Good day, ladies and gentlemen, and welcome to the Life Healthcare Annual Results presentation. All attendees will be in listen only mode. There will be an opportunity to ask questions when prompted. If you should need assistance during the call, please signal an operator by pressing star and then zero. Please note that this event is being recorded. I'd now like to hand the conference over to the Group Chief Executive Officer, Mr. Peter Wharton-Hood. Please go ahead, sir.
Thank you very much and welcome to you all to Life Healthcare's 2021 annual results. I'll get straight into the results presentation. I'm joined in the room by my colleagues who will unpack these details as we move forward. At a very high level from a group perspective, an excellent operating performance. Alliance Medical's revenue up 21%. EBITDA improvement by 41%. Good performance in Southern Africa with a 10% improvement in revenue and an EBITDA increase of just over 12%. We reported earnings per share from continuing operations of just over 120 cents per share, compared to a loss in the prior period. This is clearly our business benefiting from a diversification strategy across geographies and business lines. We have declared a dividend of 25 cents per share.
We have a strong balance sheet position, where our normalized net debt to normalized EBITDA has now improved to a ratio of just over 1.82x. Next slide, please. If one has a look back at what our objectives for 2021 were, we wanted to restore the business to pre-COVID levels, and we've seen progress in higher margins across the group and an excellent cash generation performance at 113% of our normalized EBITDA. Quality care remains an imperative, and our quality metrics remain consistent with prior years and improved patient satisfaction scores despite the real challenges that COVID placed on our operations. We are the radiology partner of choice across the United Kingdom and Europe as a key partner to the public sector, and we won additional contracts and COVID-19 solutions within that sector quite convincingly.
From an SA perspective, we said we'd enter the SA imaging market. We've made real progress, both from an acquisitions perspective, collaboration discussions, and the announcement of our joint venture with AXIM to deploy two cyclotrons in South Africa. An overall portfolio review took place, and we looked to review and optimize our current asset portfolio. ScanMed disposal was completed. Our MyLife centers and Life Health Solutions absorbed into the continuing structure within South Africa. Next slide, please. We've made continued progress in our drive towards diversification. Revenue now internationally reported at 29% of total. From a normalized EBITDA perspective, South Africa at 64%. From an acute versus non-acute revenue perspective, we now have a 65%-35% split. Next slide, please. We have a unique diversified offering.
In describing our organization from a southern African perspective, 66 healthcare facilities, 9,000 hospital beds, additional mental rehabilitation beds to add to that, over 400 renal dialysis stations, five oncology centers and just over 3,000 beds in a public-private partnership. We are also the largest provider of employer-based onsite healthcare services. Complementing that internationally, we're the leading provider of imaging services to governments across United Kingdom, Italy and Ireland, with more than 147 diagnostic imaging centers, 77 mobile diagnostic units, and we already own 11 radiopharmacy cyclotron sites. Added to that, we are also the largest vertically integrated PET/CT network in Europe. In all, a unique offering a diverse range of growth alternatives going forward. Next slide, please. Our environmental, social and governance journey remains an imperative, not only for making life better for our patients, but all our stakeholders.
In this regard, I'm pleased to report that we have now received a AAA rating from the MSCI ESG rating, an improvement from our A rating in 2020. What I'd like to now do is hand over to Mark Chapman, who will unpack our international results, and then to Adam Pyle, who will look into the detail of our South African performance. Mark Chapman, over to you.
Thanks, Pete, and good morning, everybody. I'd like to go through the international operational review. Firstly, I'd like to thank every member of the team across all our countries and territories who have delivered a very strong performance in 2021 across all parts of the business, which has been a very challenging yet rewarding year. If we move on to slide 10, the overall performance, you'll see it's been very strong revenue growth at 21%. This has gone into the EBITDA at the normalized value at 41% growth, delivering the absolute number of GBP 89 million. I'm pleased to see the EBITDA margin has also grown from 20.8 to 24.2. We've seen this growth come from a number of areas. We've seen the resilience in the PET/CT scan volume activity in the U.K.
We've seen very strong growth across Ireland. We've also seen increased demand for CT imaging across all areas that we operate in. The mobile market in the U.K. has been strong, and this is outside of the CT contract across MRI as well. We've managed to stabilize the radiopharmacy business, which had its challenges in the prior year. With the opening of Dinnington, this has helped relieve some of that pressure. The EBITDA growth percentage growth has come from a number of areas. It has been supported in year by a number of initiatives to support national health providers across all territories. We have stabilized the radiopharmacy, as I explained, with Dinnington coming on board, and Dinnington has impacted and diluted the margin by 1%. I'm sure you'll agree, overall, a very strong performance. Can we move on to the next slide, please?
