

Kuwait is expected to report 2.6% GDP growth in 2014, aided by quick decisions from
the new cabinet, expansion of the non-hydrocarbon segment, increase in government
The new cabinet expenditure, rising domestic consumption, and higher foreign direct investment. Political
would provide Kuwait wrangling, lower crude output, and lack of economic progress had hurt growth in 2013.
a jumpstart in 2014
GDP growth for Oman has been set at 3.4% for 2014 due to lower oil revenue. However,
rising government expenditure, a robust banking system (with a system-wide capital
adequacy ratio of 16% and gross non-performing loans at 2.1%), coupled with the
governments efforts to expand the labor-intensive SME sector, would drive growth of
the non-oil economy.

Bahrains economy is expected to grow 3.3% in 2014, due to strong performance by the
non-hydrocarbon sectors like tourism & leisure and finance. Increase in government
spending, coupled with aid received from GCC states, is likely to boost the non-
hydrocarbon segment.

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MENA Healthcare Sector

GENERAL OVERVIEW OF THE MENA HEALTHCARE

SECTOR
Global healthcare sector
Our workings on data available from the World Health Organization (WHO) indicate that
The global healthcare
sector was worth the global healthcare sector was worth USD5.9 trillion in 2010, accounting for
USD5.9 trillion in 2010 approximately 9.2% of the global GDP, or per capita healthcare spend of USD941.

Healthcare spending in mature and high-income economies was much higher than that
in the lower-middle-income and low-income nations. In high-income economies (taken
as a group), total health expenditure increased to USD4,828 per capita in 2010 from
USD2,567 per capita in 2000, a compound annual growth rate (CAGR) of 6.5% vis--vis
the global average of 6.9%. In contrast, over the same period, health expenditure in
upper-middle-income countries increased at 12.8% per annum to USD384 per capita
from USD115. In high-income economies (taken as a group), total healthcare
expenditure stood at 12.4% of GDP in 2010 compared to 9.9% in 2000. The Africa,
Southeast Asia, and Eastern Mediterranean regions continued to spend the lowest on
healthcare as a percentage of GDP.

Healthcare spending in Exhibit 2: Healthcare spending across the globe

mature and high- Healthcare spend as % of GDP Per capita spend (USD)
income economies was
12.4% 4,828
much higher than that High Income
in the lower-middle- 6.0% 384
Upper Middle Income
income and low-
4.3% 72
income nations Lower Middle Income

Low Income 5.3% 28

14.3% 3,373
Region of the Americas
9.3% 2,217
European Region
9.2% 941
Global Average
3.5% 920
GCC Region
6.4% 579
Western Pacific Region
4.0% 329
MENA Region

Eastern Mediterranean Region 4.5% 182

Southeast Asia Region 3.8% 135 2010

African Region 6.2% 89 2000

Source: WHO, Al Masah Capital Research

In 2010, the US spent The Americas (comprising 35 countries, including the US, Canada and Brazil), led the
17.6% of its GDP on regions in terms of healthcare spend as % of GDP and on a per capita basis. However,
healthcare compared
country-wise, the US was the worlds largest healthcare market; in 2010, it spent 17.6%
to 4% by MENA
of its GDP on healthcare.

In comparison, the MENA healthcare market is small and underdeveloped. In 2010, the
MENA region spent 4.0% of its GDP (about USD72 billion) on healthcare, or USD329 per

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MENA Healthcare Sector

person. Healthcare spending in GCC stood at 3.5% of the GDP (about USD40 billion), or
USD920 per person, in 2010.

Healthcare is one of the fastest growing sectors worldwide. The healthcare business
comprises clinics, laboratory and diagnostic facilities, pharmaceutical manufacturers and
retailers, hospitals, medical equipment manufacturers and health insurance companies.

Healthcare in MENA is largely provided by the government

Healthcare markets in MENA and GCC are predominantly driven by governments, which
Governments in MENA
bear ~64% of the total account for a major share of total healthcare expenditure. Our workings on the data
healthcare costs in the available from the WHO indicate that governments in MENA bear ~64% of the total
region healthcare costs in the region, higher than the global average of 60%.

However, the governments share of healthcare expenditure in MENA is lower than that
in the UK (83%), Japan (80%), and Germany (76%).

Exhibit 3: Government share of healthcare spend (2011)

100%
17% 20% 24% 27%
80% 36% 40% 44%
54%

60%

40% 83% 80% 76% 73%

64% 60% 56%
46%
20%

0%
UK Japan Germany GCC MENA Global China US

Government Private

Source: WHO, Al Masah Capital Research

In Saudi Arabia, the largest economy in the MENA region, the government (through the
Ministry of Health) finances 69% of total healthcare costs. The governments share in
healthcare expenditure is high in Kuwait (82%), Oman (81%), Algeria (81%), Qatar (79%),
and the UAE (74%).

