In the context of our overall results, we start with a strong underlying performance of our businesses. In South Africa, revenue grew by a shade over 10.10%, normalized EBITDA by 6.6%, with paid patient days rising by nearly 10% during the course of the year. Life Molecular Imaging had a strong performance, with revenue growing by 18.2% off the back of the news that PET/CT is now being reimbursed in the US for Alzheimer's disease care pathways, and Neuraceq has also received approval to be used in China.
Alliance Medical Group, which we will discuss in more detail later on as the discontinued operation that we've sold, saw a growth in revenue in excess of 10%. We have reported that we have sold the business for GBP 910 million.
The shareholder vote to approve the transaction will be on the 8th of December of this year, and we expect to close out all the conditions precedent by the beginning of quarter two of 2024. Overall, the group's revenue is up 10%, normalized EBITDA is up 4.4%, with normalized earnings per share improving by 11.4%. We will declare final dividend out of continuing operations of 27 cents. In our review of the Alliance Medical Group's performance, we see this as a positive transaction to sell the business as it unlocks significant shareholder value.
We announced the transaction on the 5th October, 2023, valued at an enterprise value of GBP 910 million. We will use the proceeds to settle all our international debt and pay for the transaction costs, the balance being repatriated to South Africa. We anticipate distributing in excess of ZAR 8 billion to shareholders early in 2024. We will retain about ZAR 2 billion for further growth opportunities, and we have already earmarked those specifically for Fresenius renal base transaction and further investment in Life Molecular Imaging.
The net proceeds have already been hedged via a deal contingent forward, and while the transaction is subject to a few conditions precedent, we do expect these to close out early in 2024. I must reiterate again that this disposal does not include Life Molecular Imaging. After the transaction is completed, our net debt to EBITDA ratio will be below 1x.
When we look at the underlying performance in Alliance Medical Group for the year, it was a strong growth in volumes, and while we've held it as an asset classified as a discontinued operation, it is fair for us to report that the overall performance came off a volume growth of 7.3%, with the UK volumes up 9.5% and Irish volumes up 13%.
Revenue grew by 10%, and their normalized EBITDA by close to 6% to GBP 83 million during the year. When we talk about Life Molecular Imaging, it's important to note that the Neuraceq opportunity is gaining momentum. Our sales of Neuraceq, which is the primary driver of LMI's revenue, grew by 18% to ZAR 656 million for the year.
Clinical trial revenue was up 7.7%, commercial sales up 29%. There is, however, still a reported EBITDA loss in the division, primarily off the back of our investment in the sales and marketing team to drive Neuraceq sales. Headcount in the division rose to 122 people off a base of 104 last year, and we've extended the agreement with Alliance Medical to continue manufacturing and distributing Neuraceq in Europe.
The table to the right-hand side shows the extent to which we've already achieved our global presence for Neuraceq, where we have 44 active and contracted sites to manufacture Neuraceq around the world.
The bottom right-hand portion of the slide starts to show the most important metric by which we will judge Neuraceq's success, and that is the sales of Neuraceq doses, be they commercial sales, clinical trials, or those used in R&D. I'll now hand you over to Adam Pyle to take us through the South African results.
Thank you, Pete. So in terms of the South African overview, I'll talk about our underlying activity growth. I'm also going to touch on the change that we are seeing in the medical aid market. I'll talk about our acute and complementary lines of business and how that feeds into our results. Then I'll end with some commentary on our capital allocation 2023. So we had a really strong year in terms of our underlying activities.
Our overall PPDs grew by 9.5%. This is off the back of our acute hospital PPDs growing by 10.2. Mental health and acute rehab PPD is up 6.8, resulting in our overall occupancy percentage being 68.1%. If you look at the graph on the bottom left, the occupancy levels, you'll see that, firstly, from 2022 to 2023, our acute hospitals grew the occupancy from 61.1 to 67.6, so really good growth in occupancy levels there.
We saw good growth in our complementary services, with occupancies being just below 73%, and overall occupancies increased from 61.9 to 68.1. So really good growth in occupancies, getting close to 2019, and I'll touch on that a little bit later. This growth was really driven by the continued recovery post-COVID, but a really strong performance from our network deals, particularly with the introduction of the two significant networks from January this year. We've also seen good doctor recruitment and some additional beds added.