Many of you have seen this slide before, which just unpacks the territories and the size and the revenues. I think the main thing I'd like to just pull out of this slide will be the slight movement that we're seeing in the U.K. and Italy, where there's been a slight switch to increasing percentage points in the private sector of scanning. I think that's evidence of the waiting list that we are seeing in the U.K. and Italy, and some patients taking the decision to have the scan privately. In Ireland, slight change to that, where it's always been predominantly a self-pay and insured market. We have seen the HSE, which I'll explain shortly, award a number of contracts for waiting lists above what they would normally do.
Again, highlighting the pressure in that health service in Ireland. Can we move on to the next slide, please? I'm pleased to say, and you've heard me talk about this before, the diagnostic business has been resilient in COVID. In wave one, it was a V effect in the recovery. I'd like to draw your eyes to the charts to the right and in H2, you can see that the PET volumes in molecular imaging have been ahead of pre-COVID activity numbers consistently and growing, and I'll come onto the growth shortly. The diagnostic imaging, which is effectively the CT and the MRI, it's been around the pre-COVID levels, but again, very encouraging the last few weeks, that activity has started to ramp up significantly.
To the chart on the bottom, you can see Ireland actually from the beginning of the calendar year broke the pre-COVID levels of activity and has had a steady growth thereon and again, growing at a nice trajectory. For Italy, it's been hovering around the pre-COVID levels. That dip in August is very seasonal and is expected in a normal year. Again, recovery is happening in Italy, but it has been supported by the additional COVID laboratory work for blood tests for COVID-19. Next slide, please. If you look at the molecular imaging, you can see the volume year-over-year has grown by 19%. Very encouraging. Before COVID, it was tracking around the 15%, 16%. We are now seeing increased referrals coming through at a steady pace.
I think it's worth noting that we don't effectively have a waiting list because we scan, report back to our referrers within seven days, and that's happening consistently above 90%. When we see the patients, we scan them, and like I say, that growth is starting to come through in a nice way. Just to recap, the position, we are contracted for circa 70% of all PET/CT services in England, and that's made up of two large contracts. The first one we call wave one, which in fact, both of them have price surety. Wave one till 2025, and wave two is a 7 + 3, and those contracts were awarded in 2019, and the last one in 2021. Next slide, if we could.
Unpacking the diagnostic imaging part of the U.K. business. Again, you saw that it was coming, tracking at the pre-COVID levels and starting to increase nicely. As an absolute like-for-like figure, it's 16%, which again, is encouraging. That does include some of the COVID initiatives. The strategy still remains in the U.K. to form long-term partnership solutions with hospitals and ICSs, integrated care systems. However, over the last 12 months, we have been reactive. We've addressed at pace short-term opportunities while we've supported the NHS as an example to meet that pent-up demand. I think it's also worth noting that the 16 mobile CT under contract with NHS England has come to an end at the end of September.
However, pleased to say that those services are now being awarded and procured to local trusts. Demand is still there for those CT mobiles. Next slide, please. Wanted to put this slide up just to try and highlight the pressure and the challenges that health systems have, certainly in the U.K. There's always been a target for the U.K. to have its imaging services, diagnostics within six weeks. It has been tracking at under 1% target. You can see when COVID impacted, and it's the highest it's ever been for the NHS. You can see when it was a hard lockdown, it touched 50% of patients were beyond that six weeks. It's coming down, but it's still a significant challenge for the NHS.
This is where we are now talking to a number of trusts around community diagnostic centers, creating these public-private partnerships, which is being encouraged, and certainly the Mike Richards report, which was commissioned by the NHS, supports that. We continue to be in talks with a number of trusts and ICSs for these long-term partnerships. Next slide, please. This is a great example, and it's a real example. We're just in the final throes of contracting this out with a trust in the U.K., and AMG will invest in a new standalone diagnostic center in England. It will open up with two MRIs, two CTs, and a PET-CT on day one, and with a further expansion ability, and I think it will go to nine scanners, this one facility.
It is a long-term contract, as you'd expect with our level of investment and also the trusts and that's over 10 years. Building and planning commences in the next couple of weeks actually, with a completion early 2023. I think this just shows it's a very exciting time in the U.K. for the development of the long-term standalone diagnostic centers. This is nothing new to us. We have examples of this in Colchester, we have examples across Ireland, and indeed, if you look at some of our facilities in Italy, you'll see MRI, CT, PET/CT, mammography, endoscopy to name but a few. Next slide, please. Second is in Italy. The Italian business has done well. Revenues up 18.4%.
It has been supplemented by some of the laboratory work, but overall, you can see the volume growth at 9.1%. This is where there's been a relatively static ASL budget, which is the government provision. That has, as I alluded to earlier, driven some of the private and self-pay elements up. I think within Italy it's good to say that the acquisitions in recent years are performing very well and this will continue to be an area of focus for us as Patricia and the team continue to consolidate the activities and ensure that the cost base is reduced effectively. Next slide, please. If you look at Ireland. Ireland has had a very, very strong year.