Expenditure on healthcare in the region is low by global

standards
Healthcare expenditure in the MENA region is low in terms of percentage of GDP and on
MENA per capita per capita basis. The region spends 4% of its GDP on healthcare, lower than the global
healthcare average of 9.2% and that of the developed countries like the US (17.6%), Germany
expenditure of USD329
(11.5%), Japan (9.2%), and the UK (9.6%).
is lower than the
global average of Healthcare expenditure on per capita basis in the MENA region stands at USD329, lower
USD941
than the global average of USD941 and that in some of the developed countries like the
US (USD8,510), Germany (USD4,656), Japan (USD3,967) and the UK (USD3,543).

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MENA Healthcare Sector

Exhibit 4: Expenditure on healthcare in MENA is low (2010)

8,510 Expenditure per capita (USD)

4,656
3,967 3,543

941 920
329 222

17.6%

11.5%
9.2% 9.6% 9.2%

4.0% 5.0%
3.5%

US Germany Japan UK Global GCC MENA China

Source: WHO, Al Masah Capital Research

Nearly two-thirds of all hospitals in MENA are government

owned
Our workings indicate that the healthcare needs of the people in MENA are currently
Healthcare needs of
the people in MENA is met through 3,300 hospitals with a capacity of 380,000 beds. The share of government-
currently met through owned hospitals (which form 64% of total hospitals in MENA) is the most in countries
3,300 hospitals, 64% of like Egypt, Algeria, and Saudi Arabia.
which are government
owned Approximately 80% of the government-owned hospitals in MENA are located
in Egypt (52%), Saudi Arabia (12%), Algeria (12%), and Morocco (6%).
Similarly, 80% of the privately-owned hospitals in the region are located in
Egypt (43%), Algeria (15%), Saudi Arabia (12%), and Lebanon (11%).

Exhibit 5: Most of the hospitals in MENA are government owned

Government owned hospitals Privately-owned hospitals

64% 36%

Egypt 52% Egypt 43%

Saudi Arabia 12% Algeria 15%

Algeria 12% Saudi Arabia 12%

Morocco 6% Lebanon 11%

Tunisia 5% Jordan 5%

Libya 5% Libya 5%

Oman 3% UAE 5%

Others 6% Others 4%

Source: Al Masah Capital Research

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MENA Healthcare Sector

In terms of patient bed capacity, government hospitals (which are generally thrice as big
as private hospitals) account for 82% of the overall beds.

Government hospitals in Kuwait, Qatar and Bahrain are relatively big in terms
of the number of patient beds.
Within the private hospitals category, average number of beds is on the higher
side in countries like Tunisia, Morocco, and Saudi Arabia.

The healthcare system of two MENA countries is ranked much

above that of the UK and US
In 2013, Bloomberg conducted a study to ascertain the efficiency of healthcare systems
Hong Kong has the 1
most efficient of countries worldwide. It released a final list ranking 48 countries using three criteria:
healthcare system in (1) average life expectancy; (2) relative per capita cost of healthcare or percentage of
the world GDP per capita; and (3) absolute per capita cost of healthcare.

Hong Kong, with an efficiency score of 92.6, topped the list based on an average life
expectancy of 83.4 years, a relative cost of healthcare of 3.8% of GDP, and healthcare
expenditure per capita of USD1,409. Singapore and Japan came second and third, with
efficiency scores of 81.9 and 74.1, respectively.
Healthcare systems of
Libya and UAE came Two countries from the MENA region Libya and UAE with ranks 12 and 13,
ahead of the UK, respectively, came ahead of developed countries like the UK, Canada, France, Germany
Canada, France, and the US. Despite large spending, the US was found to have one of the least efficient
Germany and the US
health systems in the developed world.

1
Bloomberg only considered countries with a population of at least five million, a life expectancy of
at least 70 years, and a GDP of at least USD5,000

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MENA Healthcare Sector

THE MENA HEALTHCARE MARKET IS EXPECTED TO BE

WORTH USD144 BILLION BY 2020
The MENA healthcare market is forecasted to be worth USD144 billion by 2020. The
The MENA healthcare
market is forecasted to government/public sector is likely to continue being the dominant force, holding 58% of
be worth USD144 the market. The private sector healthcare market is forecasted to be worth USD61 billion
billion by 2020 in 2020, more than double the size in 2011.

The GCC healthcare market, covering six countries, is obviously smaller, and is projected
to be worth USD69 billion by 2020. The private sectors share is expected to reach 33%
by 2020.

The GCC healthcare Exhibit 6: MENA and GCC healthcare market by 2020
market is projected to
be worth USD69 billion
(in USD billion)
by 2020
2011 52 29
MENA

2020 83 61

Government

Private
2011 34 13
GCC

2020 46 23

0 25 50 75 100 125 150

Source: WHO, The World Bank, Al Masah Capital Research

The market size estimation was carried out using data on population, healthcare
expenditure (both in terms of % of GDP and on per capita basis), ratio of government and
private expenditure on healthcare, GDP and inflation.