In addition to the PPDs, you know, we saw, you know, good business growth by renal dialysis business, our oncology business, and also from our imaging business, which has been our results for the first time, for a 12-month period. And if you look at the graph in the bottom right, which covers our revenue, you'll see that there's a good improvement in our complementary services revenue, to just over 1.6 billion.
I think it's a 20% growth, and, this is off of good growth in complementary service business lines, as well as strong performance from imaging. And we are quite confident that the growth going forward in complementary will be strong over the next 3-5 years.
If one moves on to the look at the market, you know, although the market is flat in terms of lives, there are some changes happening within that. And the first trend we're seeing is that the percentage of members belonging to preferred networks continues to increase. And you can see from the table on the top right, that the percentage of our PPDs from networks has grown by 50% since 2019.
And we do expect this trend of more members belonging to preferred network deals to continue going forward. And as such, as a company, one has to work out, you know, how one operates within this market and how one deals with preferred networks.
Our strategy has always been fairly clear, in that we want to be the number one hospital group when it comes to preferred network lives. The benefits we see coming through that this year in a flat market are the improved occupancies. Yeah, we do understand the impact that this has on our revenue per PPD and the impact it has on margins, but we believe that the higher occupancies give us better scope going forward in terms of how we manage our costs.
Looking at the second point is the aging medical aid membership, and within the schemes, you look at the information, you can see there's a reduction in members between the ages of 20 and 34, and there's an increase in members over the age of 60.
And how that plays out in terms of our admissions is that we've seen our average age of admissions increase to 45 years, from 43 in 2019, which is quite a significant shift in just four years. And if you look at the table on the bottom right, you'll see that our PPDs for the age of 20-39 is down 19% since 2019.
But our PPDs for the 60+ years is up 3.9%. And just for, just for context, the PPD category of 60+ years is much bigger than the 20-39 years, but it does show the difference in terms of patients, the type of patients coming through to our facilities. And that plays out in terms of the case mix.
So our births are down 5%, but our cath lab cases are up over 23%, and you can see the increase in volume of knee replacements and hip replacements. So we are seeing a different case mix playing out. And we've been watching this trend for a number of years, and we, you know, we are busy shaping our business accordingly to take into account this change in demographics.
Looking at our acute hospital business, you know, so strong growth in revenue of 10.3%, driven by an 8% increase in admissions and PPDs growing by 10.2%. So what we're seeing is a length of stay increase of 2% to 3.8 days per admission.
This is, you know, about 9%-10% higher than it was pre-COVID, and it's reflective of the case mix. This year we saw the faster growth medical PPDs, as well as the aging population I've just spoken about. And if you look at the split between the PPDs, you can see medical PPDs, excluding COVID-19, grew by over 20%. Our COVID PPDs, it should be a sort of red arrow pointing down, is down by 73%, which is expected, and our surgical PPD is up 10.1%.
So this year we did see a case mix change, going back to more of a normalized case mix, but it did that case mix change of more medical and less surgical, did result in a lower revenue per PPD coming through.
Good growth in theater minutes, and I've covered the kind of cardiac activity and births. I do want to touch on the occupancies, and you can see the pie charts on the right. Although occupancy is not that far off 2019, when you look at the split, there's still quite a big difference. So in 2023, we still have 19% of our beds with an occupancy below 60%, and this compares to 9% in 2019, and we only have 3% above 80%, compared to 13%.
So, you know, our strategy is, apart from increasing our occupancies, to make sure we get the right mix and more of our occupancies and beds above 60%. That's key for us going forward. In addition to that, I just want to mention that, you know, ICU occupancies, though, are over 80% for the year, so higher than 2019 and 76%, and that's reflective of some of the case mix we see coming through.
And we also had an excellent year in terms of our doctor recruitment. And it's not just the number of doctors recruited at 104, which are net additions, it's the type of discipline of doctors that we're recruiting, which fits into how we're sort of reshaping parts of our business to deal with the changing and aging demographic. Moving on to our complementary lines of business, which is really an excellent performance for the year, with revenue growth of over 20%. And this is built on the PPDs growing by 6.8%.