Malcolm and the team have seen volume growth of 34.4%, and in recent weeks, they keep hitting a record weekly and daily activity numbers. This has been bolstered up by an increase in self-pay, but I've also alluded to the HSE contracts for the waiting list, which has also supported the growth in Ireland. If I look at Northern Europe and predominantly focusing on the radiopharmacy part of that, with the cyclotrons, we've seen good growth year-over-year at 15% of doses being sold. Also pleased to say that the cyclotron in Southern Germany, which was acquired during lockdown in January 2021, is performing very well and ahead of business case. Next slide, please.
Okay, last but not least, we are a clinical business and our outcomes and patient experience are at the forefront of everything we do. You'll see here that our actuals are broadly ahead of target across the board. This has been a challenging year for us that when patient experience, long waiting lists from public services come into our facilities at the end, it doesn't just happen. I'm very pleased to report a good set of quality outcomes as well and may that continue to this forthcoming year. I'd like to pull this to a close now and pass you over to Adam to go through the South African business. Thank you.
Thank you, Mark, and good morning, everyone. The South African business had a good overall performance for the last 12 months. What I'll do in these slides, I will briefly touch on COVID. I'll look at the numbers. I'll go through a segmental analysis before finally finishing with quality. Just before I start, I do wanna thank all the Life Healthcare employees and doctors from Southern Africa in terms of both their contribution and their commitment over the last 12 months, which has been a very difficult and trying period. I would like to start by thanking them. The next slide, which is slide 21, shows the COVID impact on our business.
We know we've had two severe COVID waves over this period, and each wave more intense than the previous wave. These waves play out differently across the country, and they play out differently across the hospitals. The graph on the left shows how our hospital PPDs for COVID played out across each province. It is a reflection in terms of what we experience in each wave. In wave two, you'll see that our KwaZulu-Natal and Eastern Cape Hospitals were severely impacted by COVID. Yet into wave three, we found that Gauteng and our other, which is rural hospitals in the Free State, North West and Mpumalanga, were severely impacted.
What's interesting in wave three was that our hospitals in KZN and in the Eastern Cape, which are roughly a third of our hospital beds, had a relatively benign COVID wave three with no COVID PPDs. In fact, their COVID PPDs in wave three were half of their experience in wave two. It does show how the wave plays out differently across all our across the hospitals in the different regions. For H2 2021, our COVID PPDs as a percentage of our total PPDs was 21%. You'll find the difference in one aspect to note in terms of our COVID wave three was the slower downswing in terms of that wave compared to the first two waves.
That has a sort of knock-on effect in terms of your non-medical COVID PPDs and your surgical PPDs in terms of the ramp-up. That can also be reflected in terms of the graph on the right. Move on to the next slide 22. This slide shows the sort of five-year sequence of the revenue for the Southern African business across each of the business lines. What is pleasing to note is that for each business line, the acute business, the complementary services, and the healthcare services lines, that we are now at slightly above our pre-COVID levels, which is pleasing to see. What's also of interest is that in the 2017 financial year, the acute business made up 89% of the Southern African business.
That has now down to 86%, which is in line with our strategy of diversifying our across our different business lines. If you move on to the next slide 23. This slide shows our revenue numbers and our EBITDA percentage margins over the last four halves. I suppose the point of the slide is to show how we've improved over each of these halves as the business has adapted and performed better and within this COVID pandemic. Starting with the graph on the left, the H1 2020 bar is really a pre-COVID half. Then you see the next three bars reflect the halves with each one having a COVID wave.
What you see on the revenue line is an improvement across each of these halves across each of these business lines. Finally in H2 2021, experiencing revenue higher than our pre-COVID half, which is good to see. The graph on the right covers our EBITDA margin progression, and you can see the steep drop-off in H2 2020 when the first wave hit and the country went down into a severe lockdown. You can see how, you know, despite waves two and three, our margin has improved. In H1 2021, we jumped to a 16.6% margin. In H2 2021, that improved again to 17.6%.
As we adapt to COVID and become better at managing our costs, you know, this is an ongoing process and we do expect to continue to see margin improvement going forward. Move to the next slide. This shows the sort of the numbers, and Peter will go through our numbers and our financials in more detail. I'll just focus on a couple of points. Our PPDs are slightly above prior year, which is good to see. But you can still see that we are down on pre-COVID PPD numbers, and that's reflective in our lower occupancies. We've had a good improvement of revenue with revenue growing by 10.3% from prior year, and an improvement to our margins with our normalized EBITDA growing by 12.2%.
What we do still see is a very different case mix within our hospitals. You can see that within our acute hospital business, we had a 9.8% growth in our revenue per PPD. That's made up of a 4% tariff increase and a 5.8% positive case mix shift. This case mix shift plays out not just in terms of the sort of that 5.8%, but also plays out in our length of stay. That has changed from normally in pre-COVID levels from around about 3.6 days on average to now closer to 4.4. That is something which will continue to be there as long as we have COVID cases coming through our hospitals. Go to the next slide, please.