Being conservative, we maintained healthcare expenditure by governments (in terms of

% of GDP) at 2.4%, as was in 2011. However, for private sector expenditure on
healthcare, we used our estimate of private per capita spend on healthcare of USD242 in
2020 and multiplied the same with the population of 253 million during the year.

Refer appendix for country-wise market size details.

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MENA Healthcare Sector

GROWTH DRIVERS FOR THE HEALTHCARE SECTOR

MENA enjoys favorable demographic conditions
The MENA region is likely to experience a sharp increase in healthcare needs, primarily
led by a growing and ageing population. The rise in elderly population means more
business for healthcare providers, as the elderly generally seek more medical care and
have more expensive health profiles than the younger populace.

According to the World Bank estimates for the 10-year period 201020, the MENA
The population growth
rate in MENA is among region is likely to witness a population growth rate of 1.4% per annum, much higher
the highest globally than the growth rates experienced in Southeast Asia (1.0%), Latin America and the
Caribbean (1.0%), East Asia and Pacific (0.5%), and Europe and Central Asia (0.2%). Only
Sub-Saharan Africa is projected to achieve a higher population growth rate of 2.4% over
the period.

In addition, given the improvements in life expectancy and decline in mortality rates,
demographic profile of the MENA region is likely to undergo a shift.

As per the World Bank estimates for the 10-year period 201020, the elderly population
(defined as people over 65 years of age) in the MENA region is likely to witness the
quickest growth of 4.1% per annum, much higher than that in East Asia and Pacific
(3.9%), Southeast Asia (3.6%), Latin America and the Caribbean (3.3%), Sub-Saharan
Africa (3.1%), and Europe and Central Asia (1.4%).

The elderly population Exhibit 7: Rise in population (CAGR %) over 201020

in MENA is likely to
grow 4.1% over 2010 Overall Population (CAGR) Elderly Population (CAGR)
20
Middle East and North Africa 1.4% 4.1%

East Asia and Pacific 0.5% 3.9%

Southeast Asia 1.0% 3.6%

Latin America and the Caribbean 1.0% 3.3%

Sub-Saharan Africa 2.4% 3.1%

Europe and Central Asia 0.2% 1.4%

Source: WHO, Al Masah Capital Research

Life expectancy (at birth) for the MENA region has increased past 70 years from as low
as 47 years in 1960. Similarly, mortality rates in the region have dropped to below 25
infants per 1,000 live births from 260 in 1960.

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MENA Healthcare Sector

There is high prevalence of lifestyle related problems like

diabetes, heart ailments in the MENA region
Lifestyle related diseases like hypertension, diabetes, cancer and heart ailmentsan
Lifestyle related
diseases have become outcome of sedentary lifestyle and unhealthy diethave become a common feature in
common in the region the region. Prevalence of Type 2 diabetes, particularly within GCC, has been found to be
unusually high relative to the rest of the world. According to the WHO, one in three
adults in the UAE is obese, and one out of five people live with diabetes.

The WHO report also states that the number of deaths among the 3070 age group due
to cardiovascular diseases and diabetes for GCC stands at 339 per 100,000, nearly 2.5x
that of the US.

Mortality rates due to Exhibit 8: Mortality rates among adults due to cardiovascular diseases and diabetes
cardiovascular
diseases and diabetes 400
in MENA are quite (per 100,000 population)
339
high

300 273
245

199
200

137
102
91
100
68

0
GCC MENA Global China US Germany UK Japan

Source: WHO, Al Masah Capital Research

Countries within MENA with high mortality rates among adults due to cardiovascular
diseases and diabetes include Oman (504), Jordan (418), Saudi Arabia (401), Libya (320),
and Egypt (303).

Governments are offering support

Governments have increased spending on healthcare

Of late, MENA countries have increased their budgetary spends on healthcare. Aided by
MENA countries have
increased their large budgetary surpluses, GCC governments, in particular, have been allocating large
budgetary spend on sums to improve their healthcare infrastructures. Saudi Arabia, for instance, upped its
healthcare 2014 budgetary allocation for healthcare to USD28.8 billion from USD7.9 billion in 2009.
The Kingdom is building 34 new hospitals and healthcare centers, in addition to
continuing work at 132 hospitals and five medical cities currently under construction.
The five medical cities are expected to add 6,200 new hospital beds in the Kingdom.

Looking at the 19952010 period, it is easy to conclude that several of the MENA
countries like Jordan, Tunisia, Saudi Arabia, Morocco, Kuwait and Egypt have been
allocating higher percentage of their budgetary spend toward healthcare.

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Jordan, Tunisia, the Exhibit 9: Government expenditure on health as % of total government expenditure
UAE, and Kuwait have
increased allocations 20%
toward healthcare

16% Jordan

Tunisia

12% UAE

Kuwait
8%
Saudi Arabia

Morocco
4%

0%
1995 1998 2001 2004 2007 2010

Source: WHO, Al Masah Capital Research

However, despite this progress, MENA countries need to boost their budget allocations
for healthcare to make it comparable with the developed countries like the US (20%),
Germany (19%), Japan (18%) and the UK (16%).