So we had mental health up by 8.4, acute rehab 3.3, and that 3.3%, we have excluded the closure of our one acute rehab unit in Bloemfontein. We saw good growth in oncology and renal dialysis, and the slides that points there on X-rays and MRI, CT, and PET/CT, percentages are high because they're in for 12 months, whereas in the prior year, I think we had East Coast Radiology in for 7 months and Eugene Marais Radiology in for one month.
What's more interesting, I suppose, is if you look at the point on the top right about our underlying MRI and CT scan volumes growth, so that's on a 12-month comparison for 2023 to 2022. Those underlying volumes grew by 14.6%.
So we've had a really strong performance from our imaging business, and it certainly exceeded our expectations and becomes a you know a key growth area for us going forward. This feeds into our segmental breakdown. You can see our revenue up 10.1%, and that's split between hospitals and complementary services growing by 11%, and our healthcare services down by 2.7% on the revenue line.
We you know we had a strong performance from Life Nkanyisa, and the reduction in revenue is primarily due to Life Health Solutions, and it's how we're focusing our attention and making sure we have the right contracts in place. And with the benefit we can see coming out in the normalized or operational EBITDA line.
So operational EBITDA grew by 7.7%, with hospitals and complementary services growing by 7.1, and healthcare services, you can see growing by 22.7%. So the, you know, good performance from Life Nkanyisa and, you know, our reshaping of the Life Health Solutions business is starting to gain some traction. Just in terms of the... You can see the corporate costs, which Pieter will deal with a little later in the finance section.
But there has been, you know, continued investment in our value-based care products, which are essential to us going forward in terms of how we reshape the delivery of healthcare in our company, our IT infrastructure and our platform, as well as investment into data analytics.
Just in terms of our last slide, you know, this last year, we spent over ZAR 1 billion on our maintenance, and it's really an investment into our portfolio and our assets. On top of that, you know, we have been focusing our growth by facilities and areas that benefit from the market changes. What you see is an increase in ICU and high-care beds, a focus on emergency units, cardiology, oncology, renal dialysis, et cetera.
And that trend you will see going forward as we carefully map out how we grow our business in a market which shows very little growth from a membership perspective. You know, we continue to invest in our technology, and we completed the modernization of our underlying IT infrastructure.
I mean, there's been continued investment into our IT platform and systems and security and cloud storage, and we've made good progress this year on those vectors. And then finally, just on our acquisitions and disposals. You know, we completed the acquisition of TheraMed Nuclear and PET Vision. These are three outpatient molecular imaging sites, and this is part of our strategy of building a countrywide PET/CT network.
And that process will continue in the next few years. You know, with the Comp Com in terms of the Fresenius Medical Care acquisition, and we're just awaiting hopefully approval from the SA Comp Com after receiving approval from the other two territories.
And then we, you know, we continuously looking at our portfolio of assets, and we, you know, we closed one birthing unit, and we also closed an acute rehab unit. And discussions continue going forward and how we look and we continue to review our portfolio going forward.
And then just finally, there's one point I would like to mention, is I'd like to thank, you know, all our staff and our management and our doctors for the hard work and the quality of care they deliver to all the patients that come through our hospitals. And on that note, I will hand over to Peter.
Thank you, Adam, and good morning, all. The results for 2023 reflect a good operational performance and especially a strong activity growth from the Southern African operations. The strong activity growth in SA, with PPDs growing at 9.5%, largely as a result of network gains, and the revenue growth in LMI of 18%, results in group revenue from continuing operations growing at 10.3%.
Normalized EBITDA in SA resulted in a 6.6%. It's lower than the growth in revenue, and as Adam stated, this is due to a number of factors, increased costs in corporate, as well as mix change and lower revenue per paid patient day in the Southern African operations.
The EBITDA loss in LMI when resulted in normalized EBITDA growth from the group at 4.4%. Earnings for the group has been impacted by a number of non-trading related items, some of them which we've disclosed in the half year. But the largest one is the AMG impairment and transaction-related costs, that we had to disclose as part of discontinued operations, and it reflects for the current, in the current period, the ZAR 990 million loss, and I'll talk about that in the next slide.
