Okay. Welcome everybody, and thanks for those being here attending in this room. Welcome everybody, for those attending online for this Capital Markets Day for Ramsay Santé. A new chapter for this company, a new chapter of profitable growth and medical excellence. Through this morning and with a site visit, four objectives I would like to share with you. Four objectives that we are going to discuss with the following agenda. First, what makes Ramsay Santé unique as a company in Europe. Secondly, we would like to frame with you, we are going to frame with you the market in which we operate. We will be pleased to unveil today to you our next chapter for the next year, a new strategic plan called Connecting Care 2030.
Finally, with no surprise, we will do an update on the financial performance as of today and what are our guidelines for the future. Today, I will have the pleasure to present alongside Clément Lafaix, our Group CFO, with Jérôme Brice, who is our CEO for France, with Dr. Britta Wallgren, who is our CEO for Sweden, and with Dr. Margareta Danelius, who is our Chief Medical Officer for Europe. In order to share with you, to discuss with you, to explain to you this fair objective, we have built the following agenda. I will start with a global introduction regarding Ramsay Santé, then important certainly to look forward regarding, once again, the market in which we operate in the next year. We will have a financial overview once again with Clément.
I will be pleased to share with you the guideline, the first pillars of the strategy that we have built in the last year with 600 managers, once again, called Connecting Care 2030. After a break, we will go through the medical excellence for our group in Europe, what makes us unique regarding medical excellence. Of course, because of the size, the importance of footprint both in France and in Sweden, we will have a deeper look to these two countries, regulation, footprint, what do we do? How do we want to roll out Connecting Care 2030 in these two countries? Finally, we will do some closing remarks and commitment guidance, I would say with Clément.
There will be time for Q&A, and we will be very pleased for those of you who have been registering to do tomorrow two site visits, a primary care, which is a walking distance from here, and later, one of a big flagship Medicine, Surgery, and Obstetrics , MSO, as we say in our industry, in the Left Bank of Paris called Hôpital Privé des Peupliers , The Poplar, if I am right, in English. Talking about introduction of Ramsay Santé. Let's share the context and to some extent, the importance of today. On February 20th, as part of the strategic decision to simplify its portfolio to focus on Australia, Ramsay Health Care announced its intention to propose to distribute the Ramsay share to their shareholder. The same day, Crédit Agricole Assurances reiterated its long-term commitment shareholder regarding Ramsay Santé, its confidence on the strategy, the team, and the potential of the company.
July 22nd was an important day as we have successfully completed the refinancing of our debt, and Clément will take us through that maturity, simplification, et cetera. Today, once again, our strategic roadmap for the next chapter of profitable growth. October 2026, the demerger booklet of Ramsay Health Care will be provided in a nutshell to the Australian Financial Authority, as well as a court approval. November, we will release our first Q1 result. Just to remind that as of today, our results are June-June, so we will release our first three months results. As well, during the Ramsay Health Care General Meeting in Sydney, Ramsay Health Care will ask the shareholder to approve the demerger. Would it be the case? The implementation of the demerger will take place afterwards, and then, let's say, new year, the new areas, the new chapter for our group.
To be a bit more precise, what has been announced by Ramsay Health Care on February 20th, and what would be the impact, would the demerger take place regarding the shareholder? As of today, just to remind everybody, if I may, the current ownership structure, Ramsay Health Care owns nearly 53% of the capital of the company, whereas Crédit Agricole Assurances owns 40%, and this had been the case since 2014. We've got an individual shareholder, Dr. Attia, owning nearly 7%, and as of today, our current free float is 1%. Would the demerger take place at day plus one, and assuming that the Ramsay Health Care shareholder, they keep their respective Ramsay Santé share, de facto, the floating will come from 1% to 54%.
Once again, that being happening regarding Australian, Asian shareholder, we are building with Ramsay Health Care, we have been building a specific tool, a CDIs, a CHESS Depositary Interests. Long story short, Ramsay Santé will be too listed on the Sydney Stock Market, easing thus, I would say, any transaction, et cetera, that could happen. Beyond, I would say, what will happen on day plus one, regarding the board, undoubtedly, the governance will change, and it will change to respect the best practice of the profession and compliant with the French AFEP-MEDEF Code, which mean that the new board, there will be independent directors that will constitute the majority of the board. The chair of the board will be independent. The chair of the audit committee will be independent. As to the new member of the board, they will be appointed through a very rigorous selection process.
Now, that being said, let's summarize what is Ramsay Santé as of today. If I were to use four words, I will use Pan-European, market-leading, diversify, and integrated. Let's build a bit on these four words. Pan-European. As you can see on the left on this slide, we operate in five countries through, by the way, the Ramsay Santé brand for France, the Capio brand for Denmark and Sweden, and the Volvat brand for Norway. A couple of figures. As of today, we are taking care of 13 million of patients every year, out of which over 1 million are pure digital patient. Beyond that, these patient are taken care in 491, to be very precise, facilities in Europe. A strong footprint in MSO, a strong footprint in primary care, a strong footprint in mental health, et cetera. We will come back to this.
We have got 1,000 operating rooms in Europe. Beyond that, we are working with roughly 10,000 doctors, non-salaried in France, salaried in Sweden, for example, non-salaried in Norway, et cetera. Pan-European, we were saying. Market-leading position. Undoubtedly, and we will come to this with further detail with Jérôme and Britta, we are the number one healthcare player in France. We are the number one by far healthcare player in Sweden, number one in Denmark, number two in Norway. We have got only one hospital in Italy, but very good medical quality and very strong, by the way, economic performance. We were saying diversify. Diversifies on the right of this slide as, in the last year, the part of the out-of-France revenue has grown and represent now 33% of the total revenue. Diversification, too, because on the bottom right of the slide, MSO represents still a large part of the activity.
That being said, it is a bit a mistake to say that, because between Medicine, Surgery, and Obstetrics , emergency department, dialysis, et cetera, the variety of activity makes a stronger diversification. As you can see, it has been one of the key development of the last years. Primary care now in Europe represent around EUR 700 million of turnover, a big part and growing part of our activity with mental health, with imaging and so forth. Integrated because, as you can imagine, we are going to talk about the patient pathway and how we answer to the patient needs. Going back to a bit the key date of the history of Ramsay Santé. We have got a long-standing legacy of market leadership, transformation of growth.
Ramsay Santé was created in France roughly 40 years ago for the older in the room, as I am, I would say a daughter of the former Compagnie Générale des Eaux. Capio was created in 1994 in Gothenburg, west of Sweden. A couple of key other date. We are saying the merger, the entrance in the capital of Ramsay Health Care and Crédit Agricole Assurances took place on October 1st, 2014. If you look later at the key date, in November 2018, former Ramsay Santé acquired Capio in order to extend, to diversifies, and to begin the integration. 2018, we are saying. Then on the road, we have done two mid-size acquisition, GHP Specialty Care in 2022 to reinforce our footprint in Sweden, 24 facilities, 23 in Sweden, one in Denmark. In 2023, we entered the fragmented over EUR 30 billion primary care market in France by taking the former Cosem.
Now, very pleased today, once again, to share with you our next plan up to 2030 Connecting Care. I can't help looking at the growth figure between 2018 and 2026 from EUR 2.2 billion to EUR 5.4 billion. So what makes Ramsay Santé Group unique? Seven reason. Seven reason we are going to elaborate in due course during, I would say, the next moment. Couple of words. Compelling European market, leading healthcare platform of scale with systemic relevance in four countries, truly integrated care offering anchored in medical excellence, a partner of choice, and that's critical for patient, payers, doctors, and of course, our team. We are at the forefront of digital physical care and AI innovation, and we want to do more. We have got a solid financial performance with a clear strategy and milestone in spite of a constrained tariff environment, and we are an experienced management team.
Let's try to illustrate in a couple of facts, I would say, each of these reason. The first one, the market in which we operate. The market are supported with favorable demographic, with very good visibility and high barriers to entry. There are many facts around that. If we go on the left side, you know many of them. Aging population, prevalence of chronic diseases. I will come back to this later. Therapeutic innovation by pushing, I would say, up the demand, and we can foresee. If we look at the four key countries in which we operate on the right of the slides, very easy to remember, if I may, in the last 10 years, the healthcare expenditures in average has grown at 3.2% per year. In the next five years, we expect 3.3% per year. The bottom of this slide is really important.
Not only we've got very good visibility and a strong and growing demand, but we operate in a sector with high barriers to entry. What do we mean by that? In France, you cannot do anything without an authorization delivered, registered in the five-year plan of any regional health agency. You cannot do without. Beyond that, you need to have a significant level of certification to operate. As well, by definition, in order to be in this sector, you need medical expertise, you need the medical resource. There is a real knowhow in investment. Finally, because there are very specific regulation, you need to have a regulatory expertise. First reason, compelling market in which we operate. Second reason, the scale, the systemic relevance of Ramsay Santé in its country. Once again, we are number one healthcare player, Sweden, France, Norway. Number two in Denmark, sorry.
Number two in Norway. A couple of figures. There are many, but trying to share with you some according to us important. In France, the private sector, which plays a key role, we've got a 21% market share in Medicine, Surgery, and Obstetrics. In Sweden, primary care, we are the leader with 1 million of Swedish patients listed in all primary care. The primary care, if I may, is the organization of GP in towns. I would say, once again, 10% market share. We are the leader, and at the same time, opportunity to keep on developing. We are the leading, as an example, in France, leading national expertise in cardiology. South of Paris, we've got one hospital, the larger one for cardiac MRI in Europe, in the top 15 in the world for implantation, is that the right word in English, of aortic valves, as an example.
Another example of a systemic relevance, we were sharing the number of patient visit per year, which has grown from 9 million to 13 million in the last five year. In France, 67 million inhabitants, as you know. If whatever is the type of hospital, public, private, non-profit, religious or market share in surgery, we are taking care of one French person out of eight. One French person out of eight. Another example of being a trusted partner for the government, the complexity, the importance of what we do. In France, we've got 350 oncology authorization. I would like to end this presentation of maybe too many figures, but one according to us, which is really important, an acid test of our strategy in the last year.
As we have been sharing, our strategy has been to build integrated pathway. Out of these 13 million patients, 20% are coming from internal referrals from one activity to another in order to ease the patient pathway. We will come back to this. That is very important, and we want to build on that. Another reason why we consider being unique, we have become a mission-driven company in 2022, a very specific French status. It does not change at all on focus on profitability and value creation. Rather, it serves as external recognition of principle that has been always in our DNA: medical excellence, taking care of our own people, respecting the environment, et cetera. It has always been central, and you can see example, I would say, on this slide regarding Ramsay Santé. All these topics are key drivers of sustainable, profitable growth.
Moreover, our commitment as a mission-driven company are audited every year, and the Chairman of the Audit Committee is Mr. Martin Vial. Another reason that makes us consider having built differentiating competitive advantage is this integrated pathway. To be a bit more detailed, it means that in these four key countries, and sorry not to talk about Italy, but France, Sweden, Norway, and Denmark, we are a player. We are delivering care in prevention, in primary care, imaging in radiology in three countries out of the four. We are a key player, of course, with 250 hospitals being Medicine, Surgery, and Obstetrics, being full care rehabilitation after a stroke, for example. We have got dedicated hospital to recover after a stroke. We are a key player in mental health in all these countries, and we are more and more developing at-home taking care, including in palliative care.
Britta will give us example where we are very developed with a fantastic medical excellence in Sweden. Finally, we are working around this with digi-p hysical solution. Why do we consider it makes sense to have been working on this integrated pathway? Because once again, the patient suffering more and more from chronic disease with more and more specialized doctor, et cetera, they do need an horizontal coordination of a pathway. It reduces the time, it is better in term of delay, and there is a continuity of care. It is better for employee and doctors, of course, to be able to take care of a patient, to follow up a patient in their pathway.
For the payer, because we are reducing the access to time, and of course, it promotes access to healthcare to all, and it avoids us, in any case, to be disrupted by any other, I would say, player. I have been talking already quite a lot regarding our footprint in various countries. We are not just an addition of country. If we are chosen to be in this country, it is because of the medical excellence, the role we play, and being a pan-European player, we are relentlessly leveraging our best practice from one country to another. Our mantra is sharing is caring, or another way is stealing with pride. What does it mean?
It means that in the last year, we have been entering from scratch the primary care market in Denmark, in France, developing in Norway because we have been leveraging our unique expertise of managing primary care center in Sweden. Very proud, and Britta will come back to this. In Stockholm, we are managing a fantastic flagship called S:t Göran . S:t Göran maternity ward has been opened a couple of years ago. Over 3,000 babies now every year with the support, the expertise of the French team. The French and Danish team are working together in order to expand our imaging footprint.
Maybe more importantly, in terms of working as a team together as a clinical networks that we are building between our specialists, and our Chief Medical Officer will come with many more detail how we are better from a patient and efficiency standpoint through, I would say, these clinical networks. Another reason we have to be, and we are, a partner of choice for patient, payers, doctors, and employee. We are going to deep dive a bit on these four topics with a specific focus on employee on the next slide. Patient in our industry, as in the service world, NPS, Net Promoter Score, has become, I would say, the level of measurement from a patient experience. Very, very pleased to share with you that in France we have been improving in the last years, and that as of today, we are at 74.
Once again, Margareta, our Chief Medical Officer, will share with you how do we rank what means the 74 on a worldwide basis. In Sweden, very good to NPS with 69. Same, you will see later Norway, Denmark, Italy. Regarding our payer, we are interested partner with our payer. We play a key role, as we're saying, being in oncology, accessibility, emergency department. We will share with you some facts, I would say, on all this working side by side with our payer, with, by the way, many cooperation with public hospital and et cetera. Being France, being all the country in which we operate, we are seen as a partner for public authority. We'll give you some facts about this.
Regarding employee and doctors, regarding employees, our engagement score has improved in the last year, reaching a best-in-class 87% in Sweden, a good 65% too in France, and we cannot not see a correlation between the engagement score, the quality of care we deliver, and the decrease regarding the turnover rate of the team. We were saying focusing about the team, of course, those who delivers okay, that's more than critical. We are a people business, and if we were, once again, to have some keywords, we would say we need to attract, we need to develop, we need to lead, and we need to care. As to attract, maybe to take two points I would say on this. The first one in Sweden, we are the number one employer seen by all the nurse community in Sweden, number three for doctor.
In France, we are proud to say that we have 6% of our total workforce with disability, which is, as you know, a commitment versus a French law. Regarding develop, as an example, we have trained in the last 3 years, 2.5 years to be precise, more than 5,000 of our team members regarding AI. We are working a lot with junior doctor. As to the lead with the management of this company, all management, all CEO of all the facility. Every year we have over 300 of our top manager which are trained through specific Ramsay Santé Group leadership program. Finally, putting our people at the heart of everything we do. As an example, in France, we are the first company to have a work-life agreement signed with all the trade unions in order to take care of those who are delivering the care.
We were saying to a trusted voice among payers, policymaker, and healthcare leader. That is critical, obviously. A couple of points to try to share that with you. First, we do contribute to the future of healthcare delivery. Beyond the fact, as an example, to take care of one French people out of eight regarding surgery, we have close to 1 million of French people in a 30+ emergency department with a 20-minute average time before seeing a doctor, whereas the average on the French market is 2.5 h ours , 2 hours and 30 minutes. We have a Ramsay Santé Foundation, which in the last year we have been incubating key startup in health prevention, close to 200 in the last 6 year. As well, with this foundation, we have 6 million of people, France and now in every country, to which we are proposing prevention programs, et cetera.
