Welcome to the analyst presentation for the fourth quarter and for the full year 2023, Bumrungrad Hospital Public Company Limited. Thank you very much for your time listening in the webcast today. My name is Achiraya Sritratana, Investor Relations and Sustainability. Today we have the management here to give a presentation, Khun Neil Sorrentino, Corporate Chief Strategy Officer, who will talk about the key takeaways in the year 2023, and also he will give some guidance into the first quarter of 2024. Today we have a special executive coming to give a presentation. We have Khun Daniel Kastner, Chief Transformation Officer, who will give us an update on the insurance business development update. And then we have Khun Rajeev Rajan, Chief Business Development Officer, who will give us an update on the business development performance in 2023.
We have Khun Oraphan Buamuang, Chief Financial Officer, who will talk about the key financial highlights and the financial performance, both in the fourth quarter and also the full year 2023. We have Khun Artirat Charukitpipat, Chief Executive Officer, who will talk about the business update during the fourth quarter. Today the presentations will be as the format of the presentations will be as usual. We'll have the prerecord of the analyst presentations posted on the website, and then we'll follow by the live analyst meeting, which will be held on Thursday, 29th February, at 10:00 A.M., where our management will be happy to answer any of your questions that you may have. If you have questions before the meeting, you may send your questions via email to ir@bumrungrad.com.
In 2023, we achieved a record high year for us in terms of the earnings performance, both the EBITDA and the net profit, as well as their respective margin. Our management will talk about this in detail later on into the presentations. What I would like to note in this quarter is that if you compare the quarter-over-quarter comparisons for the fourth quarter compared to the third quarter, you may saw a slight dip in the fourth quarter, which this is mainly due to the normal seasonality lower in the fourth quarter when compared to the third quarter.
As in the fourth quarter, there are many international holidays, such as the Christmas period and also the New Year period, while in the third quarter is typically our strongest quarter for us, after in the second quarter we had the Ramadan and also the Thai New Year or the Songkran period in the second quarter. So that's all what I would like to note in terms of the Q-over-Q comparisons. The last thing that I would like to mention is that, in December, on the occasion of the Bumrungrad 43 anniversary, the Bumrungrad Hospital Foundation, and together with the hospital, organized the Bumrungrad Run for Health 2023 at the Chatuchak Park, where we bring all the Bumrungrad family, including the patients, relatives, staff, executives, and our partner, as well as the public, to join us in promoting good health and also doing good deeds.
The proceeds from the event, after deducting all the expenses, will go to the Bumrungrad Hospital Foundation. The Bumrungrad Hospital Foundation is established since the 1990s. One of the very special programs under the foundation is the Rak Jai Thai, or the Healing Heart Program, where the hospital provides heart surgery to Thai underprivileged students who have, like, a heart defect or a heart disease. Since the establishment, more than 800 Thai underprivileged students have gone through the heart surgery free of charge, and most of the time it's a life-changing surgery for them. I would like to thank you everyone who joined us as a part of making this positive change for our community. That's it from my part. Now I would like to hand over the presentations to Khun Neil Sorrentino to talk about the key takeaways in 2023.
Sawadee Kap, and welcome to Q4 and the final period of analysis for year-end 2023, which I and a number of other presenters are going to provide you pretty significant detail about because it was an extraordinary year in 2023. Following me will be two other executives, one you haven't seen in a while, who used to be the Investor Relations Executive, now in charge of our total business development insurance operations, Daniel Kastner, Chief Transformation Officer, and a new person you have not met before, which is Rajeev Rajan. He is responsible for both the international and the domestic business, absent the insurance operations business. It's probably appropriate to begin this presentation and the year in referring back to someone by the name of Edward Murphy.
Edward Murphy was an aerospace engineer, and in 1949 he was doing some very, very experimental tests, and he came up with the term, "What can go wrong will go wrong if you wait long enough in any endeavor." And we experienced the opposite of that in this extraordinary year of 2023 at Bumrungrad. Very, very little went wrong, with a few minor exceptions which I'll raise and talk about later in the presentation. But as we begin the year, this year, 2023, was our highest earning performance year in the history of the company, and we were recognized by the SET as, in our sector, the best company performance award by the SET on behalf of BHPCL. We've never won that award in the 43-year history that we've been in existence, and we're, we're gratified, humbled, and extremely proud of that award because it's based upon metrics.
It's not based upon advertising or anything else. What led the way in the year, specifically the second half of the year, was the Middle East business, and that's because of Ramadan in the first half of the year, and our Indochina performance absent Myanmar. Myanmar was sound for the year, but it did push off a little bit from prior highs, and that's principally because of the instability of what's going on in Myanmar with the military really knuckling the people down in that country, and then they're fighting the rebels at the same time. It's a pretty harsh environment for people to be in, and there's been a lot of Myanmar people coming to Thailand, buying resources and assets, and hopefully not trying to go back.