Contingent consideration in the prior year, where we released a contingent consideration that was payable on LMI to the tune of ZAR 457 million, made it difficult from a comparative basis in the current year. We settled the tax matter in the current year, and in the current year, there's a charge of ZAR 47 million, and in the prior year, an accrual of ZAR 199 million. So there's a net gain in the current year.
The base metric that we think you need to look at from an earnings per share perspective is normalized earnings per share, to, to strip out these, non-trading-related items, and that grew by 11.4%. That's also the metric that we use, to determine the dividend. We had strong cash conversion, and earnings growth, as I stated, on a normalized basis. The cash generated as a percentage of normalized EBITDA is above 100%, above our metric of 95%, and it was an exceptional good job, specifically in the SA operations after the half year-...
where we had the impact of a failure at one of our service providers that impacted our ability to bill and collect cash, and that we've recovered most of that money. Net debt to normalized EBITDA is at 2 times. It does include the debt that we intend to repay as part of the disposal of Alliance. If that disposal goes through in the new calendar year, net debt to normalized EBITDA will be below 1 times.
The total dividend for the year increased 10% to 44 cents. On Alliance Medical, as Pete stated, we disclosed it as part of the discontinued operations. The ZAR 990 million is made up of a profit after-tax loss of ZAR 90 million, largely driven by an increased finance cost in the Alliance business.
They did have a good operating performance, with operating profit increasing by 20%. Transaction costs already incurred in the transaction of roughly about ZAR 150 million, as well as when the impairment that includes additional transaction costs to the tune of about ZAR 550 million. The strange thing with IFRS 5 is you, you need to fair value the asset, but you can't bring in the unrealized gains on exchange rates.
That will realize when the transaction close. As at the end of September, the unrealized gains is ZAR 2.9 billion. So a potential profit, if the transaction had to close out on 30th September, would have been approximately ZAR 1.9 billion. Segmental results excluding AMG.
Just want to show you at the bottom right-hand side of the slide, as Adam stated, the income grew in corporate by 15.3% and the cost by 18.8%. I'll talk through on the next slide in terms of the implications of that. Life Healthcare runs a centralized service operating model in the Southern Africa, where we've got perform a large number of services on behalf of the business operations.
These include central finance, debt collection, patient services, payroll functions, and the like. The centralized service costs increased by 22%. It does include an increased insurance pool that we're creating to do self-insurance for our malpractice claims of around ZAR 60 million. And as Adam stated, we've also increased the investment in our value-based care products and our data analytics teams.
That's part of the centralized services. If you strip out the insurance cost, the centralized services increased by 10% only. IT, that's a function of two factors. One is the increased utilization of applications by users. So as we bring more users into the digital, it does have an implication on licensing costs. And the second part of that, the licensing cost is denominated in dollars, largely. So if the rand weakens, that cost increases.
And then thirdly, due to the IT incident that we had in the half year, some of our key projects, the cloud migration project, has been delayed, and that will only be now being concluded in the new financial year. It does mean that we still have some duplicate costs coming through. That cost have increased by 20%.
The two corporate costs that we can't split out to the South African operations that we service, also part of the AMG business, and the LMI business, has grown by 8%. Most of that cost is salary cost. So. And then we've got the long-term incentive plan related to the people based at our corporate offices in Rosebank of ZAR 141 million for the current year. That's a total cost of roughly about 19% increase to the ZAR 1.5 billion.
On the income statement, just want to highlight a few items. The non-trading related items, as I've stated previously in the prior year, we had ZAR 299 million, in the current year, a ZAR 29 million loss.
In the prior year, it's ZAR 457 million related to the contingent consideration in LMI, and then it's set off by the SARS matter of ZAR 157 million. Profit after tax, down 12.8% against last year, and the discontinued operations of ZAR 990 million. Earnings per share, due to the discontinued operations, it's quite messy.
But as I stated, the one metric that we think is best to look at is normalized earnings per share from continuing operations, up 11.4% to roughly 90 cents, 0.891, compared to last year at 0.86. So it's a like-for-like comparison. We're still in a strong financial position.