We have been, it was a long time ago and yesterday, we have been at the forefront of the pandemic response. In France, half of the COVID patient in resuscitation bed were taken at Ramsay Santé, whereas our market share is 21%. The team has done an exceptional job, I would say, by creating in less than 6 weeks over 370 additional resuscitation bed. Many COVID patient has been taken in S:t Göran. Finally, being a co-pillar of the healthcare system. A couple of figures. In France, 60% of our facilities are in underdeveloped medical area, as such, recognized by the French state. As well, in France, 20% of the patients we are taking care are patients with low income revenue. For the French person listening, the CMU- C. So, 4 million of poorest people.
Regarding our university hospital in S:t Göran, the student we are taking care every year, Britta will share with us many more details. Another reason that we consider makes us unique, the fifth one, is being at the forefront of digi-physical care and AI innovation. This is for the patient, this is for the team, for the management, and this is for the doctors, I would say. Regarding the patient, we have been the first one in France to create an online admission tool already 10 years ago, Ramsay Santé, which as of today, more than half of the patient, they do everything online. They are booking the day of the surgery, the type of room, if they consider they will need a taxi when getting out, et cetera. So it is a real tool, I would say, in order to ease the access.
By the way, it's a tool to increase the revenue cycle management. As to Capio Go in Sweden, we've got fantastic tool in order to take care of the patient through workflow, referrals, and including prevention program that we push to the patients. Management, Ramsay Compagnon is an internal AI tool that have been built as an umbrella of the best, I would say, classical AI we know we use, and we are leveraging on that in order to do medical content. Finally, regarding employee doctor, we are working with a lot. The list is not exhaustive. We are working with a lot of startups in France, in Europe, and NetMed, as you know, the Nordic country are more digitalized, so great deliveries from our team in the Nordic, Sweden, Norway, Denmark regarding startup.
Once again, transfer our best practice, Tandem as an example being one as a speech-to-text rollout in our primary care in Sweden, and we begin to roll out too in France. There was, by the way, an announcement two days ago on that. Another reason what we consider differentiators, going back to figures. Solid financial performance in the last 2 years. On the left side, the revenue has grown, if I were to work through rounded figures, from EUR 5 billion to EUR 5.3 billion, which is a growth year on year of 3.9%. Quite well-balanced this growth, as you can see, because the 3.9% is 4.3% in the Nordic country and 3.8% in France. On the top of the slide, you will have the like-for-like growth, excluding the FX effect, which has been 2.5%, 2.3% in the last 2 years. Now, moving to the EBITDA on the right side.
There is a first way to read the figure, and I will propose a second way that we consider more accurate. The first one is to note that the EBITDA has grown from EUR 611 million to EUR 638 million. That being said, post-COVID, the French state for all hospital in France, public, private, whatever, have put in place a very specific system called the French revenue guarantee system, and a couple, too, of inflation grants. As of today, in the last year, these specific grants put in place post-COVID were 0.0, whereas they were still EUR 60 million 2 years ago. So excluding these grants, it cannot go below, I would say. But if you finish excluding this grant or margin, the EBITDA margin has increased from 11.1% to 11.9%.
All this we have been sharing with you has led to a couple of result on the slide regarding the strategy we are just getting out called Yes We Care 2025. As we can see on the right, beyond the financial figure, huge increase in the number of patient visits, and we will see later where do they come from, on what type of segment specialty we have been building for the future. Increase by 50% in the last 4 years, 5 years, sorry, of the digital consultation, undoubtedly an enabler for the future and a demand from the patient. So website visit has been increasing by, has been doubling. You may be surprised that we talk about website visit. Well, patients suffering from chronic disease, a patient becoming more and more a consumer in our industry, we are proud of what we deliver and being proud once again.
We propose, we try to build a pathway for him to reduce the delay, et cetera, and creating, I would say, some loyalty is very important and explaining what we can do. Finally, it is not by random that we will close by this imaging volumes increase, namely 41% in the last year because France, this is a figure mainly for France. France is still underserved regarding imaging equipment, all type of imaging equipment. So there is an unmet patient needs, a very still interesting segment from an efficiency and economic standpoint. Imaging is at the crossroad today and even more tomorrow of any diagnosis assessment for a patient. As we will see, we have got 130 now imaging equipment in France, and our number of volume has increased by 41%.
As a consequence of this, now moving, and we will detail later with a specific session with strategy. Next year strategy moving forward to 2030 is going to unlock the full potential of this integrated care with some acceleration, with, I would say, some specific focus. We want to ensure active portfolio and contract management. Please accept now the words, we will detail later what it means. We want to strengthen integrated and accessible healthcare offering. We will embrace the digital transformation of healthcare delivery, still certainly at the beginning. More than ever, we will continue to focus on cost initiatives, and we will accelerate additional profitable growth through new revenue stream. Connecting Care 2030, we are going to share with you with more detail what it means, what are the consequence, and with a further look, I would say, in France and Sweden.
Finally, we are a people business, so once again, pleased to share with you, the management, the ExCo team in Europe of the group. Everybody is here today, and people will be very pleased to have a discussion with you for those, by definition, attending here in the room, at any break. That being said, it is certainly very important to do some deep dive, 10 minutes, regarding the market or forecast of the market in which we operate in Europe. What about the healthcare market as a whole? First slide is to illustrate that if we step back, there are very, very few industry where we can anticipate with some accuracy, we think, what will be the need, the demand in the next five, 10, if not 20 years.
Really, in our industry, we have got so many key and foreseeable drivers that we can say that as of today, we say that in the last 40 years, healthcare expenditure in France and Sweden used to represent, as you can see on this slide, in the 1970s, roughly 5% of the GDP. Last year, 11%, roughly in France, Sweden, net-net, around the same in Norway, Denmark. Whatever the study you may look like in the next five years, healthcare expenses will grow faster than the growth of the GDP. It not go without asking some question, undoubtedly, but this is a real asset of growth for it to know that there will be more and more need and to remember at the same time, very high barriers to entry. What is driving that? Aging population, obviously.
Aging population, as you can see on this slide, the number of people that are going to be over 60 years old is going to grow very rapidly. It was roughly 41 million people in 2020. It will be 48 million in 2030. Why insisting on the people over 60 years old? Because as you can see on the right of this slide, they represent half of the healthcare expenditure, and as a percentage, it will increase. We are very well positioned to answer the need of these people as we as a leader in cardiology, in oncology, in dialysis, in orthopedics, et cetera. We will take care of a growing number of people because of the aging population. Another key reason is chronic disease.
In France, as you may know, as an example, there are 31 disease, cancer, insulin-dependent diabetes Type 1, et cetera, that are considered as a chronic disease. Roughly 16% of the French people are suffering from a chronic disease. It represent already 66% of the total expenditure of healthcare in France, and this percentage is growing. Thus, once again, the importance to be accessible, integrated, and to build pathway. An expected rise of the chronical disease. On the right of these slides, we are an amazing industry with a lot of passion because we know that tomorrow we will take care better than today of the patient, being through medical, I would say, innovation, being in surgery, drugs, et cetera, but to the way of delivering the care. Innovation is a fantastic driver of this industry. Innovation mean that the demand is increasing.
Maybe two example very different and very cautiously on the first one, versus 20 years ago, some cancer become chronic disease. Not all of them, unfortunately. Another positive example on that side, hip prosthesis. On a daily basis, we are taking care in all country of patient 90, 92 years old to do a surgery on hip prosthesis. 30 years ago, it was not the case. All this innovation and diffusion and with an increase, I would say, standard living, people are more and more taking care with, once again, innovation. These are key driver. There are many other regarding an expanding demand. Another one on the left side of the expanding demand in all the country in which we operate, waiting lists are increasing. Being to see a GP in towns, being sometimes to have access of a surgery. These are figure for the global market.
For example, in France, in the last five years, having an appointment with an ENT doctor, an otolaryngologist, an ENT doctor was in average 37 days. Now it is two months on average in France to meet with a specialized ENT. Sweden is facing, as the world in the country, an increase in the waiting list of patient, which is front page of the Swedish newspaper every day. On the contrary, versus this increase in waiting list, you could ask, yes, but what about the ability that you have or the world industry to take care in the future on this patient needs expectation? Good news. Good news versus some figures five, seven years ago, the number of doctor graduates now is increasing in all the country in which we operate.
Another point to share with you regarding the strong market fundamental for the next five, if not 10 years, is that as we are saying more and more, the patient is comparing. The patient wants to look where he is going to. If the waiting time is too long, he will not hesitate more and more to change, I would say, his choice, where he wants to go, where he wants to have a surgery, et cetera. He becomes, to some extent, a kind of consumer. It is as it is, and versus, I would say, this change in the patient expectation or answer is agility, flexibility, and to be digitalized. We have been already in this pathway. Connecting Care 2030 is going to take us to the next step regarding this pathway.
Another point which is very important regarding the market fundamental and the roles, what is our footprint as private operator in each and every country? Let us take two key countries, if I may, France and Sweden. In France, 36% of all the hospital are private, and if you take only surgery in France, more than half of surgery is delivered in the private hospital. It is a legacy of the 1945, I would say, decision and history. So surgery in France is mainly done in private hospital. 40%, in France of the chemo session are done in private hospital, and by the way, we are the number one on that. In Sweden, regarding primary care, the organization of GP interns, more than half of the primary care patient are taking care by private provider. Once again, we are the leader.
If we look to regarding, I would say, our own coverage on all this, as you know, and we will see later, we are the number one player. So what it means regarding the role of the private hospital, and let us talk a couple of seconds regarding France. We all know that France is facing, to be polite, quite a complex economic situation. On the bottom right of this slide, you will have, we think, very important figures. Private hospital in France represent 25% of the total beds, or let us call it capacity. We are doing 35%, 36% of all the activity in France, whereas for the French state, the payer, the French tax, we are representing only 18% of the total cost with, in average, a better quality.
Long story short, the private hospital in France, they are part of the solution regarding the challenge of the French economy. As to Sweden, as you can see, as we have just said, more than half of the primary care are private, whereas for the Swedish taxes, any citizen, they represent only "38%" of the total. So this is first, we are operating with one of a fantastic market where we see a foreseeable demand for many driver that we can predict, and we do consider that a differentiating factor make us very well-positioned in order to answer to this future unmet or, let us say, patient needs. Now we are going to move, I am sure you have been waiting for that, too, to figures with Clément.
Thank you, Pascal. Good morning. Good afternoon, everyone. Maybe before going through the next few slides that cover our historical financial performance, I would like you to keep three important facts in mind. First, our revenue growth has remained resilient, predominantly volume driven. Two, underlying profitability has continuously increased over time despite a constrained tariff environment. And three, operational execution has providing us a solid financial position, solid foundations for our next phase of growth. Let me now set the context in which this performance was delivered. As outlined by Pascal, we are supported by powerful and structural tailwinds that are here to stay as care demand is growing in all our geographies, and that's a very important point.
However, we operate in a constrained tariff environment where tariff have lagged inflation over time and, as outlined, temporary grants that were here to offset missing volumes post-COVID or specific inflation has now been totally discontinued. Against this backdrop, the last two years are the perfect proof point on how our strategy has enabled us to grow profitably, to diversify our revenue streams, to build a more integrated platform, and to develop our activities in the right segments. The key achievements of the last two years have been, first, in France, the acquisition of ex-Cosem primary care centers in June 2024, the opening of 11 Médipsy mental health centers, and the rollout of 25 new imaging equipment over the last three years.
In the Nordics, and specifically in Sweden, we have been awarded the contract to operate S:t Göran Hospital for the next eight years plus four optional years at a better tariff conditions versus the previous one. And importantly, this growth was supported by effective performance actions driving further productivity. I will have the occasion to come back to this today, but performance in our industry is the engine that converts growth into higher margin. Here are the key figures that I would like you to retain. First of all, our revenue have reached EUR 5.4 billion in FY 2026, growing 3.9% on average every year over the last two years. Scale matters, and as you can see on these pie charts, we are now well-diversified, both in terms of geographies and specialties.
Our EBITDA margin reached 11.9% in FY 2026, EUR 638 million, out of which 70% is coming from France, 30% for the Nordics. Before diving further into figures, I would like to remind one important point. France and Nordics, they share a lot of similarities and operate obviously in the same group, but they do not share exactly the same earning model. One major difference is the revenue base. In France, more than 80% is regulated by the French state, with tariffs typically revised once a year, and Jérôme will have the opportunity to come back on the French funding system later today. Increasingly, we generate hospitality revenues that are non-regulated and directly get from patients. And we also reinvoice to the French Social Security, specific medical purchases at no margin, representing approximately 8%, as you can see here, of our revenue base in France.
That mechanically contributes to dilute our margin percentage calculation. In the Nordics, our funding model, it's much more diversified with basically three main segments. First of all, primary care in Sweden, 136 primary care centers operated under a capitation model with a fixed fee per listed patient. S:t Göran Hospital, under a long-term contract agreement with the region of Stockholm, and Britta will have the opportunity to explain how essential our role here is in S:t Göran. Specialty care in all our Nordic countries, that are regulated under different kind of contracts, and especially in Sweden, funded by 21 different regions. The second difference is the cost base. Personnel cost, obviously, is the main cost driver in both geographies, but is not directly comparable between France and Nordics because the medical model is not exactly the same.
In France, most of our doctors, they are self-employed consultant doctors, therefore their cost is not reflected in the cost base. By contrast, in the Nordics, most of the doctors are employed, driving personnel costs, as you can see here, representing 65% of our revenue base. With that in mind, let me now deep dive into our recent historical trading performance. Our growth, as I mentioned, has been resilient 3.9% on average per year over the last two years. Well-diversified and increasingly diversified by geography, 4.3% in the Nordics, 3.8% in France, and by specialty. By specialty, as you can see in this bridge, MSO remains the main growth driver over the last two years. The other segments such as Primary Care, Imaging, Geriatrics, are growing at a faster pace. So back to MSO, 2.7% increase on average.
Driven in France by higher volumes, 2.5% on average, partly offset by a continuous switch from full hospitalization to ambulatory care. In the Nordics, MSO growth has been fueled, notably by the new S:t Göran contract under better tariff conditions, so with higher revenues over the last six months. The transition was successful in January 2026. Primary care increased by more than EUR 150 million over the last two years, driven in France by the acquisition of the ex-Cosem primary care centers, and in the Nordics by both increasing in the patient base, but also better tariff support from the regions in this area. Geriatric cares have benefited from the strong demand in this segment and are fueling the specific business line in Sweden by more than EUR 20 million additional revenues.
Finally, imaging is growing by more than 4% a year, reflects our ability to roll out new equipment, to secure new authorization in this segment, as you know, which is a very interesting segment because strong demand and but also good profitability. Let me now further comment our historical revenue performance, but on a organic versus M&A versus FX perspective. Organic revenues has remained resilient 2.4% on average over the last two years. We operate in a tariff-constrained environment, notably in France. In France, tariff increase has remained modest 0.5% in March 2025, 0% in January 2026, and no restitution of the prudential coefficient either in December 2024 nor December 2025. As a reminder, prudential coefficient is a retention that is made upfront by the French state, 0.7%, that may be released afterwards, depending whether the national expenditures met or not the total targeting envelope.