We also had a little bit of a pushback from Kuwait, which we will see some of in the first half of 2024. Kuwait is reorganizing and redeveloping how it is that they develop preferred providers in different countries around the world that their citizens go to, principally the U.S., Europe, and Thailand. They're going to slim down the number of preferred providers. They are reorganizing internally. Right now there's not a great deal of guarantee of payment, Kuwaiti citizens leaving the country. Most of them are being serviced inside the country, and that's going to continue through, in our case, 1H, and then after Ramadan it'll return to more normal levels. But we had some of that affecting second half of 2023, and we'll see that through 1H 2024. But for 2023, because we're talking about 2023, an astounding year-over-year EPS growth of 42%.
I've been doing this a number of years, and I haven't been associated with a company that's grown its EPS by 42%. And as I've remarked in other quarterly analyst presentations, we didn't do it through price increases. This was done through volume, through purification of our business, which Daniel Kastner is going to talk about on the insurance side, and through revenue intensity. Those three pieces are what drove EPS and, of course, the way our operations people ran the interior of the organization. I'll come back and talk about our DPS, our dividends per share, and talk about guidance for 2024 in general terms and for Q1 in specific. Next slide, please. Here is a photo of the presentation that was given to us at an evening event for the Best Company Performance Awards, which we were awarded.
It's worth showing because we're extremely proud of it. Our market cap now is somewhere around $5.2 billion, depending upon the price of the day, the shares of our stock, and we exceeded that $5 billion number over the last nine months. Next slide. So going into some detail, I'm not going to go into a great deal of detail because Rajeev Rajan and Daniel Kastner are going to talk in rather significant detail about the pieces of each of the verticals they represent. But I do want to show you trend lines because it's always good to show the investor community what the trend lines have looked like since right before COVID, which was 2019. And I'll remark that 2018 was a stronger year on metrics than 2019, but everybody relates to the year prior to COVID.
But those numbers are even larger in 2019. So you can see THB 5.7 billion on EBITDA in 2019. In 2023, that trend line has moved almost double, not quite, THB 9.597 billion. But what's of interest is the variations in the change year-over-year, and of course why 2022 is going to have a big uptake of 158% because it's coming off of the COVID year. Next slide, please. Margins reflect the same kind of thing, almost, not quite, in our business insurance development, vertical as high as this, as the high in the company, but 37.5% off of 34.1% the prior year. That's 3.3 percentage points. On our base, our turnover for 2023 was about THB 25 billion. So when you look at that kind of platform of turnover, 3.3% is quite dramatic to be able to push that high against that kind of turnover. Next slide.
Net profit reflects all the same kinds of variations, positive variations, THB 3.7 billion in 2019. More relevant in 2022 was THB 4.9 billion, and then look at the jump, that reflects DPS of 42% growth from THB 4.9 billion to THB 7 billion, with an increase of 41.9%. I call it 42. Rounding is fair enough, if you're at a 0.9. Next slide. The net profit margin shows the same kind of positive trends from the time that COVID was here at 9.6%. We came back in really strong fashion, and I have to thank, not only the people that are doing business development, both domestically and internationally, but as well the operations people at the medical center and the other verticals like VitalLife, like Esperance, to be able to deliver cost-effective servicing of the care.
The other thing that we don't show here, it's possible that our hospital CEO will show at [Kunling], is the customer service improvements and patient satisfaction improvements that we've had that continue to improve year-over-year. Next slide, please. Before I get to this slide, just a comment about Phuket for those of you that are interested. We get a lot of questions, and we will be answering some of these questions in our live stream Q&A next week. Phuket now has moved from the plan design being finished by our international architects. It's been turned over now to our environmental impact consultants in Phuket, and they're now beginning their work to try and get an approval for our project there.
We're hoping that we'll get that favorable approval within six months, perhaps sooner, but six months is the average, and that will take us to September. So we're looking to break ground tentatively on the property, in September, which would be our Q4 2024. So if you look at the proportionality of the revenue, it's very, very steady, especially from 1H 2023 forward. We ended up at 67% international business, which we include revenue as part of the expat business, and then the balance, which was Thai business, was 33%. That was at the end of any year, 67% was the highest we had in, as far as I can remember. The highest was 66% in previous years. This is the highest it's been at year-end. Next slide.
I won't go into the details of why here because others will do that, but if you look at the 1H versus 2H on the left-hand side, you will see how it changes, especially international on the right-hand side, which is year-over-year, and that international was driven principally by Middle Eastern and Chinese business. In 2023, our China business was THB 631 million, 22% growth from the prior year. The reason why I remark about that in particular is because it not only includes Chinese nationals traveling into the country internationally, but it also includes expats living both in Thailand and living in other places, either part-time or full-time, like Cambodia.