Mandatory health insurance

Earlier this year, Sheikh Mohammed bin Rashid, Vice-President and Ruler of Dubai,
Health insurance has
become mandatory in signed a new law requiring compulsory health insurance for all the residents of Dubai.
Saudi Arabia and the The law will be applicable in phases. In the first phase, all companies with 1,000 or more
UAE employees would be required to provide their workers with health insurance by October
2014.

Similar directives were issued in Saudi Arabia and Abu Dhabi in 2005 and 2008,
respectively.

Exhibit 10: Health insurance timeline across Saudi Arabia and the UAE

Saudi Arabia makes Abu Dhabi extends the law to all expatriates Dubai makes
mandatory health health
insurance for all residents Abu Dhabi extends the law to all insurance
nationals mandatory for
Abu Dhabi makes
all residents
mandatory health
insurance for expatriate Dubai makes health insurance
workers mandatory for all expatriate
workers

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Source: Al Masah Capital Research

Health insurance is known to have several benefits: it not only reduces/cuts the burden
on governments and/or the population but also helps enhance the quality of health
services.

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MENA Healthcare Sector

MENA healthcare benefits from high per capita income, leading

to improved literacy and increased healthcare expenditure
Rising purchasing power in the MENA region, especially GCC, has positively impacted
Per capita expenditure
on healthcare in MENA healthcare spending. Over the past decade, overall income levels in the region have
has grown in tandem surged substantially. In 2010, MENA and GCC had a per capita income of USD8,180 and
with the rise in per USD26,197, respectively, compared to USD3,727 and USD12,782 in the beginning of the
capita income
decade. Over the same period, per capita expenditure on healthcare in MENA and GCC
jumped to USD329 and USD920, respectively, from USD127 and USD439 in 2000.

Per capita GDP in MENA is projected to grow 5.1% over 201020; this is likely to further
drive healthcare spending in the region.

Some of the MENA countries are targeting medical tourism

Medical tourism is defined as the process of patients travelling abroad for medical care
and procedures, usually as certain medical procedures are less available or less
2
affordable in their own country .

Governments in the MENA region are realizing the strong potential of medical tourism
The UAE is trying to
promote itself as a hub and rendering the required support to the industry. The UAE, particularly Dubai, is trying
for medical tourism to promote itself as a hub for medical tourism so as to attract foreigners to its hospitals
and specialized clinics.

Joint Commission International (JCI) in the US, one of the world's leading accreditation
organizations, has accredited nearly 100 hospitals in Saudi Arabia and the UAE. JCI
accreditation assures that a healthcare organization meets the highest international
benchmarks.

There are over 100 JCI Exhibit 11: Number of JCI accredited hospitals in MENA
accredited hospitals in
MENA Saudi Arabia 50

UAE 49

Jordan 10

Qatar 5

Lebanon 3

Egypt 3

Oman 2

Kuwait 2

- 10 20 30 40 50 60

Source: JCI accessed in March 2014, Al Masah Capital Research

In a bid to attract foreign patients, the UAE recently announced a new three-month
medical tourist visa, which can be extended twice.

2
Dr. Cornelia Voig, Adjunct Research Fellow, Curtin University

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KEY TRENDS IN THE HEALTHCARE SECTOR

Western healthcare companies are increasing presence in MENA
Within MENA, especially countries like the UAE and Saudi Arabia, offer world class
health facilities through the presence of brand names like Johns Hopkins, Mayo Clinic,
Cleveland Clinic, Harvard Medical International, Bumrungrad International, Bourn Hall
Clinic, Moorfields Eye Hospital, VAMED and Medical University of Vienna International.

Baltimore-based Johns Hopkins is currently associated with six hospitals in the MENA
Western healthcare
companies like Johns region, including three in the UAE (Al Rahba Hospital, Corniche Hospital, and Tawam
Hopkins, Mayo Clinic, Hospital); two in Saudi Arabia (Johns Hopkins Aramco Healthcare and King Khaled Eye
Cleveland Clinic are Specialist Hospital) and one in Lebanon (Clemenceau Medical Center).
present in MENA

Exhibit 12: Western healthcare companies in MENA

Source: Al Masah Capital Research

There is also a shift from curative to preventive care

Governments across the globe are paying due attention to the age old saying
Governments across
the globe are realizing prevention is better than cure. A rise in healthcare costs is forcing most countries to
the importance of shift focus from curative care to preventive care.
preventive care
Curative care refers to the health care practices that treat patients with the intent of
curing them and promoting recovery. Preventive care involves measures taken to identify
and minimize risk factors for disease and screening for early detection of disease.

Let us take an example. Cardiovascular disease is known to be the worlds leading killer
disease, accounting for 30% of deaths in 2010. Preventive care can help reduce the risk
of cardiovascular disease among the population. If people are made to cut their smoking
habits, improve diets and take other primary precautions, a major chunk of this
population and their money could be saved.