No restitution means a tariff decrease of 0.7%. However, on the positive side, we also benefited in June 2024 from a 2.17% increase, when a specific coefficient called CICE coefficient was canceled. It was a coefficient specific to private sector, now canceled, so now fully secured in the tariff base. More importantly, since this date, now every variation in tariffs that we observed have been similar between public and private players, reflecting a principle of equality of treatment that we advocated and that was agreed at this time with the French government. Organic growth has been resilient in France, MSO-driven, organic and volume-driven, in the Nordics, sustained by a strong demand of care and S:t Göran new agreement. We were able, through this growth, to translate sustainable demand of care into tangible volume growth.
M&A, I mentioned it mainly reflects the acquisition of the ex-Cosem primary care center, but also a couple of bolt-on acquisition done in the Nordics. FX has improved over time thanks to the appreciation of the Swedish currency against the euro. Let me now zoom in our EBITDA margin, that was sustained by this growth, converted into tangible margin improvements thanks to higher efficiency and productivity. In FY 2026, our EBITDA was at EUR 638 million, 11.9%, increasing by 0.8 percentage points over 2 years. This margin improvement has been powered by all geographies. In France, 0.6 increase in percentage points in 2 years if we exclude the temporary grants that have been phased out. That's an important point to remind.
In the Nordics, 1.1 percentage point increase over 2 years, notably fueled by a new contract, S:t Göran transition in January 2026, so with a 6-month effect, but more to come in FY 2027. Again, tariffs have lagged inflation over time, and if we were able to increase profitability, thanks to good conversion of this growth into tangible operating leverage and additional performance actions, and I will come back to this point. Importantly, in this environment, performance, operational excellence makes a difference to navigate a challenging tariff environment. Let me come back to this performance plan. As you can see here, they are made of different streams, new revenue streams, segments, new strategic focus, such as enhance hospitality revenues, but also cost-cutting actions in every region, in every functions, both administrative but also medical. Concretely, it means leveraging our scale. It means aligning on internal best practices.
It means benchmarking each others and developing internally a true culture of performance. Over the last year, FY 2026, we estimate these actions delivered EUR 80 million of additional EBITDA. It's not one-off. They are structural actions and impacts that are now embedded into our operating model. It's a tangible proof point on how we were able to convert operational performance and excellence into tangible financial results, and we will not stop there. We already identified new actions to come that will bear fruits in the future. Let me now highlight a couple of action that were successful, that delivered tangible results over the past, and where we believe again, we can do more. In France, we have multiplied by seven over the last 5 years, the day medicine specific revenues, out of which, +30% increase over the last 12 months.
It is accretive to our margins and at the same time, fully aligned with public payer expectations. We believe we can still accelerate in this area. On the cost side, we reduced by 72% the temporary staff cost over the last two years by more efficiency and productivity, but also prioritizing on permanent staff recruitment. In the Nordic, a couple of examples as well. In the Primary Care segment, we reduced by 13% the ratio of pharmaceutical cost on revenues, thanks to the use of Geriatrics and the alignment, the rollout of the best practices across the whole network. We also optimized our orthopedics sourcing, thanks to reduction of the number of reference of implant references, enabling to increase the volume per reference and therefore decrease the price per reference. Again, we will deliver more. We monitor these plans.
We have a specific monitoring of all of this action to make sure that they are converting into tangible EBITDA and cash flow delivery. In parallel, our capital expenditures have remained, as you can see here, fairly stable, around EUR 200 million every year over the last three years, focusing on high-value segments to ensure profitable growth, to ensure the continuity of our operations, and also AI and digital investments. In addition to our maintenance regulatory CapEx representing roughly 2.9% of our revenue on average, we have focused our development CapEx capabilities to the areas where we see a strong demand, where we see a clear strategic focus, and of course, obviously, where we see higher return. It includes notably CapEx to continue to optimize our MSO portfolio, and Jérôme and Pascal will come back to a few example later, notably in Valence.
25 new equipment in imaging, but also CapEx in medical innovation, including surgical robots, including AI-assisted tools, including specific digital medical care delivery to increase the patient access, improve the patient access, but also the operational performance. Margareta will have the occasion to explain how critical these investments are to maintain and further improve our medical quality. Let me now have a look on how our revenue, combined with higher EBITDA margin, converted into robust cash flows, combined with disciplined allocation of our capital, enable us to reduce the leverage over the last two years from 4.9 x in June 2024 to 4.7 x in June 2026.
As you can see in this bridge, we benefited from positive working capital variations thanks to an improvement of our DSO receivables in France, notably, but also from the one-time effect of a factoring program that we implemented recently, which is now recurring and will be reconducted on a recurring basis. Again, remind, in our industry, working capital is a cash resource with DSO from patients, PHI, Social Security, being shorter than our DPOs. We also benefited from a one-off specific opportunistic transaction regarding our real estate, a sales-and-lease-back operation that has been performed in June 2026, generating EUR 45 million of additional cash, therefore reducing the debt and improving the leverage. Let me now show you how we reinforced our balance sheet. June 2026, we finalized successfully our refinancing of EUR 1.75 billion senior debt package, Cov-lite, including EUR 200 million of RCF lines.
This operation was supported by both existing lenders but also new lenders and our banking partners. This senior debt package now fully accommodate with the contemplated transaction distribution of our shares by our shareholder, Ramsay Health Care. We also extended our maturities from 2031 to 2033, so by 2 years, providing higher flexibility to deliver our strategic ambitions. We reconducted our ESG sustainability-linked package behind this debt that now covers approximately more than 85% of our gross debt, enabling to reduce our financing cost. We profited also from this operation to simplify our balance sheet structures with a refinancing of EUR 100 million of former Euro PP notes. Overall, this operation enables to provide higher flexibility and reinforce our capital structure. On the balance sheet again, let me now have a word on our real estate.
Our real estate portfolio at the end of June 2026 is valued at approximately EUR 1.5 billion, quasi-exclusively in France, 42 facilities. As you can see here, it represents roughly 21% of the square meters that we operate, 380,000 sq m. If we zoom on the location, as you can see, more than half of it, or roughly half of it, is located in prime areas: Paris region, Lyon, or Lille. Owning high qualitative real estate is a key asset for the group. It provides higher flexibility on the operating leverage. It provides also opportunities to secure financing at attractive conditions, EUR 350 million at the end of June, including real estate finance release, mortgage loan, Fiducie Sûreté, what we call Fiducie Sûreté in French is security trust mechanism.
This is a key asset enabling to increase the flexibility and reinforce our balance sheet structure as well. As a conclusion, as you have seen in this presentation, we have been able to deliver a resilient, broad-based growth. We intensified our performance actions, and we will continue to do so, thanks notably to an embedded culture of performance and innovation. Paving the way, of course, to a future profitable growth going forward. At the same time, we continued to invest selectively in our platform. We leveraged the company, and we reinforced our balancing structure. Altogether, this provides a solid foundation from which to execute our Connecting Care 2030 strategy and move confidently into our next phase of development, that Pascal will now detail in the next section. I thank you for your attention.
Thanks, Clément. Just to summarize, resilient and solid result, a stronger balance sheet, paving the way for the future profitable growth for this company. Talking now about the strategy, we have been sharing with you before, at least the name and the 5 pillars, to give you more content, more flesh, I would say, versus as of today, just a flavor. This strategy undoubtedly is part, I would say, of a continuity of the last 10 years. If we just rewind a bit. The plan we had launched in 2015, called Let's Do It 2020, was undoubtedly regarding the diversification to scale into a European group. Tick. In 2021, we have launched a Yes We Care 2025 plan in order to create a robust platform, being more integrated, more diversified with digi-physical solution. Tick. Now we do want to unlock this full potential.
We want to work on very specific action we are going to take you through in order to open the new chapter of good medical excellence, best-in-class medical excellence, and profitable growth for Ramsay Santé. Just coming back on the left side, we have seen already some of this figure, but a different angle regarding where we are. You certainly remember that in the last four years, if we go on the left on this slide, we have said we are pan-European, more diversified, leading position, and more integrated. As a consequence, as you have seen, the percentage of turnover outside of France has grown from 19% to now one-third. As a consequence, the footprint in MSO in France, in a constrained tariff environment, as a percentage, has decreased.
As a consequence, in the specific PHI segments in Sweden, where 15% of Swedish citizens now do have an insurance, and this is a growing number. We are the leader. We are around 30% market share. We have been multiplying by three our footprint, and we will keep on. Britta will come back to this. Once again, and very importantly, our number of patients is now fueled by internal referrals. Talking about the number of patients, we have been saying before that the patient in the last year has grown from 9 million to 13 million. But where does this growth has been coming from? In fact, it does not stem from the inpatient. The future of this industry is outpatient. We are very proud, of course, to take care of inpatient patients if they do need, of course, this type of care. However, outpatient is critical.
As you can see on the second bucket, I would say, on this slide in the dark blue, the growing patient, 3 million, has come from outpatient imaging, primary care, day hospital, mental health, et cetera. As well, as you certainly remember, our number of digital patient has been growing a lot. In the continuity of this, where we are, what we want to be, how we are going to deliver, and how we are going to build to keep on building a sustainable competitive advantage. Five pillars we are going to detail one by one with further detail, of course, when talking about Sweden and France. The first one is ensure active portfolio and contract management for the profitability. The second one is strengthen integrated and accessible healthcare offering to capture the growth.
The third one is to embrace digital transformation, ongoing accelerating of the healthcare delivery efficiency for the patient. The fourth one is to continue to focus on cost initiative. Clément has shared with us the EUR 80 million delivered last year, obviously, for the profitability. Finally, and very importantly, both for profit and undoubtedly efficiency and for the patient, accelerate additional profitable growth through new revenue stream. All this, more than ever, embedded in our ambition, our DNA, that we once again reiterate more than ever, quality care at every step for everyone, more than ever our ambition. In order to deliver these five pillars, in order to respect this plan, we do think that we do need to leverage seven capabilities, and they are all linked one between the other. Medical excellence, we will have a specific session with a Chief Medical Officer. People, of course.
Data and AI, an enabler of strategy, a fantastic opportunity in our industry. Brand and reputation, customer centricity, putting patient at the heart of care. Sustainability, we want to keep on building on sustainable deliveries. Finally, the word IT infrastructure encompass a lot of core topic in order to build, once again, to be risk safe and to look forward. These five pillar, let's give you some content. The first one, in order to work on the efficiency and the patient, is entry, active portfolio, and contract management. What do we mean? If we go on the left side of this, in the world, in Europe, we've got 491, once again, facilities. The MSO network in France, we will keep on, we will accelerate the network rationalization, the refocus of medical offering, and the active transfer, and the potential closure.
As you know, we have been clusterizing our business since the last 10 years. Jérôme will take us through a very concrete example, and more than ever, we want to optimize the facility network, transfer some activity in the close by activity in an industry where, in a given place, the more you do volume, the better in average your quality, the more efficient you are, the more you can reinvest. Just to share an example that will take place in 10 days, October 1st to be precise, in Valence. As of today, Valence is a town south of France between Lyon and Marseille. We've got, as of today, three facility very close by. We will transfer one of the activity and the team for one facility in the other two.
Net-net, we are going to close one of the facility, and we will deliver through that a better EBITDA performance. We will go back to this. On the other side, and it's more impacting, I would say, potential on the Nordic country. We do a lot of activities through contract management. Britta will explain us the regulation and our footprint in this in Sweden. It has been already said, 8 years plus 4 years, 12 years, to manage since January 2026. Very proud to have won once again, this RFP, S:t Göran, and only six months as of today in our accounts, once again, with better tariff terms. It is a contract management. We have done a ramp up of a new maternity.
We are going to enhance once again the high quality of our deliveries, and we expect, in the next year up to 2030, 30,000 additional patients to be taken care. The second point, which is, I would say, versus the patient and the growth, strengthen integrated and accessible healthcare offering in our Connecting Care 2030. We want to keep on growing on where there is unmet patient needs and where we can deliver a good profitability. As such, and Clément has been already a bit touching base on this, in the last two years, over 20 authorization and net MRI scan have been open in France. We are going to keep on more than ever doing that. We will take some additional example with Jérôme. Regarding primary care, I'm on the right of that slide. In Sweden, we are the leader in primary care. It's still very fragmented.
We have only the 10% market share. In the last year, the team has done a very good job by increasing the number of listed patient. We are best in class regarding the medical outcome and the experience measured patient outcome, and we plan to keep on growing in the market that we consider is considered by specialist company to keep on growing at a 4% CAGR every year in the next year up to 2030. That is regarding accessible healthcare offering. Regarding the further driving development of integrated care chain, I would say that has been, once again, the logic of the last year. We want to increase, we want to keep on working on that. On the left side, it is maybe a better, more detailed example regarding the entry point of the patient through the healthcare system.
Sometimes the patient enter directly through a MSO facility, through a needy MSO, and this patient, he, she needs to go to a primary care GP, so we can refer to the close by primary care that now we have in many country once again. As well, getting out of imaging, I would say, activity, 62%, to be precise, of people having an imaging activity in one of our department, they will need, there will be something, let us call it something. They will need a nearby GP consultation, surgery, whatever. So we are integrating this care. As well, getting out of MSO hospital, taking care at home of the patient. Many times old patient, but not always. S:t Göran is a great example of proposing our elderly and mobility activity in the Stockholm region.
All this with digital approach, continuity of care in order to take care of the patient what he or she needs. As a consequence of that, we have been sharing that as of today, 20% of our patient last year have been taken care through internal referrals. We plan to increase this figure in the next year. In order to do that, one, I would say two of the key initiatives, these five pillars are very correlated, one with the other, is to keep on embracing the digital transformation of healthcare delivery. We are convinced that all the industry needs to accelerate. We are convinced that we are already well-positioned.
We are convinced that best practice sharing is a necessity, and we are trying once again versus all our managers, all our team, to promote internally this sharing is caring, and we are working more and more with some specific startup. We are testing to prove concept. It is in the middle of the slide with living labs. Living labs, for example, in Aquitaine in France, south of France, close to the Spanish border. We have got many large hospital, et cetera. We have got dedicated team testing, I would say, somewhere to take care of the patient with a digital solution. If it works, of course, we have got this avidity through our innovation hub and our culture to roll out rapidly where it makes sense from a patient and economic standpoint. Focus on cost initiative. Clément has shared some initiative. Jérôme and Britta will share.
Once again, that is critical for the profitability. We anticipate a constrained tariff environment. We want to be resilient. We want to be able to navigate, and we will navigate through that. A couple of examples, procurement optimization in France. 10 years ago, we used to have roughly 300,000 references on the shelf being hip prosthesis, drug implants, et cetera, eye implants. We are now below 100,000. We are going to keep on improving the occupancy rate of operating theater. That is critical in order to amortize the fixed cost. As you can imagine, an operating theater, to be best in class, is quite a cost. Jérôme will share with us later what has been our delivery in the last year and how we plan to keep on increasing.
Overhead reduction, we are going to keep on working on how to improve, to do better with less, and how we can work on the non-medical staff in order to increase the productivity with various tools. Maybe just an anecdote, but an example. In three weeks, we are going to move our headquarter from the north of Paris to another place outside of Paris, dividing by more than two the cost of our HQ. Medical staff efficiency, big decrease in temporary staff, over 60% in the last two years, and that is not a one-off. That is a structural improvement that is now done, and once again, there are other stones to be turned in order to keep on doing that. Let us call it workflow optimization relentlessly in order to work on all the dimensions. So key focus, once again, on the cost initiative.