There are a number of Chinese nationals who live in Cambodia that seek care here, and they come to. I'm sure they go to other places, but at 22% growth year-over-year at THB 631 million, it was a dramatic increase, and frankly, it was a bit of a surprise for us. I hadn't expected it to be that big, but it was, it was, it was materially large for our baseline of Chinese business historically. Expats grew nicely, and when you look down this slide, what is reflected behind the numbers is the same thing I mentioned earlier. It's volume. It's not price, but it's revenue intensity, very, very high revenue intensity, which drives a lot of resource consumption, which, as I've mentioned in the past, is really what we're about, taking care of very, very sick people.
You see year-over-year the overall growth on net revenue is almost 23%. That's the highest we've ever had. Next slide. And of course, Middle East has been our biggest driver, year-over-year at almost 52%, and it grew 23.3% mainly because in 2H, that's after Ramadan, and typically it's going to be much larger in Q3 and Q4. Indochina, I've mentioned, it's a little lower in Indochina, and that's because of the pullback a little bit on Myanmar. But the other countries inside of Indochina, Cambodia, Bangladesh, et cetera, all performed very well, including Vietnam performed very nicely this year. Next slide. So here are the top 10, which I like to show you because it gives you a sense of where the business is coming from.
And we don't typically get into the revenue numbers by country vertical, but if you look at number 7, the United States, not only was it large in percentage, but it was also substantially large in revenue change year-over-year. That revenue change came principally, one, from U.S. citizen expats working in-country, but this huge influx of U.S. citizens who came into Thailand for holiday. Oman, the same way. Oman grew substantially. The UAE, in the same way as the United States, but only a bigger number, it grew dramatically in 2023. We've done some things there in market, in-country that have helped this, significantly, and I have to thank our, international, business development organization for coming up with some creative and different ways to reach out and bring patients here. We are now, speaking of reaching out, we are now at 125 referral offices going into 2024.
We were at 83 for the most part in 2023, and this is the net of some we don't renew and many that we have added. So we expect that addition, which is almost 35-40 new referral offices around the world, to produce for us in 2024. Next slide. So I like to show this slide because it shows the variation in the margin changes. I'm not going to read you the numbers there for you to look at, but everything is a positive situation here. If you look at the 2H growth versus 1H on the left-hand side of that chart, up 8.9%, and it shows the reflective margins. They're about dead even for the 1H and 2H, and on the, of course, the right side, 2023 far outpaced 2022, both on EBITDA and EBITDA margin. Next slide. Same thing for net profit and net profit margin.
The trend line is the same as it is in EBITDA, all positive, not negative. In growth, you can see the margin changes and the EBITDA and the net profit changes, THB 4.9 billion in net profit in 2022, and there's your 42% EPS growth on NOPAT of THB 7 billion in 2023. We look at these things and say, how are we going to beat that? But we expect to in 2024. Next slide. This is pretty straightforward. You can see that this trend line on debt to asset, it continues to either flatten out or grow very, very nicely on assets versus liabilities. Next slide. I haven't presented this slide to you in the past before, but I thought I would so you'd get a sense for what we call operating, investing, and financing.
So if you look at this, I'll spend a little bit of time on this, not much, but if you look at it, the 7,094 was the operating cash increase out of operations, and you would expect that to grow as your turnover grows, but not every business is able to turn over their revenue into cash. But we were able to do that very, very well to an increase of THB 1.6 billion. The next line is in investing, and that THB 2.5 billion, 2.4-something, that number there is associated with property, plant, and equipment investing throughout the year. We spent THB 2.5 billion in property, plant, and equipment. And then over there, 3,051, which I've called financing for lack of a better term, that's our DPS. That's our dividends that we issued to our shareholders of record last March, a year ago.
So when you compare them, period over period, what you see on the left is a substantial increase in the areas that you want, which for me is operating cash flow turnover. That's the most important thing because if the two bottom ones are growing and the middle blue part is not growing, you've got a problem. But we are very happy to see that conversion on net revenue, turnover, net revenue to cash. Next, please. I've been showing for the last, I think, a couple of quarters expanding the VitalLife information that we have given to you. It was another extraordinary year for VitalLife. Again, I'm not going to read you the numbers, but if you see the improvement on 2022 versus 2023, the revenues were up 30.5% year-over-year, and 1H over 2H up 16.7%.
The margins continue to be right at about 40%-low 40%. In this case, it was 42% year-over-year and 42% 1H-over-2H, and the net profit grew substantially. You can see the number there, 43.6% growth in net profit year-over-year. This is a business that is right in line with the whole lifestyle and longevity modernization of what used to be called anti-aging and wellness medicine. We've taken this to another level. This business now is 23 years old. We'll be opening up another VitalLife Scientific Wellness Center in Phuket in 2H, in 1H, at the end of 1H, and we expect that to begin to get some brand identification and some brand identity in Phuket, and then move that from Old Town.