Moving into the sort of looking at each of our business segments, starting with our acute hospital business, which is 86% of the Southern African business. The graph on the bottom left shows the impact of the COVID waves in our business. You can see the drop and the pickup of our acute surgical PPDs, as well as our acute medical PPDs. What's interesting, there's always the debate about what's happening with theater cases and surgery, but what you can see from that graph is actually the impact on our non-COVID medical PPDs is more severe in each wave than what we experienced in the surgical PPDs.
That's something we have to deal with, and I think it's reflective not just of the hospital environment, it's reflective of the environment we live in terms of COVID. The graphs on the right show our recoveries over the halves in terms of our PPDs and our theater minutes. Our acute PPDs are now on par with last year, and our theater minutes are slightly down, but that's reflective of the longer wave three and the impact that had in H2 2021. You can see there's only a slight increase in our theater cases or theater minutes. The graph on the bottom right shows occupancy levels, and it was good to see that as a group we had, for the last six months, occupancy of 60%.
It's broken down between a 59% occupancy for our acute business and a fast improving recovery in our complementary services of getting to a 65% occupancy, which traditionally in the past has always had strong occupancies. Move on to the next slide, which covers our complementary services business. Yeah. This business really can split into two. You've got our mental health and our acute rehabilitation on one side, then we have renal dialysis and oncology business on the other. And both the mental health and acute rehab businesses are severely impacted by COVID waves. You can see the steep drop-off from PPDs in H2 2020 for both those lines of business. We have recovered in both, more so in mental health.
The acute rehab business is still slightly down on 2020 numbers, but understanding that that business comes off an exceptionally high occupancy. The occupancies for the acute rehab businesses are still good. The trends we've seen for both those businesses over the last few months is good and continues to improve. The renal dialysis business and oncology business have both done extremely well. Both those businesses in terms of activities, revenue and EBITDA are above pre-COVID levels. That's a result of, excuse me, of an increased footprint of those businesses, as well as the focus on the underlying operations in both renal dialysis and oncology. We move on to the sort of final segment of our business, which is healthcare services.
That's made up of our two businesses, Life Esidimeni and Life Employee Health Solutions. Firstly, in terms of Life Esidimeni , it's had a really good performance, consistent revenue growth and stable margins despite the pressures that we know COVID brings. Life Employee Health Solutions also had a good year, good revenue and good margin growth. This is on the back of, you know, the traditional occupational health and wellness business has been supplemented by a whole range of COVID products. This particularly benefited us in the first half of this year. It did taper off a little bit in H2, but still an overall, for the 12 months, a good performance from both of these businesses. Then finally, just in terms of our quality slide and slide 28.
This shows our quality outcomes. I think it is really an excellent performance under some really difficult circumstances. Our patient experience is on par with prior years. Our patient adverse rate shows a good downward trend. Employee safety shows improvement. Those numbers exclude the impact of COVID. If you had to include COVID, that 2021 number, 3.5, would increase to just over 9.1, which really does show the impact that COVID has on healthcare workers. As a matter of interest, that number in 2020 would have been over 14. It does show the improvement that Life Healthcare's had in terms of managing employee safety with the COVID pandemic.
I think it also shows what happens when circa 80% of your staff get vaccinated and the improvement that flows through from there. In terms of infection prevention measures, we had a good overall performance despite the impact of COVID. On that note, I will now hand back to Peter Wharton-Hood for the growth initiatives section.
Adam, Mark, thank you very much and my sincere thanks to you and your teams for the successful results delivered during the course of the year. If we move on to slide 30 and start talking about the growth initiatives. We start with Life Molecular Imaging. A small part of our business, but one that definitely has attracted a disproportionate amount of attention, some speculation and a lot of curiosity. Just to refresh memories, our target product there is called NeuraCeq, which is an imaging tracer and a key part of diagnostic process in the treatment of Alzheimer's. Be influenced by the ability for clinicians to be able to treat Alzheimer's disease with a drug. In that particular regard, Biogen's aducanumab, a drug which slows the effects of Alzheimer's disease, it did receive FDA approval on the seventh of June.
Clearly, the ability to treat with the drug will drive up the volumes of diagnostics that are required to identify the disease in patients. Some of this is now beyond our control because clearly, until such time as the medical aids in the U.S. agree to pay for Aduhelm treatment, the growth in that market has to wait. The deployment or sales of our NeuraCeq isotracer is dependent upon the reimbursement agreements being established in the U.S. Clearly, we have two choices. We could either wait for those reimbursement agreements to be completed, or we could preempt those and as we detail below, invest for the success of NeuraCeq.