We want to enter new revenue streams addressing patients' needs. There are many, in fact. Let us start, by the way, by Sweden on the right of this slide. Through our Capio subsidiary in Sweden, we are about to address a growing need. There are over 3 million of Swedish people salaried, and the company in which they are working, they want to promote for their employees preventive packages. Something we do see, by the way, in many countries in Europe. We are very well-positioned with Capio, our team, in order, I would say, to capture this growing need. As well, to stay on Sweden one second, the private health insurance on which we are already the leader, we have got a strong expertise to discuss with the local insurer in order to capture market share versus the increasing waiting list.
In France, just two examples regarding needs of the patient unmet and profitable growth. We want to expand and we will expand our home-based care, which is something on which France is lagging, and as well, as we know, France, we are very far behind many other countries in Europe regarding taking care of some mental health issue, mental health patients through daycare. We have been already expanding in the last two years. We will increase this expansion in the next year. So to summarize, Connecting Care 2030, we would like you to remember our ambition, quality care at every step for everyone, quality of care, patient safety, Choosing Wisely, and give us a couple of minutes with Margareta to detail what means and where we are on Choosing Wisely. International collaboration through clinical networks. Innovation, research, and training.
Our DNA to keep on recruiting the best doctor, the patient, and looking forward. That being said, I think if I am right, we are a bit in advance, by the way, regarding timing, which is quite rare. I propose, I think we can do a break by now, and we will reconvene at 10:55 A.M. Am I right saying that? Yes. Thanks a lot, and I propose, of course, for those attending in this room to share a coffee and to come back at 10:55 A.M. [Non-English content].
Welcome back from the break, everyone. I hope you had some good interaction, and welcome back to you online as well. Hope you found something good to do during the break as well. I am very happy to present to you something that lies very close to my heart, that is medical excellence. Medical excellence is actually the core of our business. Medical excellence is what gives a good outcome for our patients, and that is what will make them trust us, come back to us, and stay with us. This is not only true for the patients. The medical excellence is also what will make us win tenders, what will make health authorities trust us with contracts, and what would make public healthcare insurers trust us as a partner. For doctors and staff, medical excellence is also of huge importance.
They want to be in places where they have the resources and the environment to perform their best. Furthermore, medical excellence is what brings quality, and quality is what is bringing productivity, and that is what will lead to the long-term financial outcome. To do the right thing with the right patient at the right moment and nothing more. That is what brings productivity and quality. Medical excellence is an important strategic driver for long-term success. We can look at medical quality from many different perspectives, and one of them is evaluation from external bodies. We have in France, the HAS, the Haute Autorité de la Santé which will give accreditations to hospital. This is done every fourth year by a peer review, and you can see that we- Am I on the right slide? No. Why is this?
It is the next one.
Yeah. Sorry for that. I didn't recognize the numbers. Now you can see on this slide. Sorry to confuse you. You can see on this slide that our Ramsay Santé hospitals have a higher degree of accreditation, both compared with other private hospitals and with the public hospitals. I think an external evaluation that is maybe more influential, and that is the one that is very much talked about by healthcare professional and healthcare providers. That is the ranking done by the French magazine Le Point every year. This is not a ranking of healthcare providers, but it's a ranking of hospitals and procedures. And you can see here on the slide that among more than 1,000 hospitals in France, actually 15 of our Ramsay Santé hospitals are among the top 50 hospitals.
This is the external evaluation of quality, but now we go to the maybe opposite perspective, the patient's perspective, the patient satisfaction. We want the patients to be happy with their contact with us and to feel confident with us. Again, this is what will give loyalty. This is what will make them stay with us and make them come back to us. But we actually know that a high patient satisfaction also affects the medical outcome because it will make the patient more compliant to the treatment, and it will make the patient more engaged in his or her own healthcare. I think Pascal passed briefly through these numbers of NPS. Patient satisfaction can be measured in many, many different ways, but one of them is the NPS, Net Promoter Score.
This is used in many different businesses, but in healthcare, a number from 25 and above is considered to be very good. And you can see here that in all the Ramsay Santé countries, we are far above that number. Moving on from this to the medical outcomes, I think that both Britta and Jérôme will dive a little deeper into what different services we have. But I have picked out four examples of this. But first, I want to quote Voltaire. [Non-English content ] The art of medicine consists of amusing the patient while nature cures the disease.
This was probably true in the 18th century when Voltaire said it, but since antibiotics and anesthesia came to medicine, there has been huge advances that really makes medicine give a difference for medical quality, for health quality, for the individual patient, and for society. So what I want to share with you, that's four examples, and on the top left, you see the myocardial infarctions. Myocardial infarctions, that means a heart attack. That means that the heart does not get enough oxygen to pump. The outcome after a heart attack is highly dependent on how quickly you get care and exactly what care you get. And here you can see that in the Ramsay Santé hospitals in France, the mortality rate after a myocardial infarction is significantly lower than the average in France. Moving one step down, we look at breast cancer surgery in Sweden.
This is a survey on small breast cancers that are screen detected often before the woman feels any symptoms. Those are almost 100% curable, but they can be curable in different ways. The traditional way is to remove the breast. We today know that many of these women can actually keep their breast with the same curability rate. The Swedish National Breast Cancer Register has a target of 85% of the women with this type of cancers that should be able to keep their breast. In Capio Sweden, we achieve 95% of the women. It is not enough to only measure medical quality in the hospital. Something happens with the patient also after the hospital stay, and to make sure that we are really doing good quality, we have to follow the patient and see what happens after.
On top right, you can see the results on surgery for gastrointestinal hernia in France, and the slide shows the readmission rate. This means all the patients that got good surgery and went home after the surgery, but a certain number of them will come back to need to have to redo the surgery. You can see that this readmission rate is lower in our hospitals compared to others. Another really long-term result that I think is very valid because it is really into the quality of life for the patient, not only for the surgeon who has done well, but actually that this affects the patient. This is the follow-up of the quality of life after hip replacement one year after the surgery, so that is quite a long time.
These results are really sustainable one year after, and you can see in the Capio Sweden orthopedic units, this surgery leads to a higher quality in life compared to other hospitals, which also means that not only the surgery was good but also the rehabilitation. My role as a Chief Medical Officer in Ramsay Santé is to make sure that we are always on top of medical excellence. Medical excellence is not something that you achieve and then you stay there and keep doing the same. We know that society is changing a lot. Pascal mentioned the different trends. We know that our possibilities to cure and to bring health are getting bigger and bigger, but at the same time, the demands and the wishes from both patients and society are growing. Therefore, research is a very important strategical driver for us.
We know also that units that are engaged in research, they are much quicker and prone to adapt new methods, new treatments, new interventions, new innovations. That is not only true in their own field of research, it is true like a cultural thing, that if you are into research, you are also prone to adapt and change. One out of five physicians in Ramsay Santé are engaged in research. We have more than 1,000 publications in scientific magazines every year. For the last five years, more than 10,000 of our patients have been engaged in more than 700 clinical studies. So research really strengthens our quality of care today, but it will also attract a new generation of healthcare providers. Innovation is another important field, and that sort of overlaps the research, but it is not really the same thing.
Innovation often addresses the how we do things, not the what. We do the same thing, but we do it in a different way that brings higher quality and higher efficiency. Sometimes it is only a behavioral change, and maybe the word only is not really good because behavioral change is one of the hardest things to do. But often it also includes innovation, the use of new technique. I will here show you three examples of this. First, robotic surgery. Robotic surgery means that we can do surgery with a much, much higher precision than the traditional way. That means that the tissue around is less damaged. That will mean a quicker healing and a shorter rehabilitation. This is used widely in cancer surgery, but we are now in Ramsay Santé also doing pilots in other fields, for example, even joint replacement.
Pulsed field ablation is also a wonderful new technique. It is a treatment against something that is called atrial fibrillation. Atrial fibrillation means that the heart, instead of pumping steadily, solidly, strongly like this, it flickers, which makes a much less strong heart, much less efficient. It also gives a risk for blood clots forming in this flickering heart and going away, giving stroke and infarctions. With pulsed field ablation, you can treat and cure the electrical pathways that have gone wrong in the heart. Traditionally, this is done by heat or cold, burning or freezing in the heart, which again brings a lot of damage around the place where it should cure. But when you do it with purely electrical impulses, you can do it with much higher precision.
My third example is digital healthcare or virtual healthcare, and that means giving the possibility for patients to meet us through chat and through video. Five years ago, this was really controversial, but today we know that all medical consultations that do not include a physical examination can actually be done online. That makes the availability for the patients much, much higher, and it also gives the opportunity for our doctors to work in a much efficient way and also save their time for the patients that really, really need the physical contact. In Sweden, in Scandinavia, this is so much used now, so we no longer talk about digital healthcare. I think we hardly say digi-physical healthcare. It is so natural that digital tools are part of any patient pathway.
In France, we are also using this more and more, and we are also trying in new fields, for example, into mental health, where this technique helps us to move mental healthcare from inpatient to outpatient. So these types of innovation add to improve quality and productivity, but also to achieve sustainability for healthcare. I have some problems with the slides here. Clinical networks. Being a multinational healthcare provider is really a great opportunity. We can learn from each other. We know that medical excellence and medical science does not have borders. It is global. But we know that we can learn from each other by seeing how we do things differently, for example, by adapting to our healthcare systems that are different in different countries. This helps us take one step aside and look at our own services and see how we can do them differently.
We can also add knowledge. What we do in Ramsay Santé is that we make professionals meet over the countries within the specialties, also to help Executive Committee and management with knowledge that is important for strategic decisions. I will give you four examples from the clinical networks that we had during the previous year. The first one is in sports medicine, that takes the base that many of our orthopedic clinics are highly specialized and have collaboration with elite sportsmen. The Capio Artro Clinic in Sweden, Nimi in Norway. I can give you the example from the Olympics in Paris. We had actually 80 of the athletes coming for medical interventions at our clinics before the games, 24 of them won medals, so I think we did something good.
In this clinical network, they looked at the very specific competencies for different types of sports that we have all through our countries and made a business plan on how we can use this competence so that it is available in all the countries and therefore attract these athletes everywhere. That also attracts the lay sportsmen. They want to be in the same clinics as the athletes. The obesity network got a question from the executive committee, that is, how do we handle all these new medications and all these new pharma that can help obesity, which is one big challenge and a big opportunity globally.
They did a big mapping, they did a deep dive into research and science and came back with a very good suggestion on how to work with patients with obesity very broadly through all our businesses, addressing this group, picking them up, offering them the best services, and where to use pharma. What was maybe a little surprising for us was also they said, "Keep the bariatric surgery right now. It will still have a place in medicine." I think those of you that go to the site visit this afternoon will hear a little more about that. We had two more clinical networks, ophthalmology and anesthesiology, and they did more of a classical benchmarking, looking at what we do where. They also came to the conclusion that we should join the global movement that is called Choosing Wisely.
That is actually looking very carefully at all the procedures we do to try to identify tests, imaging, small things that are not actually necessary for the quality outcome and remove this, thus giving a more efficient pathway for the patients and for us. Prevention is maybe the most effective type of healthcare because it prevents the disease from coming in the first place, and we work with that on many different levels. The first one is the Prevent2Care Lab program in France, where we, through the Ramsay Santé Foundation, support startups in prevention and help them with expertise and mentoring and to try their products in real world. That makes us also be frontline and see what is coming. The Prevent2Care Lab also participated in the French prevention week.
But we also work with prevention in clinical care, and here is an example of hypertension, how we treat high blood pressure in primary care in Sweden. Pascal mentioned the capitation system, and Britta will come back to that. But in the Swedish healthcare system, it is actually very good to keep your patient healthy. Of course, in every healthcare system, that is good for the patient. But in a capitation system, reducing the blood pressure for our patients and preventing heart infarction, more serious and more costly things, that is actually good for all in the long run. Finally, I do not think you can talk about the future without talking about AI. Of course, this is something that is important in Ramsay Santé as well. Yeah, that is right. One good example is mammography screening in Sweden.
Mammography screening is that women are called in certain intervals to get a mammography screening to detect early breast cancers. Traditionally, these images are looked at by two doctors. We did a big scientific study led by Karin Dembrower at Capio S:t Görans Hospital where one of these doctors were exchanged to AI. We showed that by doing this, 12% more early cancers were detected. That was not the only benefit. 13% of the false positive were not seen. We reduced that level a lot. Also 26% less of the women had to come back for new imaging. This really got lot of attention. It was published in The Lancet and The BMJ, and Karin Dembrower was the keynote speaker on many international conferences. But best of all, I think, is that we could immediately turn it from a scientific study to clinical everyday practice.
Big data is also something that is very important, and we are investing in healthcare platforms where we can collect data, transform it into knowledge, and use it for our strategical planning and for better medical excellence in the future. I would say all through these teams about medical excellence, they have one thing in common, and that is that they lead to quality leads to productivity, and that will also give the good financial outcome. Medical excellence is not a destination. It is a journey, and we are very well profiled to lead that journey. With that, I leave over to Jérôme to introduce our services.
Hello, everyone. Thanks, Margareta. Delighted to be with you in order to present you a few slides on the French businesses. Once again, one of the core business of Ramsay Santé. I will take you through, in fact, of a journey that the implementation during the last couple of years on all the action that we have launched with the team in order to navigate in a changing environment, in order to reshape the French activities and locations, as mentioned by Pascal, to adjust our organization to the new trends, and as well, in order to be ready to accelerate on the implementation of the new strategic plan. Three ideas I will develop in the following slide.
The first one is that we are operating, but we are as well well-positioned in a regulated market, French one, with having as a headwind the tariff, and as a tailwind, the growing volume demands. Second idea is that most of our past and future performance and efficiency measures improvement will be, in fact, done through levers that we control ourself. Third point is that the next five-year strategic plan could be seen mostly as the acceleration of the existing strategic plan with the right balanced approach between continuation of all the action we have launched, especially in terms of efficiency and improvement measures, and as well, fueling the next growth levers that we have identified. Now, first, let's discuss about a quick snapshot on the market where we are operating on. As you can see on this slide, we are operating, in fact, in five different sectors.
First one being MSO, and I will not come back on the breakdown of the activity in France. Full Care Rehabilitation, Mental Health, Imaging, and Primary Care. When you read this slide, you will see that there is a total market size for all of these sectors. Then second, the market size related for the private operators, and after, market concentration or market share for the private operators. The main comments on those slides are the following. First one is that when you look at our positioning in those specific sectors, you see that, in fact, we have a leading position. Being in a leading position is quite important in order to play an active role in the next five years evolution of those markets. Second thing as well is quite important from a dynamic or performance standpoint, size matters a lot.
Second comment is that when you look at the addressable markets. First talking about the first four verticals, you will see that the global addressable market for private operators is roughly EUR 30 billion. So that's the market we can address. Then after, and that's a specific point, primary care. Primary care, as you know, for France, is a new market. It's a new area. It's a new activity that we have developed in the last five years. Now, thanks to the previous strategic plan, thanks to as well a nice support from Sweden, given their expertise, given their size on this sector. At the end, it's a market that can represent up to EUR 39 billion or EUR 40 billion total. It's a market where it's a bit more difficult to see what is public, what is private.