We'll move that to our campus when our campus opens, and by that time, if we do our homework well, people will know VitalLife very, very well in Phuket. Next slide. So we're back to the beginning. So what didn't I cover here? There were two aspects at the end I did not cover. One was the dividends per share. Our board met on Wednesday morning, and they approved a total dividends per share for 2023 of THB 4.50. This will be taken to our shareholders for final approval. The interim dividend was approved in an earlier part of the year, and that was paid. I think that was THB 1.35. The board approved THB 3.15 for the final dividend for the year, total THB 4.50, and we'll take this to our shareholders for approval.
It represents about 51% of EPS when you calculate it, and when you consider that EPS had grown by 42% year-over-year, that 51% in relative terms is extremely high on absolute Thai baht. So if approved by the shareholders at our AGM in April, we're hopeful that our shareholders' record will be very, very happy. The final point I want to cover for you now is moving into 2024 because 2023 has sort of been in our rearview mirror now for about three months as we've been focusing on 2024 with budgets, et cetera. And what you will find as a different phenomenon for us in 2024 is this whole question about Middle East support. Because the Islamic calendar continues to move backward in time, which is normal for the way their calendar runs, Ramadan for us will impact us in Q1 by 50% of the total days.
There's 40 days in Ramadan. 20 of those days will be in Q1. So we will see a different orientation in the way our company performs, assuming we continue to have 25%, 26%, 27% of total revenue being Middle Eastern revenue. It's risen from 25%. I'm not exactly sure where it is today. I think it's 26%, 27%. 26 is probably the good number of total. And what we'll see in 2024 because of this Islamic calendar rotation, we will see half the Ramadan days happening in Q1. So when you look at the relative value of the performance of the company in 2024, the way I look at it, there's going to be more back-end, higher levels of growth rather than front-end, meaning Q1 will not be as strong historically as it's been in the past because of Ramadan being much earlier.
Conversely, so we expect that the back end of the year, especially Q3 and Q4 and part of Q2, because Ramadan will end sometime around Songkran, something like that, and then there's Eid, which is about an 8-10-day holiday. Then you have school break in the Middle East, and then it should start picking up again. So as we monitor how we expect the flow coming from the Middle East, that's what my expectation is for 2024, different than in prior years. So please be mindful and be reminded of this point as you look at quarter-to-quarter performance. And I'll mention this again so you get used to the idea, as we're getting used to the idea. So as a result of that, my 2024 guidance has to do with this reorientation of earnings moving around a little bit because of Ramadan changing earlier into the calendar year.
For Q1, I'm guiding single-digit top-line revenue growth. With that, I will close, and we thank you for your continued support and interest as an investor community in Bumrungrad Hospital Public Company Limited. Thank you very much. Swadee khap.
Swadee khap. Happy to be with you again. I would like to provide you with an update on the insurance business for which I've been a part of over the last year. The insurance business has been a significant contributor to the growth of 2023 for Bumrungrad BH PCL. There were a number of factors that we have set since the beginning of the year that have borne fruit throughout the year that we've had, and I'd like to run through with you on that in the next couple of slides. The key area that we wanted to focus on when we started this journey in 2023 can be classified into three areas. One is renewal of our relationship with our insurance partners. I checked this morning, and it surprised me that we signed approximately 60 contracts over the last year.
That equates, if you deduct holidays, weekends off, et cetera, to around three contracts a day, which sorry, three contracts, one contract every three days, which is a remarkable number. I hesitate to say that there's been a bit too much interaction, perhaps, with our legal team, and as a result, perhaps, I've taken aboard a little bit of our legalistic mentality in there, jokingly, of course. Second thing is also that insurance business has not really been our particular focus at Bumrungrad over the last few years, but it's only recently come to preeminence as the uptake in insurance has increased during the COVID period, where people become a lot more concerned about their health. And with the increasing cost of health care, that has driven up the interest in insurance policies and also in coverage for insurance procedures.
Moreover, we engaged with our insurance partners and our medical assistance partners, both locally and overseas, in a much stronger way, and that has allowed us to generate a lot more volume and also margin in that business as a result of a number of factors, for example, economies of scale and also focus on surgical procedures with high turnover and higher complexity as well. The other prong that we focused also on is on our operations and how we improve accessibility for our patients who are willing to use insurance. That includes communication with the patient. That includes improving overall turnaround times for pre-authorization all the way into the claims and also discharge. That has also increased the attractiveness of Bumrungrad for our insurance partners and patients as well.
Finally, it was a matter, of course, of selectively and strategically positioning ourselves in incrementally driving revenue and volume to Bumrungrad. That included both incentives for our insurance and medical assistance partners, as well as other key players and stakeholders such as our brokerages and insurance agency partners as well. Without further ado, I'll just dive straight into the numbers. As you can see in this graph, if you compare year-on-year, growth has been significant at 41% overall. We've categorized local insurance and overseas insurance and medical assistance segment into two parts, and both have shown a dramatic increase in the growth of these two segments. On the medical assistance side was the key leader in the growth of the international business, and that has been through targeted and deliberate engagement with our partners there.
