Atos KPMG Consulting The future of Heath Care in Emerging Markets Guy Ellena Rio de Janeiro, November 2009

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1 Atos KPMG Consulting 2003 The future of Heath Care in Emerging Markets Guy Ellena Rio de Janeiro, November 2009

2 Agenda Introduction Trends : Demand, Supply and Cost Opportunities IFC & Health Care in Emerging Markets L

3 First : Population is Growing 6.7 billion people in the world Adding about 80 million more per year An extra Turkey or Germany each year! Most of this growth is in emerging markets L

4 Second, Population is aging Close to 1 million more people in the world age 65+ EVERY MONTH! Top 3 countries adding people 65+ are: India, China and US Many developing countries will get old before they get rich L

5 Populations are aging Population Over 65 Years By Region (% of total) 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% EUROPE & CENTRAL ASIA EAST ASIA & PACIFIC LATIN AMERICA & THE CARIBBEAN MIDDLE EAST & NORTH AFRICA SOUTH ASIA SUB-SAHARAN AFRICA L

6 65+ pop n has much higher health needs Number of visits per year per capita by age of patients in USA All ages 3.4 Less than 6 years years years Population ageing will have significant impact on healthcare provision and financing years years years years 7.8 Source National Ambulatory Medical Care Survey (NAMCS) L

7 And hospital use increases with age Rate per 1,000 population Days of Care Hospital Discharges yrs yrs yrs yrs yrs yrs yrs 85+ yrs L

8 Third, Disease Mix is Changing Infectious disease Fewer people die young from infections They now live long enough to get diseases of older people And they have more money: afford to eat more, do less physical work, afford more alcohol and tobacco Result into : Cancer, heart disease and other chronic conditions L

9 Western Diseases increasingly becoming Eastern Cancer example: Disease map is shifting from West to East Cancer diagnoses (millions) 1.6 MM 0.6 MM 2.8 MM 4.9 MM Majority of cancer diagnosis now outside of Europe and N America 0.8 MM 0.1 MM Source: Cancer Research UK L

10 Fourth: Cost of Diagnosis & Treatment increase fast Infectious disease diagnosis & treatment: Short duration Relatively simple, cheap technology By contrast, diagnosis & treament of cancer, heart disease, diabetes etc. Long duration Complex, expensive technology RESULT: Increased cost L

11 Result: Health Expenditures are rising US$ billion LAC Africa/Mideast* Developing Europe Developing Asia/Pacific L

12 And most health expenditure are private All countries 57.3 South Asia 80.2 Sub-Saharan Africa 60.6 East Asia and Pacific 60.3 Latin America and Caribbean 54.2 Middle East and North Africa 50.6 Europe and Central Asia 28.1 High income countries Percentage of total health expenditures L

13 From the supply side L

14 First, the Private Sector grows fast Demand is growing Public sector health spending is not growing fast enough to meet demand in emerging markets RESULT: Private sector growing faster than public sector to meet the gap between demand and supply L

15 Second, (private) hospitals are getting busier and smaller.! More conditions are being treated outside of hospitals on an ambulatory basis Average length of hospital stay is getting shorter Increasing use of day surgery: US leading this trend now >77% or procedures are outpatient or day surgery L

16 Third, large Health Care Firms are emerging; and Health Care Organizations are getting international Apollo Hospitals L

17 Fourth, International Standards are getting established International Healthcare Accreditation Organisations Joint Commission International Health Quality Service Canadian Council of Health Services Accreditation L

18 In summary Demand and cost will increase due to demographic and disease mix changes The supply of health care will need to rise both quantitatively and qualitatively to meet this increased demand Private sector will play a growing role to fill demand-supply gap More private provision directly to patients insurance or out-ofpocket funding More Public-Private Partnerships to build and operate healthcare infrastructure Increasing separation of payment and provision More public payment for private provision L

19 Opportunities L

20 What type of opportunities? Buy into and consolidate/expand small hospital groups Operation & management contracts IFC often sees hospital projects with doctors, sponsors, investors, but lacking experienced hospital management Hospital Management skills There is a marked shortage of management expertise in EM private hospitals Expanding training program for hospital managers. Currently, very underserved market L

21 Geographically Asia: India the most significant emerging market, strong growth most healthcare is privately financed; mostly out-of-pocket, insurance still very small, though growing There is opportunity to look at second-tier operators also, who need partners IFC has also invested in Hospitals in Thailand, Philippines and Sri Lanka Difficulty to find operators with scale and appetite for expansion Know-how to build up chain and gain economies of scale could be a great asset to local partners L

22 Geographically Middle East & North Africa: There are growing markets in Egypt, Tunisia and others in addition to the higher-income GCC states Egypt has a large population, but no hospital operators of substantial scale IFC has invested in Egypt, Yemen and Ethiopia. Tunisia has private hospital projects seeking technical partners Fragmented; consolidation opportunities exist L

23 Geographically Latin America: Growing private markets, still very fragmented Mexico growing private market, hospital chains (except one) are small Peru growing market, fragmented, lack of professional hospital management, government doing more PPPs in health Brazil very big private market, ripe for consolidation, a natural fit for investments but regulation prohibits foreign ownership of hospitals. L

24 Geographically Central & Eastern Europe: slow population growth Growing private markets but still very fragmented; E.g. IFC has a client in Romania who was looking for technical partner; could not find suitable partners due to lack of emerging market hospital expertise L

25 Geographically Sub-Saharan Africa: Multiple projects seen where the biggest weakness is lack of hospital management experience, where clients have asked for hospital management companies to partner with. Active interest expressed in partnering with more developed hospital companies IFC seeing African healthcare providers partnering with companies in areas such as pathology labs, imaging, etc L

26 IFC in the health sector Private sector arm of the World Bank Invests in private sector projects in developing countries World s largest multilateral investor in the private health sector L

27 IFC Health Portfolio at a glance 84 private health projects in 33 countries since 2001 close to US$1 billion committed US$ 2,550+ mm of total project value Current portfolio of 47 projects and $615 million Active Portfolio by Country* Active Portfolio by Product* * Data as of September 2008 L

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