But we can consider that most of this market could be seen as private, given the fact that we are talking about independent doctors doing consultation flows. So at the end, please keep in mind that there is a EUR 70 billion addressable market for us. At the end as well, what is important is that we can consider that we are the number one healthcare provider or service provider in France, globally speaking. That's quite important when we think about our strategy, which is indeed developing care pathway integrated care. Now let's talk about the overall regulation around that. Everyone has his own view on it, but I believe that most of you will consider that France is a super highly regulated market. It's true. I will not deny it. It's true, but I think it's a very good thing.
It's a very good thing because at the end, in fact, when we have the size of Ramsay Santé in France, when we have the diversity of activity in France, when we have the footprint that we have in France, in fact, it's a super strong protection being in a regulated market. It could be seen as a very nice high barrier to entry. It goes, of course, alongside other expertise that we have, like making sure that we master quality processes in our clinics, that we master as well or that we entertain correctly an experienced team, and that we work alongside our doctors community. But all that together, I mean, in fact, that being in a regulated market is something that could be seen as very good and very important for us. Now, how this market is organized and what is the dynamics around that?
First, at national level, direction are given by both the national health ministry, second, by national administrative bodies, and they are in charge of things like pricing strategy or defining what is a care quality audits that they want to impose to each and every care player and hospital on our case. Second is that there is as well an organization at regional level. This organization at regional level is mostly organized around 17 health regional agencies. They are in charge, among plenty of other things, of one topic which is quite important and has been mentioned by Pascal, which is the authorization processes. Please keep in mind that we need authorization to operate in our clinics. If we don't have an imaging authorization, we can't develop imaging business. Okay? So we need authorization.
That's why we have more than 1,000 different authorization to cover all the spectrum of care that we want to address in each and every facilities that we have in France. Now let's talk about the funding system. That's a slide with plenty of information, and I will help you going through that. As I would say, as a synthesis or as a summary, I could say that in fact, funding in France is massive. It's growing, but it's not enough. Why it's massive? When you look at the left part of the slide, you will see that ONDAM, which in fact is a French wording to talk about the healthcare national budget in France. ONDAM is at EUR 274 billion. It cover the total healthcare services and markets. Within that, once again, we have EUR 70 billion of addressable market for us. Second comment on what is growing.
When you look in the middle, you will see that there is a CAGR over the last period, roughly between 2019 and 2026, of 4.5% CAGR in average. 4.5%. So it's growing. It's growing, clearly. Let's talk about the way the budget, in fact, is allocated and is built, because that's why, in the end, it's not enough. The way the budget for healthcare is done, first, it's completely a mirror of the French state budget in terms of process, in terms of organization, which mean, in fact, that it's a process lasting over a year between the initial assumption that are taken or the macroeconomic assumption that are taken to define the budget, and then after the implementation on real life, and in our cases, for example, on tariff.
Which mean that during this one year, if you have volatility of some of the macroeconomic assumptions, there is no chance to be completely reflected in the final implementation of the budget, and it is the case for inflation. We have in the past, a severe misalignment between the initial assumption retained or the inflation level and what is inside the tariff at the end. Another point that has been already mentioned by Pascal in the tariff is that you see that year after year, that you still have a significant discrepancies between the tariff provided to the public and the tariff provided to the private sectors. Such discrepancy can go to up to 80% + of gap when looking at some specific care, 80% +. Why do I say it is underfunded? We will talk about that later on specific to the private sector.
But first, please have a look at just the white rectangle on the left part as an example. Here it is written that in fact, the public hospital deficit has widened during the last six years from 2019 to 2025, from EUR 0.6 billion deficit to EUR 2.5 billion deficit. That is a nice example, unfortunately, of the fact it is underfunded or it is not enough funded. Now, let us move to the revenue breakdown for private sectors, where it is coming from. As I said, it is a regulated market, so obviously we have mostly paid by public administration, and that is what we see on this chart. The main payer for us, by far, is the private health insurance. Public, sorry, health insurance. In France, what we call the CNAM, Caisse Nationale d'Assurance Maladie. What it give us? It give us, in fact, very secured payment. No risk of not being paid.
It give us as well short payment delays. We are paid in less than a month, globally speaking. That is very important. Now, the remaining part is private payment. Those private payment can be mostly splitted into two equal part, one part being a patient out-of-pocket, the other one being private insurance payment, and in France it is called mutuelle. Mutuelle, in fact, is a private health insurance that are strongly linked with administrative French bodies. Okay. If I see this graph a bit differently now, what is in fact the level of revenues that are regulated, that are managed in a way, directly or indirectly, by the French administration and the French state, we go up to 90% to 95% when we add up what is paid by the public health insurance and when we add up as well what is controlled or regulated and paid by the mutuelle.
If we move to the next slide. Sorry. A bit more specific on the evolution of the tariff, the evolution of the inflation, and the main driver around that. First, an explanation of the slide. You have three graphs. The first one, which is really the tariff evolution year after year during the period 2019 to 2026. The second one, which is the national inflation index. Okay, that is the national inflation index. The third one, which is really the national volumes covering everything. So it is both outpatient, inpatient. What we can see on those graph. First thing, maybe a technical point. 2021, you see a white rectangle, 6.2% stating Ségur effect. The French government had decided in 2021 to massively increase nurses' salaries, mostly nurses' salary or salaries of people in the employees in the hospital.
To do that, they have decided to do that as a recognition for COVID, as a fact that they were not enough paid in the past, et cetera. They forced both public and private to increase the salary. To do that, they have added up 6.2% to the tariff in 2021 to finance it. At the end, please keep in mind that for Ramsay Santé, it's a net-net zero approach in terms of margin. We have not saved money, we have not paid more. Excluding this topic, you will see that in fact, when you look at the two first graphs, tariff versus inflation, that each and every year you are under finance or tariff does not reflect inflation each and every year.
Keep in mind that given the budget is done, you need to look at year N for the tariff and year N-1 for the inflation to have a direct link. Last comment on this slide, national volume. National volume is growing. As said by Pascal, it's a kind of a mega trend. We have chronic diseases. We have more and more care to deliver to the patient, so it's growing. So we have a strong underlying trend from this topic. As a summary on this slide, I believe we can say that national volumes is clearly the tailwinds, or national and growth volume is clearly the tailwinds, where tariff is the headwinds.
Now, after those few slides on the global market, the global dynamics in France, let's see in fact what are the kind of player, the kind of healthcare operators that can in fact benefit or that can benefit the more from this current environment and in order to capture the volume demand. I can simplify, and it has been said by Clément and Pascal, size matters. We need to be big. We need to be sizable. We need to be diversified. It's quite important in the French environment in order to address and to capture this growing demand. Two things on this slide. The first one is when you look at the left, you see once again a certain number of figures. They are all showing, in fact, that we have built in the past decades or years significant barrier to entries. We already have 350 oncology authorization.
We have more than 100 numbers of dialysis stations, et cetera. It's all strong barrier to entries. I would just comment one specific figure, which is a 91% certification average. This 91% from a technical standpoint, first, it has been already started to be explained by Margareta. Technical standpoint is the nine remaining percent doesn't mean that we are not certified. It means that we are certified under a certain number of condition that we need to fulfill in the coming months. Usually, it's processes that we need to adapt to the latest regulation, and that has not been updated quickly enough. It's processes that we need to adjust given the organization of the clinic, et cetera.
Nothing major, things that we need to address in order to make sure that we deliver the right set of care to the patient, and that we are working in close relationship with doctor for them to deliver the right diagnosis or the right act. I think the 91% is a very strong recognition of the work done by employees, nurses, and by doctors on the quality of the work or the offer that is made toward the patients. Now, on the right side, once again, size matters. Size matter globally speaking, we mentioned it earlier. Size matter as well at local level. We don't ship a patient from Marseille to Lille. We don't move a doctors from Lille to Marseille. We need to look at local level as well.
What you see on this chart is that, in fact, we have very strong market share at local level, Lille, Paris, Lyon, Toulouse, for example. At the end, it means that we can be considered as the main alternative or even the only alternative versus the public hospital offerings. If you want just to make one deep dive, look at the Lille region, 82% market share for private. If you don't want to go in public, you have to go at Ramsay Santé in Lille. Next slide, a deep dive on our activities. Once again, looking at the same kind of split that I have presented earlier. Globally speaking, please keep in mind one thing that we have an integrated care approach.
Now, when we look at the competition and when we look at our colleagues, we see that most of healthcare operators could be a leader, could be strong in one vertical. We are unfortunately not strong in one vertical. We are strong in several verticals at the same time, and that's super important when we look at integrated care operating model. Now, looking a bit more in the details. You see that we are leader in orthopedics, ophthalmology, cardiac surgery, oncology, dialysis. We have a leading position in rehabilitation. We have a leading position in mental health. We are number one in imaging. We are number one as well in primary care. All that goes with two things. First, recurring investment, as mentioned by Clément, on the long run.
Second, the fact that we invest on innovation, we invest on state-of-the-art tools and equipment in order to make sure that we deliver what needs to be delivered for patients and doctors. Just a few example of that. 29 robots, orthopedics, urology, covering different kind of care. Over 900 operating theater, state-of-the-art. No condition on those operating theaters, by the way, in terms of certification. Over 140 imaging equipment. Now, let's talk of something which, for me, is even more important than what I just mentioned earlier of verticals, leading in each verticals, et cetera. It's once again back to the integrated care platform model. We have developed, in the past years, a model of not looking at hospital by hospital separately, but really looking at it at regional level in order to make sure we can benefit from the size effect in a way.
It's not something that others can replicate easily because we need to have the size in each and every region where we implement this kind of organization. What does it bring? It brings, first, economy of scale by definition. It brings ability to share capacities. It brings ability to share expertise, to coordinate teams, to strengthen some of our activities, to do the right allocation of resources. At the end, please keep in mind, in fact, that once again, all that is done first as let's not talk about one hospital separately from the other. It's done as building an integrated care operating system in a way, with the objective to enhance patient outcome, to enhance capital allocation, and to make sure that we have the right efficiency measures in place. We have a nice example of that, which is the Lille cluster.
The Lille cluster, what we've done in the last 10 years is, in fact, strengthening our activity, gathering them in the same location, making sure that we share the expertise, removing what we believe is non-core, relocation of some of the specialties in one dedicated area. All that, in fact, has been done through a 10-year period, and has been done thanks to the ability to discuss both with all our employees and with our doctors as well, because a doctor should be part of it. The underlying message behind this slide as well is that when we try to execute such a plan on a 10 years basis, once again, we do it only with people and with team. We believe we have a talented team. I think Pascal mentioned it. Healthcare is a people business.
We need employees to put in front of patient or to manage patient or to help patient. We need employees as well to work with doctors. We can't escape that. So we need to manage our workforce, clearly. That's what we are doing. A few figures first. Over 28,000 employees, more than 80% being medical trained staff. We make sure that they are trained at the appropriate level. We want them to be at the state-of-the-art in terms of procedures, in terms of medical knowledge. Doctors. 7,000 independent doctors. Quite a nice community. On top, we can add more than 750 salaried doctors, mostly rehabilitation and for our primary care businesses. 11 years average doctor tenure. They are not here just popping up for a few years. They are here for the long term. Quite important.
Therefore, we have built a numerous conference, conf call, video meetings, et cetera, in order to exchange with them on visions that we have, views, difficulties, ambitions, projects. Quite important. We strongly believe that we need them. They need us as well. Two figures. 86% doctors recommendation to their relative to go on Ramsay Santé facilities. Well, it's 4% missing. It's already 96%. 65%, sorry, engagement score for employees, and it's growing. I would say that on top of those two very nice figures, we can even say that it's showing the recognition of the team on our strategy and on the fact we can leverage or use them or they can be helpful to develop and to implement the next strategic plan. Having said that, why do we believe that we have the right to win in France?
Why we have the path to success for the next couple of years? Six reasons. First one, largest integrated network in France. We mention it, we said it. It is already existing. We will continue to develop it. It is of paramount importance, as I said, size matters. Second, new care pathway, because we believe that is the new trend and because we believe that we have already built the foundation to continue working in this direction and be part of the next healthcare revolution in this direction. Third, digital first. Digitalization is everywhere. Digitalization and AI already started, as mentioned on some example by Margareta, both from an administrative standpoint and operating standpoint. Fourth, quality of care. Well, it is part of our DNA. I will not come back on the 91%, which I think is the foundation on which we can build the next evolution of quality of care.
Fifth, operating excellences, as well part of our DNA. We have an holistic 360 degree performance plan mindset in our DNA that we have already started to implement and that we will continue all direction. Public affair. We have a unique positioning. We have a unique positioning. It give us a voice. Pascal started to mention it. It give us a voice to explain our difficulties, to explain what we believe are the next five years or next 10 years view on the healthcare services, our opportunities as well, and our ambition. At the end, I would say that we have the right to win, in fact, because we have understood that in order to succeed, we will need to execute correctly or properly the underlying action plan behind those six reasons. We have demonstrated in past years tangible results in this direction. A few comments.
First one, evolution of the healthcare services. Healthcare services, as mentioned by Pascal, moved from inpatient to outpatient. We believe it will move to care pathway very quickly. Just one example, clinical diseases. The patient will not come every time in the hospital, so we need to find new care pathway in order to integrate that. That is what we have started to build. That is what we will continue to build. We will connect, or we will do the connection between our services within our hospital. We will do the connection between our hospital within the cluster. We will do the connection between our cluster within the territories managed by the health regional agencies in order, indeed, to have this vision of increasing or with better care for the patient. That is why we have invested in primary care. That is why we invested in imaging.
That is why, we have invested in mental health day clinics. That is why, in fact, we have as well invested in digital tools to make sure that we have the appropriate framework to work in this direction. Second focus, operational excellences. Operational excellences, the mindset is the following. We need to be pragmatic. We need to be agile to make sure that we are following any kind of trends in front of us or any kind of difficulties in front of us. Therefore, the strategy or the mindset is we standardize when it matters, and we remain local where it counts. Another way to look at it is that we need to focus on, or we want to focus on action plan, on improvement, where, in fact, we control the levers. Way easier to manage.
Three examples of what we have done in the past to explain as well that we are well in charge of the next plan and the continuous improvement plan that we are working on. First one, occupancy rate for operating theater, +5 points in one year. Right allocation of resources. We are careful of the allocation of resources. Second thing, working efficiency, -62% of temporary staff in two years. We have a kind of a toolbox in order to manage scarcity of resources. Procurement excellences. 88% of purchases made under the framework of a national contract. 8% reduction of SG&A cost in our clinics. We control our cost. We look at our cost.
As well, we leverage our size, and we will continue to do that with the doctors through the Choosing Wisely approach, once again, which is the right care for the right patient at the right moment. We believe it can help us as well to optimize our procurement, for example. Next focus, Pascal mentioned it, portfolio reshuffling. I would broaden the view. It is not only portfolio reshuffling, as some can consider. It is a way to adjust the services or the activities within each and every clinics or location in order to make sure that we follow the ongoing trends in the healthcare services. Here we use the full scope of actions possible or operations possible. Rationalization, refocusing, merger, transfer, whatever the kind of action that can be possible, we assess it in order to see if it is answered best to the situation.