What we did, we actually committed to invest GBP 7 million on headcount and a further GBP 2 million on manufacturing equipment to effectively set up the sales force and secure the manufacturing capability for NeuraCeq in the U.S. With that, we appointed a commercial officer in the U.S. and we signed manufacturing agreements both in North and South America, Europe and Asia. We are geared for the sale of NeuraCeq, but the demand for NeuraCeq is dependent on those reimbursement initiatives being completed in the U.S. If we move to slide 31, we can see that we're well-positioned across the globe, both with active supply sites and the site setup that is ongoing, to be able to deliver our tracer across the world as demand increases.
As I said earlier, a lot of this is beyond our control now, and we wait for regulatory authorities and the reimbursement models to be finalized. Further initiatives on slide 32 take us into the product pipeline that exists within Life Molecular. Life Molecular is not just about NeuraCeq. It has more than two decades worth of research and has products that are critical in the diagnostic processes for neurodegenerative diseases and cardiovascular across a range of targeted diseases, starting with Alzheimer's, which I've already described. Alzheimer's and PSP, neuroinflammation, Parkinson's, our florbetaben tracer for cardiac amyloidosis, and thromboembolisms, strokes. What you can see there from the development stage, some, as in NeuraCeq, already in the market position, others in phase I, others in phase II of the development stages.
We've only sought to identify the market opportunity around NeuraCeq, and as more information comes to hand, we will start to discuss the prospects for the other products sitting in Life Molecular's pipeline. Moving to Southern Africa on slide 33. We have spoken at length about our entry into the SA imaging market. We've made good progress in the acquisition of imaging businesses. Constructive discussions around cooperation and partnering. As we've always said, partnership with radiologists is key to the delivery of our endgame. In that regard, we have now covered about half a dozen of our hospitals with further details to emerge in due course. Fortunately, the HPCSA also approved the employment of radiographers, which will allow us to acquire and deploy our infrastructure in the country.
From a complementary services perspective, Adam has already described the growth which took place during the course of the year, but we will be pursuing further opportunities in mental health, acute rehabilitation, further investment in renal dialysis, and the development of our oncology center of excellence at Life Vincent Pallotti in Cape Town. We also announced during the course of the last month, the formation of our South African Radiopharmacy joint venture, in a joint venture with AXIM. Effectively, this establishes the initial footprint towards a vertically integrated PET/CT scanning and oncology offering, and we will be building two cyclotrons in Gauteng to service South and Southern Africa within the next two years. Our strategic objectives remain to stabilize the existing operations, expand our existing business lines, introducing new lines of business into our care continuum, and to transition to digitally enabled businesses in due course.
I'll now hand you over to Pieter van der Westhuizen, our Group Chief Financial Officer, to take us through the numbers.
Thank you very much, Pete. Ladies and gentlemen, good morning. Just a first, as my colleagues, just wanna thank the back office teams to help us deliver these exceptionally good results for the last 12 months. As well as for the first time in more than 10 years, we were able to produce audited financial statements on the date of release, and these are published on our website, and you're welcome to go through that. In summary, our reported revenue for the year is up 12.7% to ZAR 26.9 billion, driven by exceptional strong performance in the international business and a sequential improvement in the SA business on half and half since last year, 2020. Normalized EBITDA at ZAR 5.1 billion, up 21.6%.
An exceptionally strong working capital management resulted in our cash from operations up 24.7% to ZAR 5.7 billion. Normalized earnings per share from continuing operations up 88.3% to 109.8 cents per share. If you remember last year, we announced the disposal of ScanMed. That was completed in the current financial year, just before the half year. The net proceeds of ZAR 681 million after taxes and costs were deployed to reduce debt levels in the group. That, plus the good cash generation from operations, resulted in our normalized or net debt to normalized EBITDA at ZAR 1.82 billion, 1.82 x.
We've still got undrawn facilities of ZAR 6.6 billion, and we will, as a group, review the facilities in the next 12 months. We've kept the facilities on hand because we didn't know how COVID was gonna play out, but we wanna make sure we optimize the facilities going forward and only have facilities available so that we don't pay additional costs on these. Now going to next slide 36. On the income statement from continuing operations, I talked about the revenue at ZAR 26.9 billion, roughly. Normalized EBITDA, ZAR 5.1 billion. Normalized EBITDA margin improvements from last year at 17.4% last year and currently at 18.8%. Last year we had, in the first half, no COVID.
We had a dramatic impact in the second half. We saw the benefits coming through in the current year, where the teams have been able to manage in the COVID environment and sequentially improve the operational efficiencies, resulting in 18.8% normalized EBITDA margin. What I wanna highlight is the net finance costs reduced from ZAR 798 million last year to ZAR 578 million, driven by the reduction in debt due to the disposal of ScanMed, as well as the good operational performance and the cash management.
The effective tax rates is down from almost 40% last year, and that's largely due to the mix of business units that we can't offset losses in certain operations due to COVID and also because of performance. The current year, the effective tax rate at 26.7%. We did raise some deferred tax assets in the current year on assessed losses where we have now more clarity in terms of being able to utilize that in the foreseeable future. That resulted in the tax rate coming down. We do strip that out on our normalized earnings per share, and I'll talk to that on the next slide, please. Earnings per share at ZAR 1.206.