MENA has increased focus on medical technology

Globally, there have been substantial advancements in the field of healthcare service
Technology is
changing the face of delivery. From the maintenance of electronic medical records to the use of robotics in
healthcare medical procedures, technology is changing the face of healthcare.

The UAE is trying to keep pace with these advancements. In an interview with Zawya,
the CEO of Saudi German Hospital-Dubai said that the UAE is solidifying its reputation for
healthcare excellence. The use of highly sophisticated world-class technology in its
health system is resulting in faster, smarter and safer treatments, leading to shorter
waiting times and reduced recovery periods for health ailments.

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MENA Healthcare Sector

The UAE is also promoting the use of Mobile health (or mHealth), which uses mobile
The UAE is also
promoting the use of technologies for health research and healthcare delivery. Having launched the use of
mHealth Android tablets in hospitals and specialty centers, the Dubai Health Authority (DHA) is
targeting to include the Electronic Medical Records system. The system would keep
updated patient record on a medical network, which could be used by doctors to check
on patients past records and provide better diagnosis.

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MENA Healthcare Sector

KEY ISSUES AND CHALLENGES FACING THE HEALTHCARE

SECTOR
MENA suffers from inadequate healthcare infrastructure
The MENA region lags behind developed countries in terms of bed count. The bed
MENA has 18 beds per
10,000 people density of 18 (beds per 10,000 people) in MENA is really low compared to that of
compared to the developed nations like the US, Germany and Japan. It is also well below the global
global average of 30 average of 30 beds per 10,000 people.
beds
Taking the US as the benchmark, calculations indicate that the MENA region would need
to add nearly 360,000 beds by 2020.

MENA would need to Exhibit 13: MENA has lesser number of hospital beds for its population
add nearly 360,000
beds by 2020 175
(Beds per 10,000 population) - Last available MENA would need to add 360k beds by 2020

150 Egypt
137
Morocco
125
Algeria
Saudi Arabia
100
82 UAE

75 Others

50 39
30 30 30
21 18
25

0
Japan Germany China US Global UK GCC MENA

Source: WHO, Al Masah Capital Research

Countries like India,

Cost of medical treatment in the region is high
Thailand and
Several Asian countries such as India, Thailand and Singapore offer medical care for a
Singapore offer
medical care for a fraction of the prices in the UAE.
fraction of the prices in
According to Farouk Mohamed, Managing Partner, Grant Thornton UAE, the average
the UAE
cost of a heart bypass surgery in the UAE stood at USD44,000 compared with an average
of USD18,500 in Singapore, USD11,000 in Thailand, USD10,000 in India and USD9,000 in
3
Malaysia .

There is scarcity of doctors and healthcare professionals

The MENA region is far behind the developed economies such as the UK, Germany, US
MENA also faces
scarcity of doctors and and Japan in terms of availability of doctors and healthcare professionals. The average
healthcare number of physicians per 10,000 people in the MENA region is 21, much lower than that
professionals in the developed economies such as the UK (28), Germany (27), and the US (24). Even
the number of dentists per 10,000 people, and the number of nursing and midwifery

3
High cost of healthcare leading to competitive disadvantages in UAE, Grant Thornton

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MENA Healthcare Sector

personnel per 10,000 people in the MENA region is much lower than in developed
economies.

Exhibit 14: MENA is behind developed countries in terms of availability of healthcare personnel

28 27 (Physicians per 10,000 population) - Last available

24 23 21 21
The number of 15 14
physicians per 10,000
people in MENA is
below the global
average UK Germany US GCC Japan MENA China Global

16.3 (Dentists per 10,000 population) - Last available

7.9 7.4
5.3
3.7 3.5 2.6
0.4

US Germany Japan UK MENA GCC Global China

(Nurses and midwifery per 10,000 population) - Last available

114
98 95

41
31 29 29
15

Germany US UK Japan GCC Global MENA China

Source: WHO, Al Masah Capital Research

Taking the US as the benchmark, calculations indicate that the MENA region is short of
nearly 128,000 physicians, 294,000 dentists, and 1.6 million nurses and midwifery
personnel. By 2020, this shortage would rise to 150,000 physicians, 326,000 dentists and
1.8 million nurses and midwifery personnel.

By 2020, MENA would Exhibit 15: By 2020, MENA would largely need additional healthcare personnel in five countries
need to add 150,000
physicians, 326,000 100%
dentists and 1.8
million nurses and 80% Others
midwifery personnel
UAE
60%
Egypt
Saudi Arabia
40%
Tunisia
Algeria
20%
Morocco

0%
Physicians Dentists Nurses & midwifery

Source: WHO, Al Masah Capital Research

Findings reveal that by 2020, most of the healthcare personnel requirements would exist
in Morocco, Algeria, Tunisia, Saudi Arabia and Egypt.

