I must advise you that this conference is being recorded today, March 1, 2024. I would now like to hand the call over to your first speaker today, Ms. Penelope Koh from Investor Relations at IHH. Please go ahead, Ms. Koh.
Thank you. Good morning, and thank you for joining us. I'm Penelope Koh from IHH Investor Relations. Welcome to joining us for our fourth quarter and full year 2023 results briefing, whereby we're doing it via a live video broadcast. With me today are Dr. Prem Nair, our Group Chief Executive Officer; Mr. Dilip Kadambi, our Group Head of Finance; and Mr. Ashok Pandit, our Group Chief Strategy and Business Development Officer. The results materials are also available for download on the IHH website. This quarter we'll begin with the opening address by our Group CEO, Dr. Prem. I'll have Dilip, our Group Head of Finance. He will present the financial highlights, and his report will offer a clear view of our financial status as well as our core operating performance.
Following that, we will have Dr. Prem, give an update on operations across the various countries, and then we'll conclude with a brief outlook. Then thereafter we'll move on to our question and answer to address your specific queries and observations. With that, I'll turn the call over to Dr. Prem. Dr. Prem, please.
Thank you, Penny. Very good morning to all of you, and thank you for joining us in this early morning call. So it's been another remarkable quarter for us, and really our full year results are quite stellar. These outstanding results demonstrated our continued core operating strength of the business, and it also shows that our growth strategy is robust. Over the course of meeting more than 100 of you, analysts, investors, since December 2023, we've gotten quite a lot of feedback from you. We hear you, and we made some updates to the deck, and we hope this material will serve you better. Now, let's go straight to the results overview. So our full year results displayed double-digit revenue and EBITDA growth with a doubling of PATMI. Secondly, this was an excellent quarter for us where we saw strong revenue and EBITDA growth. PATMI ex- EI increased 20%.
Thirdly, a second and final dividend of MYR 0.055 has been declared, including the interim dividend of MYR 0.035 that was declared in October 2023. This brings our total ordinary dividend to MYR 0.09 for financial year 2023. Including the special dividend of MYR 0.096 that was paid in end June 2023, the total dividend for the year is MYR 0.186. Next, our growth plans and trajectory remain intact. We are looking to expand our bed capacity by 33% by 2028. I'd also like to mention that the cash amount that was in escrow in India has been repatriated, thus freeing up capital, and this can be deployed towards debt reduction and future capacity expansion. Finally, I would like to assure you that our outlook remains very positive. As we execute on ACE, align, challenge, empower, we expect firm continued growth and healthy returns.
To further demonstrate our confidence, we are also revising our dividend policy upwards to distribute no less than 30% of the group's PATMI, excluding EI. This slide shows our reported headline numbers, which includes MFRS 129 effects. Now, I don't intend to spend too much time on these reported headline numbers as these figures would tie in with the financial statements that you have or you have seen. Under appendices B to E, we have included four waterfall charts so that you can compare PATMI variances with and without 129 adjustments for your reference. From the management team's perspective, we want to spend more time discussing our core operating performance, that is, stripping off MFRS as the macroeconomic conditions are simply something beyond our control. So our core performance will be covered in more detail from slide 8 onwards, which I will have Dilip cover in greater detail.
Next, dividends. As I explained, a second and final cash dividend of MYR 0.055, as illustrated here, is declared, will be paid on 26 April 2024. So we are happy to share that we have increased our ordinary dividends from MYR 0.07-MYR 0.09 per share for the year, which is really an increase of 28% from the previous year. And again, to emphasize the MYR 0.096 that we paid last year from IMU divestment, it will bring our grand total dividend paid out for the year to MYR 0.186 per share. And this translates to a dividend yield of 3.1%. Again, talking about our dividend policy, to distribute no less than 30% of our PATMI up from the current 20%. And this is really demonstrating our disciplined approach to have all our shareholders participate in our success.
With that, I shall now pass the next section over to Dilip to cover the financial highlights, excluding MFRS 129. Thank you.