Last year, we had the 6.4 cents loss due to the impact of COVID, but also due to the impairment of the ScanMed asset. If we strip that out, 111.1 cents in the current year at headline earnings per share, and last year, 48.7 cents per share, 128.1% up. Earnings per share from continuing operations at 114.6 cents, and 48.5 cents in last year. That's when we stripped out Poland. Headline earnings per share from continuing operations with all the above items excluded 133.3 cents up. At the bottom, you can see the one-off tax items, that is, we excluded in the numbers.
It's a profit in the current year. Last year, it was a loss of 8.1 cents impact, giving us 109.8 cents per share compared to last year, 58.3 cents per share, 88.3% up. Next slide, please. On the segmental financial results, Adam and Mark has gone through their different operations. Just want to highlight on this slide on the graph on the right-hand side is how we try to show what the impact of COVID has been. The dramatic impact is very clear if you look at the H2 2020 normalized EBITDA and how that has been improving since then, between H1 2021 and H2 2021.
You'll see there's a slight drop-off in normalized EBITDA for the international operations in H2, and that's driven by the CT contracts that we had with the NHS, where we provided COVID-related services to them. That was repriced after the half year. Those contracts came to an end at the end of September and is not continuing in its current form. On the left-hand side, we show, we reflect the constant currency percentages as well. We had in the current year a bit of a stronger rand, and hence the numbers are slightly weaker in a percentage growth compared to on a constant currency basis.
International operations clearly demonstrate a good operational performance with revenue up in rand terms 18.9% and at EBITDA 38.2% at ZAR 1.8 million at the normalized EBITDA. On the bottom right, as we normally do, we reflect what the income and costs that sits in corporate. And as normal, the net result of that should effectively be added to the Southern African operations because currently they carry most of the costs associated with the corporate cost. Next slide, please. On the balance sheet side, strong financial position, and as I said, we've got available undrawn bank facilities of ZAR 6.6 billion at 30 September 2021. Net debt to normalized EBITDA at 1.82 x compared to last year at 2.96 x.
A very strong performance, and we as an organization target net debt to EBITDA to be below 2.5 x. Next slide, please. Probably one of the things that I'm very excited about is the ability of the teams to manage the working capital. On the right-hand side, we set ourselves a target to have cash generated from operations as a percentage of EBITDA above 95%. You could clearly see how well we've done with 113% in the current year, up from 110% in the previous year. Free cash flow is up 49.4% to ZAR 2.7 billion compared to last year at ZAR 1.8 billion roughly.
In a strong cash position, a strong balance sheet, and a very strong performance in the current year from an operations perspective. Next slide, please. The debt breakdown as at the end of September, the weighted average cost of debt on a post-tax basis has slightly increased, but that's largely due to the reduction of the Polish debt, where we were able to have very good margins on these. As we exited Poland, that's in the ScanMed business, those would have disappeared, and it's really just a mix. You could see that if you compare it on a line-by-line basis, most of these weighted average cost of debts for the various debt facilities have slightly reduced. Overall, debt at ZAR 13.1 billion, excluding the cash on hand.
Next slide, please. Our debt repayment profile. We've got maturing debt of roughly about ZAR 1.8 billion in the next 12 months. Most of this sits in the South African operations, and we are already in the process of refinancing these, and we will push that. Some of it will be repaid, and some of it will be refinanced. Next slide, please. We have updated our dividend policy slightly. Dividends will be paid taking into account the underlying earnings, cash available funding. We want to retain sufficient capital to fund ongoing operations and growth projects, and we wanna maintain gearing levels within acceptable levels.
Based on this policy, the board approved a final gross cash dividend of ZAR 0.25 for the half year ending at the end of September. As you will remember, we didn't declare a dividend in the first half. This dividend will be paid in mid-December. I'm going to hand you back now to Pete to take us through the outlook. Thank you, Pete.
Thank you very much, Pieter, and my thanks to you and all of your teams, for the delivery during the course of the year. We then move on to our outlook for the company. Our purpose is very simple: making life better. We see ourselves as an international healthcare provider. We will deliver through a diversified offering. We'll be recognized for our clinical excellence and our dependence on analytics and technology to forge the difference. Our strategic pillars that enables outlined on slide 46 remain the same. Market-leading quality care, the use of technology, engagement with all our stakeholders, and delivering growth through diversification will be achieved through skilled and dedicated professionals, the modernization of our technology infrastructure, and taking our data and analytics to the next level, so it is recognized as a key competitive differentiator.