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MENA Healthcare Sector

Private sector participation is low in MENA healthcare

As mentioned in the earlier part of the report, MENA has nearly 3,300 hospitals with a
Private sector owns
36% of total hospitals capacity of 380,000 beds. Government-owned hospitals form 64% of the total hospitals
and 18% of the overall and 82% of the bed capacity, leaving the private sector with 36% of total number of
bed capacity in MENA hospitals and just 18% of the overall bed capacity.

Exhibit 16: Private sector participation in the healthcare sector is low in oil exporting countries

Private sector Oil exporting countries 19% 81%

participation was
found to be low in oil
exporting countries

Oil importing countries 25% 75%

0% 20% 40% 60% 80% 100%

Private Sector Government

Source: WHO, Al Masah Capital Research

Participation of the private sector was found to be low in almost all countries, except
Lebanon and Jordan, which are categorized as oil importers by the IMF. The major
reason for this can be the fact that the governments of hydrocarbon-rich nations (or oil
exporters, as per the IMF) have taken the responsibility of providing healthcare to its
populace, ignoring the need to seek private sector participation.

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MENA Healthcare Sector

PRIVATE EQUITY DEALS IN THE HEALTHCARE SECTOR

Deal activity in MENAs healthcare sector has gained momentum
Over 200413, MENAs healthcare sector witnessed 44 private equity buys worth
Over the last 10 years,
44 private equity buys USD1.59 billion (disclosed value), at the rate of about 45 deals a year. Deal activity
worth USD1.59 billion during the last four years indicates that PE interest in the healthcare sector has
took place in MENAs increased, with the number of PE buy deals expanding to about seven a year.
healthcare sector
Two large deals in the healthcare sector, for which investment values were available, are
discussed below.

In 2010, Ithmar Capital invested USD272.3 million to acquire an undisclosed

stake in Al Noor Medical Group, the largest integrated private healthcare
service provider in Abu Dhabi. Ithmar Capital made the investment through
IthmarFund II.
In 2012, Abraaj Capital bought a large stake in Egypt-based Al Mokhtabar
Laboratories for USD204 million. Al Mokhtabar Laboratories is engaged in
providing diagnostic laboratory services, and pathological and clinical tests for
medical communities. It has branches in Egypt, Sudan and Saudi Arabia.

The rate of PE buy Exhibit 17: PE activity in the MENA healthcare sector picked up during the last 34 years
deals in the MENA
healthcare sector has Disclosed value (USD mn)
expanded during 34
years NA 24 531 322 181 40 285 0.7 207 2.2

Deal count (No. of deals)

9
7
6 6
4 4
3
2 2
1

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Source: Zawya, Thomson Banker, Al Masah Capital Research

Al Masah Capital and Abraaj Group were the most active PE

funds/firms in the sector
Al Masah Capital and
Al Masah Capital Limited (eight deals) and Abraaj Group (six) accounted for the
Abraaj Group were the
most active private maximum number of buy deals announced during 200413.
equity firms in the
Al Masah Capital Limited mostly bought stakes in UAE-based companies like Conceive
sector
Gynecology & Fertility Centre, Mussalla Medical Centre, National Hospital, New National
Medical Center Pharmacy, Reem Medical Group, and Specialist Orthopedic Surgery &
Physical Rehabilitation Clinic. The PE firm also bought a medical laboratory in Kuwait and

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MENA Healthcare Sector

some of the NMC Group hospitals. Al Masah Capital acted through Healthcare MENA
Limited, its healthcare arm.

The Abraaj Group bought stakes in Al Borg Laboratories (Egypt), Al Mokhtabar

Laboratories (Egypt), E3 FZ LLC (UAE), Opalia Pharma (Tunisia), Saudi Tadawi Healthcare
Co (Saudi Arabia) and Unimed (Tunisia). It acted through Infrastructure and Growth
Capital Fund and Al Kantara Fund.

Other private equity firms that displayed high levels of activity in the MENA healthcare
sector included Global Investment House (four deals), TVM Capital (three), and Gulf
Capital (two).

Global Investment Exhibit 18: Most active PE funds/firms in the MENA healthcare sector (200413)
House, TVM Capital,
and Gulf Capital were
the other firms active
in the sector

Source: Zawya, Thomson Banker, Company, Al Masah Capital Research

Countries attracting most investments

The UAE led the region in terms of private equity deal activity in the healthcare sector.
Nearly 40% of all deals announced in the region during 200413 involved companies
based in the UAE. It was followed by countries like Egypt, Tunisia and Saudi Arabia.

UAE was the largest Exhibit 19: UAE was the largest recipient of PE deals in the MENA healthcare sector (200413)
recipient of PE deals in
the healthcare sector Number of Deals Value*

UAE 17 453

Egypt 10 900

Tunisia 5 1.0

Saudi Arabia 5 238

Others 7 0.9

Note: *In USD million and includes disclosed value of deals

Source: Zawya, Thomson Banker, Al Masah Capital Research

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MENA Healthcare Sector

Pharmaceuticals and diagnostics segments garnered maximum

attention from PE investors
Pharmaceuticals and diagnostics segments witnessed a large count of private equity
Pharmaceuticals and
diagnostics segments deals during 200413. Although the deal count for the pharmaceuticals segment has
witnessed high been quite steady, the numbers in the diagnostics segment seem to be improving.
demand from PE
investors Over the last five years, MENA-based private equity firms have bought stakes in
diagnostics companies such as Advanced Laboratory Services (Saudi Arabia), Al
Mokhtabar Laboratories (Egypt), Cardio Diagnostics (Lebanon), Diagnostic Center (Libya),
Medray Open MRI Center (Jordan), Reem Medical Group (UAE), Royal English Laboratory
(Kuwait), and Technoholding Group (Egypt).