If you compare with 2019, growth also looks very, very favorably because between 2022 and 2019 and the period during that time, our insurance business did not significantly see much increase as a result of our lack of focus in that area. Given the focus, you can see clear results in the growth of this area, and we are encouraged by the performance of 2023 and the outlook for 2024 as well. How does that contribution reflect in the overall mix of revenue? Well, you can see there, if we only include insurance, it contributed nearly 19% to the overall revenue mix of Bumrungrad Hospital PCL 's revenue contribution. You can see the split between overseas and local, and you can see that significant jump on the local business and also a healthy development on the overseas insurance and medical assistance.
We expect that to be even healthier in 2024 as more international tourists come to Thailand. The key contributors for this segment will be accidental tourism, so people who are coming as tourists for both leisure and business and end up being sick for whatever reason and seek health care, but also from around the region as well, Indochina as an example, even China. On the local side, our continued engagement with our insurers, with activities with corporates and also agency brokers, et cetera, have borne fruit with that growth as well. Now, if you include copay, which is a self-pay component, copay, deductibles, or overages, so the amount that the patient needs to cover that exceeded the coverage of the insurance policy, that jumps up to 21.2%.
So it's around one-fifth contribution of the overall mix, and that has been one of the key drivers in our revenue growth as well. I'd like to give you a little bit of an indication on the profitability and on the margins. Now, with the caveat that these are unaudited numbers and these are internal estimates, so this is purely for color purposes and should not be taken as an actual and accurate reflection of the overall margin as they are unaudited. But you can see there, not only has the revenue grown and the volume, but also margins, and that's something that we were very pleased by. We've always tried to be very disciplined in how we approach growing our insurance business. We did not want to discount our business and get revenue or volume in return. We wanted to do all three. We wanted to grow our business.
We wanted to also grow it profitably and sustainably, and we also wanted to make it as a part of a marginal contribution to the overall mix of the hospital as well. I think in 2023, that has borne fruit and has clearly shown a significant improvement with margins quite in line with the overall mix of the hospital's margins as well. Looking at the breakdown in spend by specialty, I highlighted to you in bold our COEs, our centers of excellence. These are areas that we particularly focus on because of their criticality and also complexity. You can see, in general, very, very solid growth across the board: cardiology, oncology, gastroenterology, both from a year-on-year perspective and also a 2019 perspective.
Oncology has seen a particularly high increase in growth, and that's purely because of the higher cost of treatment and insurance providing that avenue of coverage to the patient itself as well. Neuroscience and ophthalmology also have grown quite nicely. Also our bread-and-butter services, pediatrics, orthopedics, or women's center, OBGYN, has also grown quite nicely as well, and that's also because of the resumption of the school year for students, and that has allowed students to once again interact with the overall environment. That has seen a growth in diseases related to children, whether it be flu, RSV, et cetera, which was particularly seasonal last year as well.
Perhaps also due to the fact that because there was a lockdown over the previous years, the immune systems of children were not as primed as what they used to be, and so therefore, we had a high number of RSV and flu cases of children in 2023. Other bread-and-butter services would also include checkup, where we've seen also a nice increase in checkup from insurance patients as well, which, of course, as you know, is a downstream channel for us for other services. What are we planning to do in 2024? Well, 2023 has shown some success, and we will continue that momentum. That will be something that we will continue to do in 2024 as well, in particular, further engagement with our partners.
That includes existing partners, whether it be AIA, Muang Thai Life, or even Krungthai-AXA, to geographic expansion within the country and outside the country as well. Within the country, we do see opportunities for growth among key tourism destinations, whether it be in the Chonburi area or Phuket to Hua Hin and even up to the north. And in fact, we were quite pleased to see growth even in, I would say, less obvious areas of catchment, such as the Isan, Greater Isan area, where we have engaged with a lot of our partners there and have seen some growth in major critical cases such as cardiology and oncology as well.
Overseas, we're going to continue to develop our referral channels, and what I mean by that is engaging with new partners, new medical assistance companies, new overseas insurance companies, and developing a direct billing agreement relationship with them in order to make it easier and accessible for the patient to come to Bumrungrad for services. Of course, we will continue to focus on critical, complex, high turnaround surgical cases, where we've seen a significant increase in 2023, and we expect that momentum to continue in 2024 as well. As I mentioned earlier, we continue to refine and be strategically selective in how we incentivize our partners to steer cases to us and to drive greater engagement and awareness of Bumrungrad as the key destination to provide health care services globally. There will be a lot of negotiations and a lot of refinement in how we manage that.