On page 47, from a vaccination perspective, we now are looking at the U.K. and Europe making solid progress with vaccinating the bulk of their populations. Approximately 90% of all our AMG healthcare workers have received their first vaccine. In Southern Africa, approximately 80% of all Life Healthcare employees, doctors, healthcare workers, and contractors have been vaccinated. In South Africa, 40% of adult population has been vaccinated. Taking data from Discovery Health Medical Scheme, we can see that 76% of those age over the age of 60 and 65% of those over the age of 50 have been fully or partially vaccinated. Clearly progress is being made, and this is factored into the way we see our business going forward.
From our own business's perspective, we played a role in assisting the government in the countrywide vaccination program by making 22 vaccination sites available, committing 320 of our staff dedicated to these vaccination sites, and we've already carried out approximately 380,000 vaccinations. In a further step forward, inside Life Healthcare, we have implemented a mandatory vaccination policy for employees starting in December of 2021. Move to slide 48. Our overall outlook from an international perspective is a more normalized operating environment off the back of the progress with the vaccination efforts. We see continued growth in underlying scan volumes across the U.K., Ireland, and Europe. As I've described, we will invest in LMI's operational capability to position the drive for NeuraCeq sales and the manufacturing of NeuraCeq.
Mark described the investment in the exciting community diagnostic center opportunities that are now becoming available in the U.K. We have committed to spend capital expenditure of approximately ZAR 1.6 billion in 2022 in our international business. Domestically, we have prepared the business for additional COVID-19 waves. Could it be waves 4 and 5? We do see that our responsibility is to be able to operate with COVID ever-prevalent as perhaps the new normal. We expect continued improvement in our paid patient days, improvements in occupancies, and further improvements in margins in 2022. Of course, subject to the timing and the magnitude of the COVID-19 waves, if and when they resurge. There will be continued focus on our business optimization programs, further execution against the SA Imaging transactions, and the growth opportunities in complementary services.
We will continue to modernize our IT infrastructure, make further progress with our cloud migration, and further develop our data analytics capabilities. Capital expenditure domestically will be of the order of ZAR 1.3 billion in the year ahead. At an overall group perspective, our outlook remains cautious given the ongoing COVID-19 uncertainty. We will continue to maintain a prudent gearing level and continue to carefully manage our cash. We do expect continued revenue growth, and we do expect continued margin expansion. We're excited by the growth opportunities both in South Africa and the international operations, and now it's down to the teams to maintain the clarity of the vision that we've established, deliver against the strategy, put our heads down, and get the job done. Thank you for your participation. We will now take questions.
Thank you very much, sir. Ladies and gentlemen, at this time if you'd like to ask a question, you're welcome to press star then one on your touchtone phone or the keypad on your screen. If you decide to withdraw your question, you're welcome to press star then two to exit the question queue.
For the benefit of the participants who have connected via the webcast, you're welcome to pose your questions in the question box provided on your screen. Just a reminder, if you'd like to ask a question, you're welcome to press star and then one. At this point, I don't have any questions from the lines. I will now hand over for questions from the webcast.
Thank you, operator. We have a few questions related to the U.K., so we'll just start with those first and give Mark Chapman a chance to answer those. A few of them relate to the same thing, so I'll only read one of them out. That is, really, could you give us an indication of how much revenue is currently generated by COVID-related contracts within AMG?
Yeah. Thanks, Mark. It's approximately ZAR 20 million in revenue and that's across all territories. So that's the laboratory work in Italy, it's the CT mobiles which is in the U.K. and some activity in Ireland as well. I've seen a question about how is that going into 2022. We know that the CT mobiles has gone to business as usual, but they are being utilized. Laboratory work continues. What we are now seeing is the waiting lists are increasing, so we are moving away from the COVID initiatives, but certainly there's still short-term waiting list initiatives that the NHS, ASL, HSE are asking us for assistance with.
Thanks, Mark. Just to be clear, that was a GBP 20 million revenue number.
Correct. Yeah.
The second question just relates to the investments into the CDCs. Does that impact our guided CapEx significantly going forwards? The answer to that is that it is included in our CapEx guidance within the international business. Mark, sorry, one more for you. Do you see any supply side risks associated with addressing backlogs in diagnostic imaging in the U.K. and Ireland, particularly referring to things like capacity and availability of resources?
Sure. Okay. If I answer the ICSs, the NHS are on a journey at the moment. A framework is just coming out, and we are in discussions with, like I said earlier, a number of trusts and integrated care systems. The impact in this year in the guidance is not gonna be significant. We are forecasting into the back end of 2022, 2023, where we'd like to have a number of these initiatives underway. That will require additional CapEx, which isn't within the guidance for this year. But we are minded of that. To Peter's points earlier on around sort of the debt and the provisions, we know the size of the opportunity, and we are forecasting for that accordingly, so that we can partake in these exciting opportunities.
I've seen a question from Kane as well. To answer that one, a reference to the challenges. I think, yeah, it is gonna be a challenge. The amount of demand out there at the moment is high. The teams are working through these effectively. But the radiographers, radiologists, we know it's a finite pool, but we do plan accordingly. There's innovation kicking in as well to help the activity, the levels. I think we also just need to be mindful of equipment, not too dissimilar across a number of other areas, but the availability of scanners are being pushed out because of the chips, like cars, et cetera.