Thank you, Dr. Prem. In this slide, we see a snapshot of our core operating performance for FY 2023 and Q4 2023. We have excluded MFRS 129, as Dr. Prem mentioned, purely to ensure that we capture the operational performance and operational excellence of the company. Full year 2023, the financial performance saw strong double-digit growth across revenue, EBITDA, and PATMI. As you can see, we had a 17% revenue growth for the full year 2023, 15% EBITDA growth for the full year 2023, and PATMI ex, we grew at 17%. PATMI itself doubled over prior year, mainly due to the IMU sale that happened previously in the year. For Q4 financials, again, was a very strong performance. We saw revenue grow by 11%, EBITDA by 10%, and PATMI ex, which grew by 20%.
PATMI, of course, grew over 500%, mainly because of a deferred tax credit that was available to us this quarter. As this slide shows, we have shown the breakdown of all our business units, and what is very, very evident here is a very strong performance, double-digit revenue as well as EBITDA growth across all our countries and divisions. The lab non-COVID revenue grew 16% without the COVID volume. As you may recall, in 2022, we had still the impact of COVID in our lab revenues. The lab EBITDA, however, declined by 6%, mainly due to some one-off expenses in Agilus relating to the rebranding of Agilus as well as some write-offs. Without these one-off expenses, our EBITDA would have been up 1% for the labs. On this slide, I would ask you to focus on the purple line on top, which is our EBITDA margins.
Our EBITDA margins ex-MFRS 129 stood at 22.3%, which is more or less steady state for the group over the last few quarters. Our PATMI ex- EI stood at 9.2%, actually expanding 70 basis points versus prior year. Slide 11 provides a snapshot of our capital efficiency ratios. We have, again, recommended that we consider the ex-MFRS numbers to highlight the core operating performance of our company. ROE, which is always our key focus and will remain our key focus, I'm delighted to announce that ROE on an ex-MFRS basis stood at 12.3%, which is clearly moving towards our stated objective of double-digit ROE. It is important to note that without MFRS adjustments and without the goodwill, our ROE actually stands well above 17% comparable to our industry peers. We are committed to our ROE trajectory and delivering a strong and profitable growth for our business.
That concludes the financial highlights, and with that, I hand it over back to Dr. Prem.
Thank you, Dilip. So to recap, the ACE framework, which I enunciated in the last quarter, aims to propel profitable growth. And you can see on this slide here, the five strategic priorities that will help us to be a sustainable healthcare leader is to grow organically, expand across the healthcare continuum, develop new growth engines in organic opportunities, and to turn around underperforming assets, all of which we explained in quite a lot of detail in the last quarter. The ACE framework is also to leverage on our clinical and care excellence to care for good for these four groups of people here. And I think this is also something that would be quite clear to all of you. Care for our patients, care for our people, care for our public, and care for our planet. And these are all the indicators that we have there as well.
We previously spoke about our plans to add 4,000 beds, that is, to increase our capacity by one-third by 2028. This slide will show you in much greater detail than before where exactly this is going to happen. We'll be focusing on organic or same-store growth, as I've put it, in the upcoming five years, adding close to 4,000 new beds by 2028. As you can see, we will have strong capacity growth in all our markets such as Malaysia, India, Turkey, and Europe. Hong Kong continues to ramp up, strong bed ramp up. Singapore and Hong Kong, we are growing our out-of-hospital businesses. That's our strategy: primary care, ambulatory care. With these facilities being set up progressively, what we are really doing is to improve the bed utilization in our hospitals because we will be decanting some of the lower-intensity businesses into these ambulatory facilities.
Now, let me go into a few of the country highlights, and we'll start with Malaysia. Malaysia continues to deliver strong performance in both inpatient volume as well as revenue intensity growth. For the full year 2023, revenue grew a solid 20%, with local and foreign patients returning to the country, contributing to the increase. EBITDA grew 11%, and margins saw a slight dip of 200 basis points. These were mainly due to one-time backdated SST approvals and also certain inflationary cost pressures, especially nursing salary adjustments. Inpatient admissions also increased by 17%, and foreign patient revenue increased over 130% compared to the previous year. That contributed 6% overall to Malaysia's overall revenue. One of the strategic priorities in Malaysia is to grow organically by adding 1,300 beds over the next five years. This slide shows you some of the initiatives that have been taking place in Malaysia.