Now, there is one transversal mindset which is quite important. We never do that without prior long discussion with both health regional agencies and local political authorities, public authorities. Why? Because we believe that, in fact, we need to look at the care offering for the patient, and we should maintain this care offering, globally speaking, at the appropriate level, and usually defined by the health regional agency. Last focus on digital. Digital first, it is everywhere. It is part of our DNA now, both for more operating processes and administrative processes, of course. Two mindset. We do not look at technology, just new technology, just for the beauty of the new technology. We look at the new technology as a way to enhance our existing processes, as a way to bring to the next level of efficiency, of quality, our internal processes, once again, both administrative and medical.
Second topic is that it is an holistic view that we are looking at. We are not looking at cost driver. We are as well looking at quality and enhancement. It is super important to look at the way to enhance the data that we have in our tools to make sure that the quality is the right one. At the end, especially when you talk about medical data, it will be used by nurses and doctors to assess, to define, to be more specific on diagnosis. As well for revenues. We need to look how it can help our revenues. It is visible that we have such analysis or such assessment in all different kind of family of processes that are presented on the left part.
On the right part, you see a specific example on the electronic medical records for the patient, which is where, in fact, we gather all the data, all the information needed for nurses, all the medical staff, globally speaking, at the time where the patient is in one of our location. Why do we need to have a strong, to have a stable EMR? Why do we need to have a standardized EMR as well? It is because, in fact, it is written on this slide, we need it, in fact, to support our care pathway strategy. We need it to support a high level of quality of data that once again, are needed by our doctors to assess correctly the situation and do the right diagnosis.
We need it as well because it will help or smooth the journey of the patient within our location. We need it as well because at some point we are delivering a care and we need to make sure that the invoice is exactly in line with the care we are providing. After those few focuses, as a wrap-up, we have built, we have created with the team a dynamics, in fact, that should be seen as the first step of the Connecting Care strategic plan that we will implement. Going through the five pillar of this strategic plan again. First one, ensure portfolio management. We have medical project in each and every of our clusters. We have already started to implement them. We need to continue. We need to accelerate when needed. Second, strengthening our care pathway. We have care pathway here and there.
Now we need to make sure that each and every cluster will develop care pathway, leveraging on what is already existing, both nationally and internationally when talking about with other countries. Third, embrace the revolution on digitalization and AI, of course, as I said earlier, on processes, but as well to support our new care pathway, especially virtual hospital. Fourth, continuation of the performance plan. Of course, once again, 360 degree view, which mean everywhere, everyone, every day, all line of cost, all line of revenues, all processes. Last one, accelerate towards innovative solution, new solution, new care pathway, new revenue stream. I will mention just one thing, which is the evolution towards virtual hospital. What is virtual hospital, just in a very simple sentence?
Once again, when we said that care pathway is going outside of the hospital more and more, outside first from inpatient to outpatient, and then to care pathway. We need as well to offer care pathway to our patient that will in fact involve being at home and being in our primary care, and therefore being less and less maybe in the hospital. That is what we call virtual hospital. I will end up on the fact that the team is committed, as I said. The team knows how to execute the plan. The team has already executed the previous plan and the previous performance and efficiency measure that we had designed with them. Therefore, I will come back on the ideas I just mentioned at the beginning. Regulation is something which could be seen as very important for us because it is a high barrier to entry.
And we know how to navigate within this environment. Second is that we need to focus, and we have already do so, on performance improvement using levers that we control. I have shown nice example on operating room occupancy rate or the temps evolution, temps cost evolution. The next five-year plan is really mostly a continuation or an acceleration of the previous one, adjusted obviously to the current situation and with a balanced approach between what needs to be continued and how to fuel the next growth level. Thanks a lot. Now I leave the floor to Britta.
Thank you, Jérôme. Are you still awake? You know that research says that attention span is 45 minutes at the most. Our kids, their attention span is maybe two minutes, so I ask you to stand up and sit down so you are ready for Sweden. You online, please stand up and sit down too. Yes. I am happy to have the opportunity to deep dive on Sweden. The first couple of slides will be on the healthcare system and the conditions for private providers. Then I will go into Capio, what we are, and where we are heading. See if I can get the slides going here. The first slide is on the healthcare market, and it is a big market in Sweden as well, with a high proportion of GDP spent on healthcare. The proportion of private health insurance is growing.
It is more limited than in France, but it is growing, and it is totally separate from the public system. So you go either into public funding or into the PHI system. The reason why I am mentioning this already now is because it is a tailwind for us with growing queues and people that are not satisfied with the public system, they invest, and their companies invest in private health insurance. But the majority of our business is, of course, being a partner to the public system. On the mid bar, you see where we are able to operate. 86% of the publicly funded healthcare in Sweden is provided by the public, but 14% of this huge amount of money is outsourced to private players, the vast majority in primary care, but also in specialist care. At the bottom, you see our market share.
We have a good position, and we have a competitive edge, I would say, that I will come back to being the only provider on the full care continuum. So that was about the money spent on Swedish healthcare. How are we organized? We are a tiny country compared to France, 10 million inhabitants. Nevertheless, we have 21 healthcare systems. We have 21 regions, and healthcare is funded on the regional level, and we have a regional taxation. Hence, it is fully tax-funded. Everybody is covered, but it is very decentralized. Even if we have a national legislation on care choice in primary care, we have 21 different rule books for how this is defined in the different regions. When it is decentralized and where you have 21 regions, healthcare is not totally evenly spread.
They are differently good at organizing healthcare, and private provision is outsourced to private providers to different extent in different regions. Hence, we have growing queues in Sweden, as you see to the right from you, and it is unevenly spread. This is a good tailwind for us as private provider as we had in specialist care. It is cheaper than the region's provisions, and we are more efficient, and we can help regions shorten their queues. Oops. Move my glasses. Healthcare in all countries are stratified. We have different care levels. The most expensive level is the university hospital level. Then you have the emergency hospitals, then you have specialized clinics and smaller hospitals, and the primary care. Primary care in Sweden is if you are used to going to a GP, primary care is a broader setting in Sweden.
It is a team-based organization where you have both GPs, you have specialized nurses, both on children care and maternity care. You have physiotherapists, you have psychologists, you have dieticians. So it is much more team-based than a traditional GP setting. If you go from the top to the bottom, the cost of care is, of course, most expensive at the top. Very limited of that is outsourced. The only emergency hospital operated by a private provider is our S:t Görans Hospital. That is the only outsourced hospital in Sweden, but a lot of the specialist care and primary care is outsourced, and that is where we are able to operate. It is also thinking about where the future is heading with a lot more day surgery, day cases.
We are very well-positioned for the future as the vast majority of the business I am running, or we are running in Sweden, is outpatient care. So the high volume is where the private providers are present, and for the regions to outsource care to private providers. Of the publicly funded healthcare, the 14% outsourced, there are two routes to outsource. One is the EU legislation called LOU, which is that you tender a contract. The other path is a Swedish legislation called LOV, and that is more like the French system authorization. It is a care choice system. In the first one, in the tender ones, the region set, they define the volume we are going to take care of, what we are going to do, and for a timeframe. We also know what indexes we will have. In the LOV setting, as it is more of authorization, there is no set timeframe.
We do not have a volume guarantee, but it is more flexible because it can be reiterated with the region, so it is more innovative in some ways. To the right, you see the PHI market is, of course, totally different, and we can have both capitation models, fee-for-service models, other types of risk-sharing, depending on how mature the local insurance company is. We spend a lot of time in developing healthcare and make them understand prevention and preventive care models that I will come back to. The two ways of procuring healthcare, the LOV and the LOU, and how are they used? I said the biggest market for private providers in Sweden is primary care. We have a national legislation of care choice, so it is procured through authorization and care choice, open for all providers. Both private and public have the same reimbursement in primary care.
That's the only area where we have the same reimbursement. It's developing more and more towards a capitated reimbursement that we, per listed patient that we can attract to our care center, we get a fixed amount of money. It depends on in what age group, if you have a lot of diseases, et cetera, but it's really a capitated system where it, as Margareta said, you make value, and it's less costly to work with prevention and not have to take care of a disease instead of working more upstream, you could say. That creates a lot of room for innovative care and how we take care of our chronic patients to make them stable in their chronic disease and not deteriorating, getting that heart infection, stroke, et cetera.
In the green, you have the specialist care that is more unevenly spread between the regions, how much they have outsourced. Of course, a lot of the outsourcing is where a lot of people live, Stockholm, Gothenburg, and Malmö, the big cities. The regions can choose if they want to create a care choice, an authorization system, or to tender a contract. They can, for instance, like in Stockholm, tender geriatric care, just take some level of the care and tender that. Or you can have a broad variety of care and tender for queue shortening, for instance. But it's a limited timeframe. The region defines what kind of care we are going to deliver. So those are the two differences between the way the regions procure between primary care and specialist care. Okay, have you understood the Swedish healthcare system perfectly now? Ready for Capio?
In short, you can say that we are the biggest and the best. So now I can go home. No, but we have the largest healthcare network. You see we have a national coverage. 50% of the population in Sweden live in either Stockholm, Gothenburg, or Malmö, hence we have a high density of clinics where the population is. We are an important and respected player. After those three regions that I mentioned, we are number four, before the fourth region in size as a healthcare employer. We employ 15,000 employees, and we are really seen as a thought leader in a lot of development and a good partner to the regions in helping them develop them.
I will come back more on S:t Göran, but that has been really a way to show the regions lead the way, and they get help that, oh, if Capio can do it, then we should do it as well. As I mentioned, we are in the full care continuum. What do I mean by that? You remember the care levels, but it's also the way, not only what you do, it's also how you do it. So we are in digital care, we are in mobile care, hence hospital at home. We are in primary care. We are in specialist care, including rehabilitation and geriatrics. As I mentioned, we run the only privately operated emergency hospital in Sweden. We also have a special business area that we call Capio Partner. It's here in green, and that's our commercial customer business area.
That is where we handle all the business relationship with insurance companies and other companies. The care is provided, of course, by the blue business areas, but all the contracts are handled there to be able to scale. The biggest business area is primary care, proximity with 5,000 employees. Why are we not regionally organized? Why have we organized ourselves in this way? It is because we think you get good at what you do a lot of, and we use this organization a lot to benchmark best practice, deal with pride, et cetera, that Pascal mentioned. Of course, we have a close collaboration regionally with internal referrals, working on integrated care that I will come back on. So this is our platform that we have in Sweden today. What are the unique capabilities that lead to success?
The coming slides will give you the proof if you don't believe me, but I will take you through the capabilities going clockwise, starting with what I just showed, the large integrated network. That is, of course, the base of being successful in integrating care and develop healthcare for the future. The second is best-in-class quality of care. As you heard Margareta said, quality attracts both patients and the staff. Quality drives productivity to do the right thing with the right patient at the right time, and not more. We have heard it several times, but that is really key, and that is why I love working with healthcare and manage healthcare, even if I am a trained doctor and did 20 years of clinical practice, that this is unique. It is much cheaper to have high quality than to have poor quality.
Of course, we are a service business, and quality is not developed behind my desk. It is in the meeting with the staff, the doctor, the team, and the patient. So have a great employee value proposition is key, and we don't have demographies, not only a tailwind for volume, it is also that we are less people that are going to take care of more people in the future. So we have to attract staff and engage them. Engaged staff are twice as productive as satisfied staff. So then you can realize if you have unsatisfied staff, how productive they are. So to take care of your workforce is really key to be successful going forward. We are at the forefront of digitalization. We are a pioneer in integrating digital and physical care, as Margareta mentioned.
To set the scene a bit, I think that the Nordics are quite ahead in digitalization in all kinds of industry, and I think that Sweden is ahead of the southern part of Europe, and Capio is leading that transformation of healthcare in Sweden. We also have excellency in tenders and integrating businesses. When you win a tender, you take over the contract, you have to integrate the staff in your culture. We also use that skill when we do acquisitions. I will come back on the big acquisition we did a couple of years ago. But to have an integrated platform, not only for our patients, but to embrace the culture for all our staff.
Last but not least, we live in a political landscape and to have a strong public affairs and be seen as the thought leader is extremely important for us to be able to help the regions and politicians to set the right things for the future. I think we are seen as a very important and respected player in public affairs in Sweden. I am also sitting We are on the board for the Enterprise Association, et cetera. Giving you some proof of what I just said. Pascal mentioned that we just re-won the tender of S:t Göran, the flagship of private healthcare in Sweden, I would say. It is very close to my heart. I spent 25 years in that hospital of my life. I think I have spent more nights in that hospital than any other place in the world.
After doing clinical practice, I spent the last eight years there until 10 years ago when I entered this position as the CEO of the hospital. It is the flagship of private provision, but it is also extremely good for our brand and for international and national benchmarking within our group. We are also associated with Karolinska Institutet in research. You heard Margareta talk about Karin Dembauer's research in mammography screening and that we implemented that right away. Normally, it takes 17 years from a research publication until you have it implemented in clinical practice. But we have a much more innovative mindset and culture in this hospital that also spreads to the rest of our businesses. We can show the public that we operate this hospital 20% less. It costs the region of Stockholm 20% less than their own hospitals, and still we do it with a healthy profitability.
As Clément said, we have stable contract conditions for the coming 12 years, eight plus four. We are looking to develop emergency healthcare even further. The latest acknowledgment we got was last month where we got the label Antibiotic Smart Hospital, the first one in Sweden. That is extremely important for the future, how we use our antibiotics to not get resistant bacteria, et cetera. So it is really a sustainability issue. To have that stamp is something that will both save a lot of lives, but also to be a guidance for the rest of the group. I said that we are good at integration, and Pascal mentioned the acquisition of GHP. 23 clinics were integrated to our Swedish operations into the two business areas, orthopedics and specialist care.
It was a very strategic acquisition, because as we wanted to build on integrated care, we needed to expand our platform, which was in specialty care. We had a lot of primary care in Skåne and Gothenburg, but less specialty care. With this acquisition, we got specialty care in those regions. But we also expanded our specialty portfolio with cardiology, expanded in gastroenterology, et cetera. So we really created a much better network for integrated care, but also to capture the PHI volumes, which have increased the revenues fivefold after the acquisition. We also set the base for the future in occupational health as we, with the acquisition, got a small digital occupational health provider included. We promised a lot of synergies to Pascal.
We delivered ahead of time. We got a lot of clinical expertise and the culture has been growing together. We have a lot of capabilities to grow this integrated care into the future. I said that I would come back to what's being on the forefront in digitalization. Margareta said that we almost not talk about digital care, because for us it's all digi-physical care. It depends on, we say digital when possible and physical when needed. We really start with the patient needs and then define what kind of care do we want to provide. In a capitated model in primary care, some things can really be done by the patients themselves by thorough guidance in self-care.
We can do it chat-based, we can do it by video, or it's a physical visit, or an emergency visit, or all integrated in our seamless interface that you see, the Capio app that you see to the right. All our units have a digital front door. We also had, as already heard, the Capio Go, which is fully digital. We can seamlessly network patients that we thought we could take care of digitally, but into the facilities. It's a network of digi-physical care that we have created. Digitalization, though, is not just the way we interact with people or our patients. It's so much more. It's accessibility, it's how we really create an efficient healthcare system.
Apart from making it easier to be a patient, not only having contact, but be able to manage your own disease, and be empowered, it's also about making it easy to be a manager. To make decisions based on information that is not from last month. You have real-time information in your dashboards and even predictive information. We have an occupancy rate of 86% right now. Three patients will go home. How can I plan? It's really making life as a manager much easier. Also for our staff. I said that there will be a staff shortage with the demography going forward. Of course we need our staff or want our staff to spend as much time and free up time to be with patients instead of behind the computer. We try to do that with better tools.