Diagnostics segment Exhibit 20: Pharmaceuticals & diagnostics garnered the maximum number of deals (200413)
seems to have
attracted PE investors Number of Deals Value*
interest over the last
few years Pharmaceuticals 11 4

Diagnostics 11 108

Hospitals 6 284

Pharmacy 3 417

Others 13 780

Note: *In USD million and includes disclosed value of deals

Source: Zawya, Thomson Banker, Al Masah Capital Research

MENA healthcare has witnessed a few private equity exits

There were just about five private equity exits in the MENA healthcare sector during the
The healthcare sector
has also witnessed last 10 years. Some of the major exit deals have been discussed below.
some large PE exits
In 2011, Foursan Capital Partners sold its entire stake in Jordan-based Hikma
Pharmaceuticals for an undisclosed amount. Foursan had received stake in Hikma
Pharmaceuticals through its investment in Arab Pharmaceutical Manufacturing
Company, which was acquired by Hikma in 2008.

In 2013, Abraaj Group sold its entire stake in Opalia Pharma to Recordati, an Italy-based
pharmaceutical company. Abraaj had originally invested in Opalia in 2009 through the Al
Kantara Fund. No financial terms were disclosed.

In 2013, Ithmar Capital completed a partial exit from its investment in Al Noor Medical
Company, the largest integrated private healthcare service provider in Abu Dhabi,
through an initial public offering (IPO) on the London Stock Exchange. In 2010, Ithmar
Capital had invested USD272.3 million in Al Noor Medical Company. Ithmar currently
holds ~25% stake in Al Noor Medical Company.

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MENA Healthcare Sector

COMPANIES IN THE HEALTHCARE BUSINESS

MENA healthcare sector has several publicly listed entities
There are about 3035 healthcare companies listed on various bourses across the MENA
The MENA region has
about 3035 publicly region. With a market capitalization of USD1.5 billion, Saudi Pharmaceutical Industries
listed healthcare and Medical Appliances Corp (SPIMACO) happens to be the most valuable healthcare
companies company on the regional stock exchanges. Considering all MENA healthcare companies
with a foreign listing, UAE-based Al Noor Hospitals Group is the most valuable, with a
market capitalization of USD1.8 billion.

SPIMACO, which was established nearly three decade ago, is engaged in production of
medicines and medical appliances for local consumption and export. The company
operates through 18 subsidiaries across Saudi Arabia, Ireland, Egypt and Algeria.
SPIMACO reported a net profit of USD71 million on revenues of USD346 million. In terms
of valuation, the company is available at a price-to-earnings multiple of 19.1 and a price-
to-book multiple of 1.5. Al Noor Hospitals Group, which went public in 2013, is a leading
healthcare provider in Abu Dhabi. The company reported a net profit of USD61 million
on revenues of USD365 million. In terms of valuation, the Al Noor Hospitals stock (listed
on the London Stock Exchange) is available at a price-to-earnings multiple of 26.6 and a
price-to-book multiple of 9.8.

Exhibit 21: Healthcare companies listed on the various stock exchanges in MENA
Market Cap Price-to-Earnings Price-to-Book EV-to-EBITDA
Company Country
USD million TTM Last TTM
SPIMACO Saudi Arabia 1,511.1 19.1 1.5 23.1
Astra Industrial Group Saudi Arabia 1,180.9 15.5 2.3 21.4
Mouwasat Medical Services Saudi Arabia 1,119.9 22.9 4.7 16.5
Dallah Healthcare Holding Saudi Arabia 1,035.2 24.1 3.3 22.4
Gulf Pharmaceutical Industries UAE 869.5 12.3 1.7 13.5
National Medical Care Saudi Arabia 726.5 26.4 3.3 20.9
Egyptian Int. Pharmaceuticals Industries Egypt 536.5 10.4 2.1 7.7
Medicare Group Qatar 517.9 16.5 2.2 14.4
Advanced Technology Co Kuwait 479.6 N/A 3.5 13.3
Gulf Medical Projects Co UAE 403.9 16.1 1.5 15.2
Marocaine Ste de Therapeutique Morocco 300.5 17.6 5.3 11.9
YIACO Medical Co Kuwait 200.0 14.4 1.7 11.8
Medical Union Pharmaceuticals Co Egypt 153.1 6.3 1.2 6.5
Promopharm Morocco 98.9 11.0 2.1 4.4
Safwan Trading and Contracting Co Kuwait 86.1 13.2 1.9 12.9
Average 16.1 2.6 14.4
Source: Thomson Reuters, Data as of Mar 19, 2014

Our data points that the Egypt Stock Exchange (CASE) has the highest number of
healthcare companies listed on the bourse. The six healthcare companies have a
combined market capitalization of ~USD850 million. Saudi Arabia (Tadawul) follows next,
with five companies worth ~USD5.6 billion.