On accessibility and digitalization, we're continuing to make health activities as one of our key channels to engage with the community. That includes directly to the consumer, but also with our corporate partners, insurance partners, embassies, et cetera, as well. It's very important that we continue to educate them on new services, new products, and doctors who we continuously recruit and continue to churn as we bring in newer generations of patients and newer generations of doctors into the hospital as well. The BH Application will be another key focus for us, how we can provide better services digitally so the patient has control over how they interact with the hospital, and also reducing the anxiety of the patient by providing more information about the status of their health care, their coverage, and also processes that they can do digitally as well.
Some of you may be familiar with the fact that perhaps some hospitals do not provide you with active communication in the status of your bill and also with the percentage that will be covered by your policy, and that's something that we want to minimize and eliminate to ensure that you have the right information real-time in how your coverage is paying for your health treatment so that we can reduce that level of anxiety and create a more positive experience for our patients. Of course, as I mentioned, these public health activities also include doctor-to-doctor engagements, business-to-business, and also business-to-consumer. Second opinion services is something that, given telemedicine becoming a lot more prevalent, is something that we would like to continue to develop.
So what I mean by that is having the patient the free service of engaging with our doctors and our medical inquiry department to get second opinion on certain procedures, or they would like to consult with us on what their treatment plan should be from local hospitals and perhaps and hopefully convert them into Bumrungrad patients as well. And that's one area that we think could be very useful, especially upcountry and overseas as well. On operational excellence, that's something that I mentioned is not typically attributed to growth in business but is highly important. The reason being is that if we can develop faster turnaround times for pre-authorization and for discharge, we're able to win back and secure the cases a lot more proactively and also increase revenue growth by reducing leakage in that area as well.
Moreover, with greater communication and relationship building with our key partners, it has a significant impact on how we drive business to Bumrungrad. The perception of our partners that we are friendly, that we are responsive, that we work collaboratively with them is very important in how we grow this business sustainably, and so therefore, that's one of our key focuses as well. Of course, connectivity being the key theme here. With more integration with platforms, with systems, we would be able to develop a lot faster communication and, of course, speedily go through the process of insurance, which typically can be quite painful and quite time can take quite a lot of time. To speed that process up would be an area that would develop a much better patient experience for our patient base as well as our insurance partners.
It is basically a win-win for both sides because it would not only reduce the turnaround time for the patient but also costs associated with providing the services to an insured patient, which typically is higher than a self-pay patient. And finally, process automation and application of AI, that's something I think all organizations are focused on, how we can be a lot more productive, faster, and also cost-effective in providing these services. So application of robotic process automation to using AI, for example, to summarize cases in order to speed up the process of claims and providing medical reporting, et cetera. These are areas that we are focusing on, and we are working collaboratively with many key departments, including, of course, our IT department, our Digital MarTech department, and our finance department as well. So all in all, we're quite encouraged by 2024 and how the prospects are looking.
2023 was a banner year for us, and we hope to see continued growth in this segment going forward. Thank you.
Swadee khap. My name is Rajeev Rajan. I'm the Chief Business Development Officer. Today, I'm going to run you through the performance update for 2023. 2023 has been a very eventful year. We achieved close to 22.5% growth year-on-year compared to 2022. The growth of 22.5% was distributed between the three sectors of international, Thai, and expat. Majority of the contribution of 31.9% growth coming from the international segment, followed by the expat segment where we saw a 17% growth year-on-year, followed by the Thai segment where we saw a 11.4% growth year-on-year. The international segment was mostly a huge contribution from the Middle East segment where we saw close to 51% growth year-on-year on the Middle East market. Now, going into detail of the Middle East segment of the business, the top five contributors majorly were Qatar, UAE, Oman, Saudi Arabia, and Kuwait.
Qatar has been the biggest contributor for the 51.7% growth from the Middle East, where we have seen over 100% growth year-on-year from this specific region. We have also made some collaborations in this region where we have, last year, had specialty-specific engagement programs for this region where we had our clinicians reach out to this geography and conduct a lot of outreach and clinical programs in terms of scientific sessions, engaging with the doctor community in Qatar. From Oman, we witnessed close to over 50% growth in terms of volumes and in terms of values. Oman is a market where we tried to reach out to a lot of corporates, to insurance, and also part of public institutions as well for the last year.
We had a major collaboration in the private space with one of the leading private health care service providers in Oman for a series of events, scientific sessions, and collaborations, which translated into pretty good tertiary care and super specialty referrals last year. Moving to Saudi Arabia, 2022 was a year where political collaboration or resumption in bilateral relations between Thailand and Saudi Arabia started in 2022.
Ever since that, we witnessed a huge number of travelers for not only medical tourists but also tourists coming in from Saudi Arabia, as per the numbers published by the Tourism Authority of Thailand, which was a great opportunity for us to explore the medical tourism space, which is outbound medical travel from Saudi Arabia, which is currently only served by three countries which are approved destinations on behalf of the Ministry of Health, Saudi Arabia, which stands to be the United States of America, U.K., and Germany. We have seen a 25% growth in medical tourists coming into our hospital from Saudi Arabia, even though there were no political or bilateral relationships between Saudi Arabia and Thailand.