You have already heard about AI and mammography. We have the biggest base of Ambient Scribe, the Tandem, more than 1,500 doctors using Ambient Scribe instead of dictation and then a medical secretary writing it. We have automated recording of our vital parameters. Instead of taking the blood pressure, write it into the electronic and medical record, it goes right into the record. That both saves time, but it's also much more patient safety. Those are just some examples on how we can do, but of course, a lot of admin support. To your right, you see the effects of all those things that we have tried to accomplish the last couple of years. The fivefold increase in digital contacts, or 275 in digital contacts, but also the share of digital contact of all the contacts.
I have tried to give you a glimpse of where we are. I am extremely proud of the achievement we have done in the previous strategy period, Yes We Care, and of our trademark of quality and productivity and continuous improvement. We will continue this successful journey in our new strategy, Connecting Care 2030. To guide you, it is a global strategy, but of course, with local adaptations, as you heard Jérôme previously. For Sweden, if I give you some example, the first pillar about portfolio management, that will be to ensure strong performance at S:t Göran with a new contract with better conditions, but of course, to continue our journey of continuous improvements and productivity. The second pillar about integrated care, to strengthen the use of our expanded network of clinics. We are on a good track, but still a lot to do in truly integrated care.
One contact, and then we are responsible for your health. That is our new mantra to guide the patient in the healthcare system, and with internal referrals, with guidance. The third pillar is about transformation, to embrace a sustainable transformation of healthcare delivery. We all know the challenges we have in the Western world with demography, when less people are going to take care of more people and less people are going to support more people. We are going from a reactive, physical, doctor-focused healthcare into preventive, proactive, team-based digi-physical world, and we will continue that journey and even do more things with Hospital at Home, more day surgery. Today, 30% of all the hips and knees implants, they go home the same day. You are operated in the morning, you go home. When I left medical school, you were hospitalized for at least 10 days.
It is a tremendous development that we will continue to work on this to drive the transformation. The fourth pillar is about productivity and cost control, and we will continue the Choosing Wisely, both medically but also administratively, to have AI-supported scheduling both for patients and staff, to work continuously with our shortening of average length of stay, the day surgery expansion, as I mentioned. Also I think Pascal or Clément showed what we have done with procurement by aligning that we only use a few high-quality implants. We are continuously working on procurement optimization within the group and have a great help also of the rest of the group. Last but not least, we are, as you have seen, very closely related to the regions, and we are working with new revenue streams.
The last pillar is to accelerate our non-public funding to develop more relationship with the private health insurers, but also to reinvent occupational health. Also, other companies than healthcare will have a workforce shortage in the future with demography. To help the companies keep their staff healthy by using our knowledge base that we have in healthcare, that is a new way of expanding and not waiting for people to get a disease, but to really work preventive back together with their employers. I am very thrilled about this angle of the use of our capacity going forward. We have achieved a lot, but there is still a lot of development to drive in healthcare. Thank you.
Thank you. Thank you, Britta. It is now time for me and then for Pascal to conclude this presentation. Looking ahead, we are pursuing a clear growth ambition. Ramsay Santé has built a unique position to benefit from a compelling European healthcare market, benefiting from dynamic and supportive demographic trends, aging population, and increasingly prevalence of chronic disease. It is not growth for the sake of growth that we are after. It is about to create long-term growth, sustainable growth, lasting value for all our stakeholders, leveraging our unique integrated platform. For that, we will build on the core, and we will further develop new segments, high-value segments, scaling up primary care in Sweden, accelerating in imaging and in mental health in France, and continuing to develop new complementary businesses, PHI, occupational health, notably.
Over the last years, we have demonstrated a capability and agility to navigate in a constrained tariff environment, and we will have to demonstrate, and we will demonstrate going forward, a discipline and agility to adapt our mix, to adapt our resource allocation to a continued evolving price context. Let me now zoom in the identified levers that will enable to drive profitability up in the future. First of all, continued optimization of our portfolio of clinics with a better utilization of our capacities, building a leaner and more efficient network. Second of all, accelerate performance actions in every country, driving higher productivity. Concretely, as it has been said, we will turn every stone in every facility. Finally, accelerating on digital transformation to unlock efficiencies and to simplify patient administration.
As you have seen in this presentation in several examples, our proven track record in terms of efficiency actions, combined with a truly ingrained culture of performance and innovation, give us confidence in the ability to pursue this ambition. We will also increase our cash flows thanks to operational and financial disciplines using the following levers, stable and optimized real estate policy. So continuity, optimizing our footprint, and engaging in opportunistic lease negotiations. Streamlined financing cost through notably an active hedging policy through the continuity of our ESG sustainability-linked mechanism, adjusting the margin, therefore reducing the financial cost, but also improved our financing mix. Three, capital allocation, disciplined capital allocation. So we will continue to be highly selective in our investment policy to prepare profitable growth. Last, improve working capital requirements with further efforts on DSO and improvements in our processes.
In the end, as you can see here on this slide, here is the equation on how we will continue to de-leverage the company. Again, first, we sustain revenue growth thanks to our unique integrated healthcare platform, strengthening the core and diversifying of activities in new segments that are high-margin, high profitability. Second point, which is important, we see a gradual margin improvement thanks to higher performance actions and efforts in terms of cost discipline. Third, we maintain, and we will maintain a disciplined capital allocation, and then we will improve and continue to improve our working capital requirements. Behind all these levers, we have clear and measurable financial objectives that will be monitored regularly, and all combined, they will contribute to our continued de-leveraging plan. I will now hand over to Pascal, who will present and unveil to you these financial objectives and conclude this presentation.
I thank you for your attention.
Okay, thanks a lot, Clément, and thanks for your attention. It has been quite a long day or for those of you online, quite a long evening, if not night, I would say. What are the guidance we are sharing for you today regarding the next year and the next three years? Guidance around revenue growth, reported EBITDA, gross CapEx as a percentage of revenue, and de-leveraging. First, revenue growth. For the year that has already started, just to remind once again, our accounts are June to June. We anticipate as we plan to deliver between 2% and 3% of revenue growth in the coming year. If we look at the next figure on the CAGR approach, it would be on average 3% in the next three years.
Regarding the EBITDA margin, which is as of today, 11.9%, our guidelines, our guidance is a stable margin this year and then a gradual, sorry, margin improvement. Gross CapEx with a strict capital allocation, we have tried to explain to you, we plan a 4% of revenue on average over the period. As to the de-leveraging, with last month of June, we end up at 4.7x, so measured as a net debt versus EBITDA, we continue de-leveraging to target below four. This is the guidance we are sharing with you today. Before opening the session for the Q&A, six points we would like, if possible, I would say, you to remind. First, we are really operating in a business in which the demand is ever-increasing with strong drivers of this potential.
Secondly, we are very well positioned in all the countries in which we operate and beyond Sweden and France, same in Norway, Denmark, and Italy, in order to capture this growth in each and every market, thanks to diversification and integration. Third point, we always need to improve when you take care of 13 million patients, medical outcomes are best in class as measured by external, I would say, agencies. Fourthly, we are pleased to share with you today a plan which is not, once again, out of the blue. We are taking the solid foundation that the team has built in the last year. We are going to unlock the potential. We are going to adapt, but we are really confident in our ability to deliver this plan.
This plan, undoubtedly, in what we anticipate to be still a constraint tariff environment, mean that we will keep on focusing on a demonstration of efficiency for the future. Finally, with where we start today, with the guidance we are sharing with you, we consider we are in a solid financial performance that we will keep on improving versus the KPI, the guidance we have just been sharing with you before. Thanks a lot. We do recognize it was quite long, but we wanted to try to explain to you, I hope with pride and patient, what we are, what we want to be. Now there is a session for Q&A.
We have received already quite a number online of question, but if you don't mind, if everybody agrees, maybe if we have first question in the room, we'll be very pleased with the team to answer to your question. If not, we will go to question that we are already receive online. Yes.
Yeah, good afternoon. I have a couple of question. I'm David Cerdan from Kepler Cheuvreux. First, I would like to come back to your objective, short and midterm. Regarding just the revenue growth, do you include M&A or is it just organic? Can you provide us the split between volume and price just to understand the dynamics? Secondly, regarding your objective to deleverage, if I'm right, you never say that you could dispose your property asset. Is it an option for you? Regarding the value of a property asset, what is the implied cap rate of this portfolio? Who is the auditor? Are you the full owner of this portfolio? The last one is-
I should have noted because not sure I'm going to remember all.
No, you have a
Okay.
Okay, and the last one is very short, is regarding the presidential election next year-
Yeah
in France. How do you expect the budget to be for France next year? I know it's not an easy question.
Okay. I am going to try to give you, with the team, by the way, some guidelines, and there are some figure, as I am sure you will understand, we don't disclose. I would say regarding the revenue growth, that today we are planned to be 3% in average every year in the next three years. M&A, we are not slave to a growth-for-growth strategy. As we have tried to demonstrate, we are already the number one in each and every country. M&A is not, I would say, big M&A on the road at all. I would say in some very specific segment, e.g., Primary Care in Sweden, would it be a bolt-on acquisition respecting of financial and medical threshold? Why not? But net net, the message, if I may, out of the 3% revenue growth, don't expect, I would say, a driver being M&A.
Now, between the delta volume versus delta price, not to disclose everything, but I really would like to share with you that we have been cautious regarding the tariff environment for France. Very cautious. Let's put it away. We consider, and I think the past has proven it, and I hope the strategy that volume, capturing volume on selected segments will be a key driver of the growth. Your second question, as far as I remember, was the deleveraging. I am right?
Yeah, deleveraging.
Yeah.
The portfolio.
Regarding the deleveraging, and I will hand over to Clément, don't hesitate. We plan to have a continued deleveraging to be below 4x. As Clément has explained, the first driver of the deleveraging will be the margin improvement. Margin improvement, going back to your point, driven by the volume growth, which in many segments are amortizing the fixed cost. As an example, the increase in the occupation rate on the theater is a critical driver of a margin improvement. Moreover, as you have seen, we have been investing in the past, and we want to develop on unmet patient needs, e.g., imaging, e.g., day hospital, et cetera, primary care, in which the economics are better. So this deleveraging will come with this margin improvement in regarding the real estate and, maybe to hand over to Clément, we could be opportunistic, but nothing else.
So net net, a stability, but please, Clément, and going back to the value.
Yes, sure. To complement, the deleveraging strategy is the result of a combination of different levers. From revenue growth, from margin improvement, discipline, capital allocation, and working capital improvement. So that's not a single, of course, measure behind this. That's a combination of multiple levers. And back to your question on the real estate. So we do not disclose on the cap rate behind our real estate value, but we believe it's a market standard cap rate according to the location of our real estate. Again, we are locating in prime location. More than half of the portfolio that we own is based in Paris region, Île-de-France, but also Lyon and Lille.
Regarding, I'm sure I'm skipping what, I'm sure you will come back, regarding the presidential election. I'm sure you would be surprised if I were today to give you personal feelings or whatever. No. That being said, what is important, of course, and that was, I would say, a key driver and will be still a key driver of being diversified. Would we be only in one vertical in one country? In an industry in which we are very dependent, to be honest, of an external decision, being priced, being authorization, we could be at risks, undoubtedly. So net-net, I've got, of course, no idea regarding the outcome of the presidential election, but what we have built we think is a platform which is, and I'm sure it's English, but waterproof, or let's say resilient, whatever the outcome of the political elections.
Of course, we are going to advocate for the world system regarding what we think should be a fair remuneration for healthcare in France. We are going to keep on advocating and starting with myself in France for a multi-year agreement. As Britta explained, we've got ambition in some of our activity in Sweden to expand in other region, e.g., under your control, elderly and mobility, et cetera. But net-net, whatever the political outcomes, and I have no idea, of course, I think we have built a platform in order to be resilient and to navigate through whatever the results. I'm sure I forgot one of your question.
Just maybe regarding the ownership of the-
Yes, it's mostly at 100%.
Yeah.
Yes, David.
Yeah.
That's correct.
Yeah. Thanks.
Quite exclusively, yeah.
Thanks for your question.
Just a question, sorry. I do not understand, why do you not disclose the cap rates?
Sorry. Please, don't you take the mic?
Sorry. Why don't you disclose the cap rate while you said it's in line with the market? Sorry.
No. As of today, I'm going to disappoint you. As of today, we don't disclose the cap rate. But it's really aligned with the market. Let's look forward. We are hearing your question, but we don't disclose today. Any other question in the room? Yes, please.
Good morning, Laurent Gélébart, BNP. One question regarding the economics of your activities in France. Can you share with us if some of them are super profitable, some loss-making between MSO, primary care, and so on?
Okay. We don't disclose, of course, I would say EBITDA, et cetera, facility by facility. Undoubtedly, there could be some difference according to the type of specialty, according to the region, to be honest with you. Now, we don't look for, I would say, having the same profitability, whatever the type of specialty, location, et cetera. What is important is undoubtedly, if we take the primary care, primary care, in average, could be seen in France as a lower profitability, but it's very CapEx light, as you can imagine, and beyond. We consider it to be an entry point in the market. That being said, whatever the facility in each and every country, the challenge sometimes we can face regarding the result are operational mainly, and as I think the team, starting with Britta and Jérôme, have explained, we are working one-on-one in each facility regarding medical excellence and profitability.
Now, undoubtedly, through the example Jérôme has given regarding Valence, through sometimes network optimization also first, or what we have done in Lille in the last year with a huge reorganization of our activity, closing one facility, it's what we are calling to network optimization sometime. But we don't disclose, I would say, of course, facility or specialty by specialty. Any other question?
Thank you for this presentation. Christophe-Raphaël Ganet from Oddo BHF. I was wondering if you could share with us your view on the impact of an improvement of one point of rate of occupancy of a surgery theater, for example. And what's the target by 2030?
Okay. I'm very cowardly going to hand over to Jérôme. Good question, if I may.
What is the impact? I am not sure we will disclose the guidance in details by points percentage. The impact of one point, the ideas behind why we are looking at optimizing the occupancy rate is that when we look at +1, +2 points, we believe we will do it at almost the same organization. Therefore, we will have, of course, a bit of procurement, a bit of specific fixed cost that will be a bit variabilized, but most of it will be a net gain. That is the idea behind having this 1- point or 2- point increase.
What we can complement is undoubtedly one or two points as a real impact. Versus other industry, you certainly know what is a bit more complex in our industry is that you have threshold of norms. What I mean, if we take, for example, a maternity, a delivery in France, when you go from 999 babies per year to 1,001, so being over the 1,000 threshold, you need one additional midwife, et cetera. So fixed costs are increasing. It is a bit more complex than just saying that, but net-net, it does have an important impact, and we do plan to increase the occupancy rate.
Still on revenues, one more question about the different margin per specialty. Would it be possible to have a kind of graduation between primary care, between ophthalmology, imaging? Is it possible to have an idea of what are the more profitable or with high return on capital by specialty? To match it with what you want to develop on.
That would be the first question on revenues. The second one, I am curious about your view of the public reaction. There is a lot of move around the GHT on the public sphere. Do you think that it could have an impact on your market position and the way you could get the inflow of patients?