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MENA Healthcare Sector

Performance during the financial crisis

MENA healthcare The MENA healthcare sector weathered the global financial crisis of 200708 relatively
sector weathered the well.
global financial crisis
of 200708 For instance, during FY 2008, Kuwait-based Advanced Technology Co witnessed a 10.3%
jump in revenues and a 6.9% rise in operating profit. Over the same period, Saudi
Arabia-based Mouwasat Medical Services Co reported a 13.4% growth in revenues and a
14.7% rise in operating profit.

Exhibit 22: Revenue and Operating profit of healthcare companies in MENA

Revenue (USD million) Operating Profit (USD million)
Company
FY 2007 FY 2008 % change FY 2007 FY 2008 % change
Advanced Technology Co 147.6 162.7 10.3% 21.6 23.1 6.9%
Mouwasat Medical Services Co 106.9 121.1 13.4% 25.7 29.4 14.7%
Medical Union Pharmaceuticals Co 97.3 107.8 10.8% 22.4 26.3 17.2%
Safwan Trading and Contracting Co 73.5 81.9 11.4% 5.2 7.4 41.4%
Kahira Pharma and Chemical Industries 42.9 48.8 13.7% 7.9 9.0 14.0%

Source: Thomson Reuters

Medical Union Pharmaceuticals Co, Safwan Trading and Contracting Co and Kahira
Pharma and Chemical Industries also witnessed double-digit growth in their revenues
and operating profit over the period.

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MENA Healthcare Sector

OUTLOOK FOR THE SECTOR

The MENA region has made significant strides in improving the health standards of its
Despite major
advancement in the populace; however, there remains enough room for improvement, given that the private
health standards, sector involvement in the healthcare sector is low in the region. Increased private sector
there remains enough participation is likely to help the region achieve its overall goal to improve access and
room for improvement
quality of healthcare available to the people. Separately, in light of the rising lifestyle
diseases such as hypertension, diabetes, cancer and heart ailments, the MENA
governments need to give due importance to preventive care, which is often ignored.

The rise in budgetary allocations toward healthcare is definitely a welcome change.

Rise in budgetary
allocations toward However, progress on work completions (particularly, construction of hospitals,
healthcare is a healthcare centers and medical colleges) has been rather slow. This needs to be
welcome change expedited.

With the right ingredients of high population growth, increased life expectancy,
Healthcare in MENA
represents a huge improved literacy rates, prevalence of lifestylerelated diseases, aspiration for better
opportunity quality medical services and greater awareness of health insurance, healthcare in MENA
represents a huge opportunity. We estimate the MENA healthcare market to be worth
USD144 billion by 2020.

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MENA Healthcare Sector

APPENDIX
Country-wise estimate of the healthcare markets size across the MENA region in 2020 is
given below.

Exhibit 23: MENA Healthcare market from 2011 to 2020

HEALTHCARE MARKET HEALTHCARE MARKET CAGR (%)

COUNTRY
2011 2020 OVER 2011-20

Saudi Arabia USD 24.7 billion / USD 36.5 billion = 4.4%

Egypt USD 11.5 billion / USD 31.8 billion = 12.0%

UAE USD 11.7 billion / USD 17.3 billion = 4.5%

Algeria USD 7.8 billion / USD 9.8 billion = 2.6%

Morocco USD 6.0 billion / USD 10.6 billion = 6.6%

Libya USD 1.5 billion / USD 9.8 billion = 23.0%

Qatar USD 3.3 billion / USD 5.6 billion = 6.2%

Kuwait USD 4.3 billion / USD 5.5 billion = 2.9%

Tunisia USD 2.9 billion / USD 5.0 billion = 6.3%

Jordan USD 2.4 billion / USD 4.7 billion = 7.5%

Lebanon USD 2.5 billion / USD 4.1 billion = 6.0%

Oman USD 1.6 billion / USD 2.2 billion = 3.3%

Bahrain USD 1.0 billion / USD 1.5 billion = 4.5%

MENA USD81.1 billion / USD 144.5 billion = 6.6%

Source: WHO, The World Bank, Al Masah Capital Research

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MENA Healthcare Sector

Al Masah Capital Management Limited

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P.O. Box 506838
Tel: +971 4 4531500
Fax: +971 4 4534145
Email: Research@almasahcapital.com
Website: www.almasahcapital.com

Disclaimer:
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under the DIFC Companies Law and is regulated by the Dubai Financial Services Authority (DFSA). The
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Copyright 2014 Al Masah Capital Management Limited

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