Now, moving to Kuwait, Kuwait is also a market where we had seen a huge pent-up demand from Kuwait in 2022, especially starting Q3 2022, Q4 2022, which continued into Q1 and Q2 of 2023. Kuwait, we also have made some strong new associations and tie-ups and engagements with some referral offices where we have collaborated with one of the oldest private health care service providers in Oman, where we have collaborated for a lot of scientific exchanges, periodic, where we are taking our clinicians there, doing some outreaches, activities, connecting with our patients in order to maintain the continuity of care. For UAE, we had multiple strategies, multiple collaborations. We tried to re-engage and reconnect with corporates, with insurance, with our ROs.
Last year, we had one of the most successful and engaging activities, the health fair, which we conducted in UAE, where we had over 300 participants which came in for the event from leading establishments, leading corporates, local entities, governments, insurance sector, and we got a phenomenal response from that activity. We also have engaged into a lot of direct corporate one-on-one engagement. We have seen approximately close to around 30%-40% increase in the OPD numbers from UAE as well, which translated into high-intensity cases and high-intensity tertiary care referrals from that region too. We saw a 35.9% growth in the other segment. The other segments stand for the rest of the world. The major highlight of this segment, specifically, number one, would be Ethiopia.
Ethiopia is a market where we have seen full resumption of services post-COVID, and for this specific market, we have achieved the highest-ever revenue last year in 2023. We grew by close to 85% compared to 2022, and this was the highest in terms of performance from this specific market. This market approximately contributed close to around THB 350 million. One of the major reasons why we were able to achieve this is also number one, the resumption in services like the full connectivity between Addis Ababa, Ethiopia, and Bangkok, the improvement in some forex conditions and the political scenario, number two. And number three being, we added some ROs, and we also tried to reconnect with the market in terms of reaching out with our clinician. So Ethiopia, last year, we had conducted close to two activities where we were there physically present in Ethiopia.
One of the events, one of a kind, where we had collaborated with one of the leading public hospitals in Ethiopia for tertiary care and super specialty care referrals, where we had one of our prominent authorities in the field of neurointervention visit there in Ethiopia, and we conducted outreach and also some scientific seminars. The second being Australia, Maldives, and United States of America. So all these three countries, we have seen a huge growth, all three above 50%, specifically for travelers coming in from residents. One other highlight from this specific segment is the Chinese business. Last year, towards Q3, Q4, we had seen relaxations in policies by the Chinese government specifically for their nationals to travel abroad. So we have seen both in terms of tourism and in terms of medical-value travel an increase in numbers from China.
Yes, of course, needless to say, from the Thailand government also, we had a new visa regulation, which was a visa-free norm for Chinese travelers, which significantly contributed to the number of travelers coming into Thailand, specifically for tourism and also for medical-value travel. Now, for the Indochina part, which contributes around 5.8% year-on-year growth, we continued to have the ups and downs for contribution from Myanmar because of a lot of external factors. Yes, of course, which was mentioned in Q3 analyst presentation as well. We continued the same trend where we did not see a significant amount of year-on-year growth, even though the volumes and the values almost remain the same in terms of year-on-year growth. For this specific segment, we saw a significant growth close to aro und 16% from Bangladesh.
So Bangladesh was a region where we had seen that year-on-year, Q1, Q2, and Q3 Q1 and Q2 was not that very high in terms of year-on-year growth, but Q3 and Q4, we improved significantly where we had again, we had a re-engagement plan for this market where we had increased our outreach because of relaxations of a lot of rules and regulations, yes, again, which led to translation of increase in OPD volumes and high-intensity cases as well. So overall, 2023 has been a very eventful year where we achieved a lot of milestones. This was possible because of our strong collaboration and strong connect with our ROs. And in 2023, we also had new ROs sign up where we have reached out to new countries like Saudi Arabia, where we had new ROs sign in from Australia, from Indonesia, from China.
We can see that we have added quite a few ROs because of the new markets and new contributions coming in, and we hope to carry the same momentum for the next year, 2024.
สวัสดีค่ะ Good morning, everyone. I'm Oraphan Buamuang, Chief Financial Officer. I'm pleased to report to you all the financial highlights and financial performance for fourth quarter 2023 and for the year 2023, ka. In terms of financial highlights, in fourth quarter and the whole year 2023, total revenue, EBITDA, and net profit amount were improved when compared to the same period last year and also above the end of 2019 pre-COVID situation as shown in the first table. The improvement mainly came from the higher contribution of the international segment had a positive impact to patient volume and revenue intensity continuously in this year. In terms of profit margin, in year 2023, EBITDA margin and net profit margin were 37.5% and 27.4% respectively. These are the new high records on a yearly basis. I will walk you through more detail in the following slide, ka.