Yeah. On the first point, to give you a bit of an answer, not the one certainly you would like, but once again, we do not disclose by specialty, I would say, what is your profitability. But once again, if I may, as long as our strategy is more than ever to build integrated pathway alongside the horizontal taking care of the patient, you could have a bit of difference of profitability as long as, I would say, you keep the patient because once again, you are proud of the medical excellence you deliver. That being said, in the last year, it is certainly not by random that through a 3 million capital allocation out of the 4 million of additional patient, we have got 3 million in very specific activities, e.g., day hospital mental health, e.g., imaging, e.g., primary care in Sweden.
Once again, because there was a need from the patient, and certainly because it was positive on the average margin and economics of this company. Regarding what you are saying, and another point maybe, and sorry to state the obvious, I think we have to be very cautious regarding a photography at 1 day regarding the profitability. Why do I mean by that? Just saying for France, you have got 4,500 different tariff with full level of severity, which mean that every year, net-net in January, there will be 18,000 new tariff. In the past, we have seen sometimes some specialty where the tariff were -2%, -3%, et cetera. Honestly, the reason why was a bit complex to understand or et cetera. Once again, being diversified, being integrated, the economy can change, and we do consider this as being very important.
Regarding your question regarding public hospital, in each and every country in which we operate, we do consider that the complementarity between public and private hospital are critical versus, I would say, the future of the patient needs and so forth. We have got, by the way, Britta explained that there is a lot of activity between S:t Göran and the Karolinska Institutet, which is very famous. We have got tens and tens, I would say, of collaboration with a large university public hospital in France. Now, regarding the GHT, if I may, for everybody, since roughly 10 years, the French system of public net-net roughly by department, there is a Groupement hospitalier de territoire, a territory hospital grouping. There is 135 in France. It has been a long road for the last 10 years. In some cases, we are really involved. In some cases, we are less involved.
Public want to reinforce or positioning, which is not, I would say, a surprise, is to say that we are advocating from starting from the need of the patient in a given territory, whatever the status of the company being public and private, and we are calling from a stronger cooperation versus the exponential need.
And a few additional questions on margins now. Is it possible to share with us the best allocation between a DSP, kind of Délégation de Service Public, and an in-house hospital? Is it better to share with us and maybe to provide some granularity? Is it better to put EUR 1 in DSP or in an owned hospital? Is it possible to have your view on that? And maybe when you look at the park of bed, would you be able to identify a certain percentage or an amount of bed that is underperforming currently within your scope? And one last question on costs. Is it possible to share with us the biggest amount of purchases you have in the group and where you do consider that you have the biggest source of saving in the near future?
Okay. Right. Regarding your first question, and correct me if I'm wrong, in France, what I think you are calling DSP, which is a delegation of public services for a private operator to operate, nearly does not exist.
I'm talking more to compare France with Sweden, actually.
Ah, okay. Sorry. Yeah. Undoubtedly, I would say Clément has shared with us that regarding the average margin as of today of the group, which is 11.9%, as you have seen, France is slightly above the Nordic country and slightly below. I'm looking at you, Britta, and the team, I don't think there is a single answer regarding in average are the margin from what you call DSP, tender, et cetera, better.
What the team is doing very carefully, every time there is a tender we are competing to obtain, being in Sweden, Norway, and Denmark, the team is analyzing very carefully what is the content regarding quality to be delivered and what is the financial proposed with a very rigorous, I would say, threshold regarding return on investment. We said it, so very pleased to say to you once again, we are very pleased to have won once again for the next, at least 8 years, regarding the S:t Göran contract, because undoubtedly we've a better tariff margin regarding this contract. Now, Britta, maybe you want to comment. According to the region, moreover, it could be different, if I'm right to-
Yeah
As I explained, we have 21 different regions, and they set the rules for the tendering. What's profitable in one region can be less profitable in another region. We also scrutinize all tenders, and there are tenders where we are not participating because they are only on price and maybe no the barriers to entry in certain segments of psychiatry, et cetera. We need a certain level of quality, of course. So it's a business case in each tender-
Yes
based on quality. I said that quality drives productivity, but you need a base, of course. Some regions are less interested in having private providers, and their tenders are not as good as others. I would say that we mainly focus on the big areas, Stockholm, Skåne, and Gothenburg.
Thank you. Trying to answer your question, I'm going to say just a couple of word before asking Jérôme to comment on the French purchasing. Net-net regarding purchasing, two- third are medical driven, being drugs, medical devices. One- third are non-medical driven, e.g. catering, et cetera, on which we are working on depth and breadth, centralization, and maybe Jérôme to explain how we are working. You are working with a doctor regarding the medical, the CDM and CEM in order to-
Yeah
work on that. Maybe recently the stent, for example, discussion on cardiology.
Yes. First maybe another comment, that when the doctor is requesting a specific equipment, we should provide it to him. That is part of the job of getting the right equipment he needs to deliver what needs to be delivered toward the patient. What we are doing, therefore, in order not to leave or to stay in this situation where everyone can order everything when they want, we need to organize, as I said in the presentation, various communication stream with our doctors in order to anticipate those kind of needs, in order to structure them. It goes to a point where we have dedicated teams of doctors for each and every specialty, in a way, in order to make sure we are able to streamline the suppliers that we will reference together and to anticipate innovations.
There is a kind of back and forth view between those two approach like what is volume driven, what is innovation driven, and how to find the right mix. It is almost a daily discussion between my purchasing team and doctors community in order to make sure that we still keep the medical care at the center of the discussion, that we continue to deliver the care the way it should be delivered. I think the example of Margareta was excellent on ablation and cardiac surgery. The underlying equipment that we need to propose, to reference, subject to inflation, subject to innovation, and therefore we are working really with doctors to see what should be integrated or not in our catalog.
Thanks, Jérôme. Maybe just on the everything which is non-medical driven, being catering, cleaning, et cetera. In the last year, we have been centralizing this for all our hospital being in France or in the other country. For example, in catering, 95% of the 130 hospital in France, we have got the same catering provider that we use, I would say, our scale in order to obtain the best condition. Oui?
Yeah. Good morning, Christophe-Raphaël Ganet from Oddo BHF. Just a clarification on the guidance. You said 3% growth for the top line and gradual improvement for the margin. But for 2027, let's say the margin are expected to be flat.
Is that came, let's say, from the range in term of sales, which mean if you match the 2% growth, the margin are going to be flat and 3% slight improvement? Or is there any other factor, let's say, that could explain that?
Well, let's say we have been very cautious regarding this year regarding the environment, let's put it that way. We have been very cautious regarding decision that the French state could take, let's put it that way. And we are repositioning, accelerating on some drivers. So we are communicating, as you are right, as of today, a stable margin for this year. We will, I am sure, go back as soon as your Q1 results.
Okay. Regarding the CapEx, there is no, let's say, specific upfront to be paid in 2027. In term of phasing, sorry.
Oh, sorry.
Phasing.
No. Okay. Sorry. I think I have got your point. In our CapEx project and net-net growth, gross CapEx around 4%. Of course, quite a part is maintenance CapEx due to the very large number of facility. We invest too in the future, being data, digital innovation, et cetera. It is no secret to say that in France or in any other country in which we operate, we do not have a plan, a big project, let us call it a big project, as we are 10 years ago. For example, in 2017 closing three facilities in Dijon to open the brand-new one, EUR 70 million, et cetera. No regret by the way, deliveries of medical and performance very good. We do not have in our CapEx projection a big project that would not be worth tens and tens of million of euro.
Okay. Thank you.
You are welcome. Yeah. Another question, then I will move online. There are more and more question, and for some people online, it is already the evening, if not the night. Please.
Okay, I will be very short. It is regarding your backlog of authorization. Can we have some information about this backlog? My feeling is that you tend to be maybe less capital-intensive in term of development because you want to develop imagery or maybe some less capital-intensive. Is it right or wrong, my view?
It is right and wrong. If I may, primary care is very CapEx-light, as you can imagine. Imaging is not CapEx-light, I would say. If you adaptedly net-net in average and under the control of our specialist machine is worth EUR 1 million. But of course, if you consider a 3.0 Tesla or a Cybertruck, we have got one, there are six or seven only in France, is a big investment. So imaging is more CapEx-intensive, with roughly seven years, et cetera, and specific maintenance contract. Primary care or day hospital mental health, by definition, are very CapEx-light. Regarding the backlog authorization, including the key segment on which we want to develop, yes, we have obtained many authorization, I would say. I am sorry we do not disclose the number, but we have obtained many authorization that we plan to implement in the next years.
If you do not mind, yeah, sorry, I am going to move because there are many question online. The first question, I think, was trying to give some guidelines regarding the revenue growth between M&A, et cetera. I hope we have tried to give you at least some flavor. Maybe Clément, following your recent sale and lease back transaction that was considering full facility in France, by the way, how are you thinking about your real estate strategy going forward?
As I mentioned, in our real estate policy we intend to be stable over time, so to stabilize the ratio between owned and leased assets, around 20% owned versus 80% leased as of today. Again, this transaction was one-off, opportunistic, at good conditions, attractive conditions for us. But again, going forward, we do not anticipate any significant movements in our real estate policy. Again, real estate provides flexibility to get attractive financing, also to have a flexibility on the leverage, so the level of lease we have in our clinics. So we believe that is the right ratio, and we do not intend to change.
Thanks, Clément. There is another question. Why do patients choose Ramsay Santé, and how do medical excellence strategy underpin this competitive advantage? We do not want to talk on behalf of the patient. However, we are trying to explain. Being best in class regarding medical excellence with NPS at 74 in France, 69 in Sweden, 71, as far as I remember, in Norway, over 80 in Denmark and Italy is very important in a world in which patient more and more compare, are becoming consumer. Moreover, we have never compromised, for example, regarding the operating theater, regarding the quality of the equipment, being hybrid room, in order to attract the best doctor. If I take France, working with consultant doctor in the last three years, the number of doctor we have been working with, net of those who have been retiring has increased by 8%.
Once again, as in many discipline in our industry, the doctor, at least in France, they will bring to their patients in our facility where they are working with. Medical excellence is critical versus being a trusted partner versus a payer versus a patient versus, of course, a team in order to demonstrate that we are taking care, and they can empower themselves and go through career paths and to be very at the forefront, I would say, of attracting the new generation of doctors. Which, by the way, they are demanding. They are more demanding, I would say, sometimes, of the oldest doctor with whom we are working today. There is another question. In Sweden, as a pioneer in digi-physical care, could you elaborate a bit more on your digitalization strategy and key factor that have been driving your success? Britta?
How many hours can we In short, I can say that digitalization is much less about technology and equipment. It is to be brave and dare to change the way we provide healthcare, and it is a lot of leadership and local engagement. Is that enough of an answer? I can spend the day.
Maybe, if you do not mind, maybe regarding ambient listening, the speech to text we have been developing in all our primary care.
Yeah.
As you said, maybe to explain the change management, how it has been done, and the outcome from a patient and efficiency standpoint.
Yeah. Of course, some technology is really easy to implement if you really make it easier to be a staff. I think that Ambient Scribe has almost, not in the beginning, because the Swedish company Tandem, now valued, I don't know, a lot.
Yeah.
EUR 500 million or so. They contacted us two years ago and said that they have this idea, and we were the first pilot, and it didn't work at all in the beginning. Of course, you have to develop something that works. So start with small pilots, develop, and once it was developed, we really scaled it, but from smaller pilots. Then as we started to implement, it was not push, it was pull because the doctors who started using it, they were so satisfied. So the ones not having it available, they were kind of, "I want it too." As a doctor, you can just have the normal conversation. You don't need to look into your computer or put notes.
You just have a normal conversation with your patient, and you can focus on the conversation, and the electronic medical record is created by generative AI, and very accurately because we have trained it. But you have to train. It's like the algorithm used for breast cancer. It's not something that can develop. You have to train those algorithms too. So when we went from primary care ambient listening to urology, we have to do some iterative training too, because different doctors make different electronic records.
Sure.
Different cultures between a thoracic surgeon and a psychiatrist, I can tell you.
Building on the success of Ambient Scribe in Sweden, now the French team is working and rolling it out in some mental health facilities and primary care.
Indeed.
For the same reasons.
For the same reasons. Very good. What gives you confidence in our ability to deliver the performance plan? Undoubtedly, performance plan will be one of the five key pillars for Connecting Care 2030. A couple of reasons may be, first, the past, the last year, EUR 80 million of deliveries. Secondly, I would say because of this environment in the last year, which has been difficult, regarding change management with all our local CEO, et cetera, we have really been trying and embedding, I would say, in their DNA to say it has to be done. Once again, what has been done, e.g., the reduction of agency staff by over 60%, as an example, in France in the last 2 years, it is not going to go up. It is structural. There is still a bit to be done.
There are still many other stones to be done, et cetera. Now, I would say in this approach, we do need to do it. We have done it. Sharing is caring. I really think that the ball is moving on, the needle is moving on, and we are committed to keep on delivering big results regarding performance plan. I propose maybe, I am not sure, I am looking regarding maybe a last question. We are supposed to have 25 seconds before the lunch and the site visit. Any last question? There are many questions online, but that to some extent I have been overlapping with some in the room. Yes. We are pleased you to be here, I would say, to ask so many questions.
Everybody is pleased to be there.
Thanks.
Now rapidly, your key capital factor, human factor. Can we have some data on absenteeism, motivation, or something like that? Do you have some programs to recruit and retain people? Thank you.
No, sure. There is not a single answer. To be honest to you, I would say three, four years ago, post-COVID, as many of our colleagues, competitors, whatever, we had an issue regarding vacant position. As an example, in France, to share with you, we were over 1,500 vacant position, whereas as of today, we have been dividing by more than three this number. So we are in the range of 400. 400 vacant position, if I stick to France, out of 28,000, I would say is nearly normal. To be honest to you, as a world industry, there are two challenge. We have got one challenge with one facility very close to the Swiss border, because always the nurse are paid in Switzerland. The other topic, and we are very well managed regarding the employee value proposition. I do not judge by definition.
The new generation, by the way, doctor, nurse, regarding the night shift, it's a different approach. Regarding the night shift, we are adapting, I would say. We are a strong player, I would say, with a lot of resuscitation bed, for example, et cetera, or emergency department that needs 24/24. If I may, as a French person, you are certainly seeing that there are many ED now closing, et cetera. It's still a bit of a challenge, but nothing to compare versus three years ago, post-COVID. As a second topic, we can tell you whatever the five country in which we operate, the absenteeism has decreased and is very good compared to our colleagues in each and every country, being public and private. Once again, it's a daily journey of management by empowering the team to feel pleased to work at Capio, Volvat, Ramsay Santé, et cetera.
We are working a lot, too, regarding the organization in work. As an example, in France, a nurse, a health nurse can do 35 hours a week within three days, et cetera. Once again, we are very strong with 34 driver work-life and working condition in order to help through cradles for young mother, et cetera. So in each and every country, we are trying to work on the non-financial conditions. It's an endless journey, as you can imagine. Okay. Well, once again, thanks a lot. Thanks for your time. If I may, special thanks for those of you online. There were over 200 people online connected, and once again, many with a huge time difference. Very pleased with the team, on the whole behalf of the team today and the whole Ramsay Santé team for your attention.
Very pleased now to share with you, I'm sure, a couple of food, and then to have many people joining for the site visit to share with you concretely what we are doing, I hope with passion and commitment. Thanks a lot.