Alliance, based on a net basis, is reflected as assets held for sale of ZAR 19 billion. If the transaction was closed at the end of September 2023, we would have realized approximately ZAR 21 billion, as I've reflected, roughly about ZAR 2 billion gain.
We will then utilize those funds, as we stated, in the earlier communication, to firstly repay the international debt of around ZAR 8.7 billion, repatriate the balance back to South Africa, service via transaction related costs and repay GBP 360 million of roughly about ZAR 8.4 billion back to shareholders and retain about ZAR 2 billion for growth opportunities that we've identified. Net debt of ZAR 12.3 billion, as I stated, does still reflect the debt of international business of ZAR 8.7 billion.
We, and we do expect to spend ZAR 2.3 billion of CapEx in 2024. On the cash flow, free cash from continuing operations grew by 78% from ZAR 576 million in the prior year to about ZAR 1 billion. The ZAR 1 billion is roughly about 28% or 30% of EBITDA, and that's a metric that we will keep tracking going forward, that we want to generate this free cash.
How we define free cash is EBITDA less working capital investment, less interest, less tax, less maintenance CapEx, and less minority distributions. That's where we've got doctor shielding in some of the hospital facilities and an employee share plan. That ZAR 1 billion is within the quantum that we see as available for growth opportunities and for distributions back to shareholders. I'm going to hand you now over to Peter to do the capital allocation and outlook.
Thank you very much, Pieter and Adam. In closing, it's important for us to express our sentiments around how we're going to spend money. Effectively, the split between growth and maintenance CapEx in an operation such as ours is a very important and necessary distinction. Our growth CapEx will deliver some exciting organic growth and innovation opportunities.
We've spoken about the need to expand our ICU, high care, and general ward capabilities across our acute settings. Investing in renal and other value-based care products is in line with our expansion of complementary services revenue, and we will continue with the Oncology Centre of Excellence strategy.
We are also very excited by our diagnostic and molecular imaging strategy, and we're in the process, as we've reported earlier, building the two cyclotrons in Gauteng, and we'll expand a PET/CT network in South Africa in due course.
Internationally, there's a small CapEx requirement for manufacturing kits for Neuraceq at the cyclotron manufacturers themselves, and we will seek additional approvals in other markets to be able to market Neuraceq, as well as invest in the pipeline investments already in play in Life Molecular with a stage-gated manner for a new isotope under phase 3 FDA clinical trials to detect the presence of tau.
Inorganic growth opportunities come along the lines of the Fresenius Medical Care acquisition in the renal dialysis space, and we've also targeted a hospital property which we currently lease and is important to us that we feel that we own, along with our ownership strategy for the rest of the property portfolio.
We have said on all our calls that we are unlikely to pursue any international M&A transactions. From a maintenance CapEx perspective in Southern Africa, it's important that we both grow and sustain our existing business, and our embedded footprint requires money to be spent in order to secure the organic volume growth and drive optimal occupancy levels.
When that is all said and done, the excess cash is promised to be returned to shareholders by way of ordinary dividends, which we've already announced, special dividends and share buybacks, which we've already telegraphed as a result of the cash coming from the AMG transaction.
From an outlook perspective, we are confident that we'll see increased occupancies through our hospital networks as a result of the network deals that we've concluded and the active doctor recruitment, which we are always engaged in. We're targeting an EBITDA growth of around 3%. We will be focused to maintain our EBITDA margin and focus on cost reduction activities where appropriate.
We, in Life Molecular, the main emphasis there is to drive the commercial sales of Neuraceq, and we will continue to invest appropriately in the required sales and marketing teams as we expand in the United States and later on in Europe. In conclusion, from a group perspective, we have to make sure that we deliver the AMG disposal according to the timelines promised, and we will also make sure that the cost base is optimized thereafter as a result of such a sale.
We have also promised to distribute the net proceeds to shareholders, and thereafter we will review the dividend policy for the company going forward. Thank you very much for your attention, and apologies for the challenges that we faced earlier in the day to deliver this presentation to you.