For financial performance, the total revenue in fourth quarter 2023 was THB 6,565 million, increased from fourth quarter 2022 by 8.2% and also above than fourth quarter 2019 by 36.9%. The total revenue improvement mainly came from the increase in revenue from hospital operation when compared to fourth quarter 2022 revenue from non-Thai patients and Thai patients, increased by 11.9% and 2.9% respectively. For the whole year 2023, total revenue was THB 25,575 million, increased from last year by 22.3% and also above than year 2019 by 37.8%. When compared to year 2022, the improvement mainly came from the increase in revenue from non-Thai patients and Thai patients by 28.9% and 11.4% respectively. The improvement in revenue mostly came from the volume and revenue intensity increase in the international segment.
In terms of revenue contribution by nationality, in fourth quarter 2023, the contribution of international was 68%, which was above than fourth quarter 2022 by 66%. This was mostly due to an increase in revenue from non-Thai at 11.9% whereas Thai patient revenue increased at 2.9%. For the whole year 2023, revenue contribution from international patients less to 67%, which came back to the same proportion year 2019 pre-COVID situation. In terms of revenue contribution by service, in fourth quarter 2023, revenue contribution from IPD service increased to 52% from 49% in the same period last year due to IPD revenue increase by 12.6%, which is more than OPD revenue increase at 3.2%. The higher increase in IPD revenue mostly due to higher volume and intensity of IPD cases.
In year 2023, revenue contribution from IPD service also increased to 51% from 48% in year 2022 with the same reason as already mentioned. In terms of revenue contribution by payer type, the government third party continued in year 2023 increased to 19% from 15% in year 2022 mostly due to revenue from government sponsor increased by 54% which associated with Middle East patient revenue increase. Insurance contribution in year 2023 increased to 18% from 16% in the same period last year due to insurance revenue for the year 2023 increased year-over-year by 41%. Self-pay contribution in this year declined to 62% from 68% in the previous year mostly due to revenue from self-pay patient increased 11.5% which is lower than the revenue growth rate of government third party payer and insurance payer.
In terms of EBITDA and EBITDA margin, as a result of increased revenue and continued cost management program, EBITDA in fourth quarter 2023 was THB 2,367 million improved from same period last year by 9.7% and improved from fourth quarter 2019 by 72.4% with EBITDA margin 36.1%. EBITDA in year 2023 was THB 9,597 million improved from same period last year by 34.7% and improved from year 2019 by 67.4% with EBITDA margin 37.5%. These are the new high records of EBITDA amount and EBITDA margin for the yearly basis. In terms of net profit and net profit margin, net profit for fourth quarter 2023 was THB 1,721 million which improved by 11.3% and 94.3% from year 2022 and year 2019 respectively. Net profit for fourth quarter 2023 improved to 26.2%.
For the whole year 2023, net profit was THB 7,006 million which improved by 42% and 87% from year 2022 and year 2019 respectively. Net profit margin for the year 2022 improved to 27.4%. These are also the new high records of net profit amount and net profit margin for the yearly basis. In terms of the leverage ratio, net debt to EBITDA of year 2023 was negative at 0.4x due to less net debt, and net debt to equity in year 2023 also negative at 0.2x due to less net debt as well. These are all financial highlights and financial performance of fourth quarter and the whole year 2023, ka. Thank you for your attention.
Swadee khap. Today I'm going to present the business updates of Q4 2023.
The first slide, this one to show everyone that since 2002, we are the first hospital in Asia that has been accredited by JCI. In December last year, we also been certified by JCI. This is the seventh time re-accreditation. This slide to show you the performance of our Center of Excellence. As you know, our strength is focused on the critical complex disease and advanced technology. The Center of Excellence, last year we focused on the six Center of Excellence. Every Center of Excellence that we focused has achieved double-digit growth. 2024, we will add two more Center of Excellence, which are Breast Center and also Urology Center. This is healthcare performance. Since late November last year, we renovated Ward 8, around 68 beds, and we tried to boost up the volume by creating the packages of the check-up.
And we saw during 23rd November to Christmas last year, we achieved nearly THB 72 million, and this check-up package can be used until February this year. And for Ward 8, in late March, we plan to open around 38 beds from 68 beds so we can provide the rooms for the patients. And this is an exclusive talk. This is a new concept of the healthy and also clinical practice by integrating longevity medicine into the practice. We have been invited by Dr. Brian, Dr. Collin, and Dr. Evelyne, and the moderator is Dr. Wanviput from VitalLife. We have got very good participants from 300 attendees from the medical schools, from the doctors, and also Bumrungrad doctors, and our hospital network to join this event, ka. That's all from me for the Q4 last year. Thank you.
So now we come to the end of the presentations. Thank you very much again for your time listening to the webcast, and then we will see you again in the next quarter on the first quarter result, next analyst presentations in May. So that's it for today, and thank you very much .