Again, we foresaw that circa six months ago and are working with the OEMs. We have put pre-orders in to make sure that we're at the front of the queue on those. It's not gonna be easy, but we're very mindful of the challenges, and we're navigating our way through that accordingly to make sure that we can maximize the opportunities that lie in front of us. Thank you.
Thanks, Mark. Okay, we've got one or two South African questions. The first one, what sort of tariff increases can we expect in 2022?
Mark, I think the tariff increases are pretty much in line with CPI like they've been for the last three, four, five, six years. Nothing changes going forward in that regard.
A second one just on what are the current occupancy levels in the mental health business? Do you wanna comment on that?
Yeah, look, I mean, we said in the last half occupancies in the comprehensive services were 65%. And I, that's kind of made up of mental health being in the low 60s and acute rehab being in the late 60s. Yeah, these numbers have improved as we've come out of wave three, and they continue to improve as we sort of go into the 2022 financial year. Those numbers for both the occupancies for both those businesses are ticking up nicely.
Thank you, Adam. One more just on, can we expand on our strategy to pivot towards non-acute services in South Africa? Do we have any specific targets, revenue split targets, in the medium term? Will most of these come from organic or acquisitive means?
Look, I suppose we have internal targets, which we have, but I mean, you know, we've consistently said that we wanna diversify across our different lines of business. Understanding that in mental health, acute rehab, et cetera, you know, the revenue per days there are lower than the acute hospital business. It is a process, right, to sort of increase the percentage of revenue that comes from those businesses. What we have seen is really good growth out of renal dialysis, oncology. You know, we've said we'd be looking at the imaging businesses in SA. We do expect that trend to continue over the next few years without kind of divulging in terms of what the sort of internal numbers are.
You can see from, I think, the slide that Pete put up in terms of overall trend for Life Healthcare as a group in terms of, you know, the diversification out from acute care over the last sort of five or six years.
Thanks, Adam. I think a follow on from that is, will other South African groups be able to compete with AMG in the SA imaging markets, as one of our growth vectors here?
I'm sure they'll be able to compete. You know, they all have their own skill sets to understand the South African market. Yeah, I can't really comment on behalf of our competitors, but what I can say is that, you know, Alliance does bring a unique skill set in terms of radiology and imaging. You know, I think they do more MRI scans than the entire private SA healthcare market does in a single year. They've got a skill set which is gonna be very useful for us in terms of SA.
Yeah, Mark, if I can also add to that, too. We encourage healthy competition in all aspects of the delivery of healthcare that promote accessibility and/or the affordability of services on offer. Clearly, the expertise from an imaging perspective that we've developed and made better internationally, we'd like to be able to deploy in South Africa as previously broadcast. It benefits the patients. Competition is good for us.
Thank you, Pete. Thank you, Adam. I've just got one question, a couple more questions back on the international front. What portion of international CapEx will be allocated to NeuraCeq sales and manufacturing?
Yeah. Overall, it's a very small proportion. As we said, for the manufacturing, it was ZAR 2 million. We've done an investment of ZAR 7 million to people. Yeah, it's a very small number. It's not significant.
Thanks, Mark. Last one. Given the Sir Mike Richards's report on the NHS diagnostic capacity and the increase in NHS budget allocated towards building out the NHS's own diagnostic infrastructure, how outsourcing moving forward?
Sorry, Mark, you just broke up on the last bit. Did you say how realistic is the outsourcing?
Yes. What are the risks to AMG if the NHS insources a lot of its own work?
Yeah. Look, at the moment, we are talking to a number of trusts, and some trusts see it as an investment or CapEx from government to bolster their own services, and they are just gonna do much of the same. The trusts we are talking to can see the benefits. They have seen what we've actually done within diagnostic centers, and it is a partnership. I think the skills that we bring to mobilize these CDCs effectively, with, in some cases, dual staffing, which is a pressure point for the NHS, we are having very positive conversations. Some trusts will want to do it themselves and have ambitions to actually do in the community rather than just inside the hospital like I said to start with. It is encouraging at the moment.
Again, the Mike Richards report and other papers, he actually cites Alliance Medical and the work we've been doing in the U.K. and Italy around diagnostic centers. It will come down to individual ICSs and trusts, but I'm quietly confident at the moment.
Thank you, Mark. Operator, do we have any calls, any questions from the call?
No, sir, we have no questions from the telephone line attendees. I will now hand over to the CEO for closing comments.
Thank you. All that remains is for me to express my thanks to all of you who've joined the call, and once again to all the management teams around the world that contributed to the 2021 outcome. Thank you very much and goodbye.
Thank you. Ladies and gentlemen, that concludes today's event. Thank you for joining us. You may now disconnect your lines.