Gleneagles recently signed an agreement with an entity called Pelabuhan Hartanah to develop a new medical block. As you know, Gleneagles is composed of several blocks. Because it's already reaching capacity, very high occupancy rates, it hopes to build an additional block. This will make Gleneagles one of the largest private hospitals in Malaysia when the project is completed in 2027, with over 700 beds in a single location. The middle photograph shows utilization of technology, medical technology. This is Prince Court Medical Centre, being the first medical facility in Malaysia using a cutting-edge imaging and navigation system, which enables spine surgeons to visualize the whole spine from multiple perspectives during the surgery. So this, again, is pushing boundaries in healthcare technology.
I'm also pleased to announce that we've completed, just completed, the acquisition of Timberland Medical Centre in Kuching, and this will strengthen IHH's position as a healthcare provider across Malaysia and strengthen our East Malaysia bed capacity to almost 500 in the near future. We also renewed our MOU with the Ministry of Health to provide free cancer treatment to 500 patients from government hospitals. We have already treated 500 patients, and now this is a renewal to treat another 500 patients. Moving on to Singapore. In 2023, revenue increased 13%, mainly driven by higher revenue intensity. And this is one of the features of Singapore: continuing increase in revenue intensity. EBITDA margins are at 29%. Slight dip because we had to hire a lot of nurses post-COVID. Nursing capacity is now at full. We have opened all our beds. Revenue intensity, as I said, increased 13%.
Case mix made a big difference, more acute patients seeking more high-intensity treatment. We have a major project going on at Mount Elizabeth Hospital, Orchard. It's a three-year project called Project Renaissance. And so we are converting large part of the hospital is undergoing renovations. We are converting multi-bed, double-bed rooms to single-bed rooms across our hospitals. But despite all that, our inpatient admissions remain stable. Foreign patient revenue was 14.2% above the prior year, mainly recovery from Indonesia. So some of the key things that are happening, as I mentioned earlier, expanding across the healthcare continuum. The out-of-hospital strategy is now a firm strategy for Singapore. We've got more ambulatory centers coming up. Just for example, Mount Elizabeth Orchard has decanted the hematology and stem cell services to a nearby building called The Heeren, where they have opened a fairly big ambulatory center.
We're also looking to expand primary care. This is in line with Singapore government's health reform initiative called Healthier SG. So we are expanding our Parkway Shenton Primary Care Clinic Group by more than 15 clinics over the next five years. It's already a leading primary healthcare group in Singapore. And you can see some of the other highlights here. We had an MOU with the leading pharmacy group in Vietnam. Now, let's move on to Turkey and Europe. On a ringgit basis, I want to emphasize this point. For full year 2023, you can see both revenue and EBITDA growth of 33% and 18% respectively in ringgit terms. So it's quite evident that our Turkish and European operations have done remarkably well and continue to contribute significantly to the group. Inpatient admissions have gone up because we've opened new facilities, Ataşehir Hospital, for example.
The acquisitions of Ortopedia and Kent Hospital have also contributed to this increase. So for the full year 2023, foreign patient revenue accounted for 18% of Turkey's total revenue. The country was last year, you must remember, they had the effects of the earthquake as well as the very extended presidential elections. But foreign revenue now accounts in euros for almost half of total Acibadem revenue, both from patients coming into Turkey and the European-based facilities as well. And this is really part of the whole currency risk diversification strategy that Acibadem has. And medical tourism will continue to be a driver in 2024. Again, bed expansion, both Ataşehir and Kent will increase their bed capacity.
You can see some of the highlights, some of the awards that they have received because they are indeed a very, very good private hospital group in Turkey and in the region. A lot of things happening in the European arm as well. For example, in the Netherlands, they have done some expansion work, doubling the number of beds there as well. Now, India, just to remind everyone, covers two of our brands there, Fortis Healthcare and Gleneagles India. So we've got two engines. For the full year 2023, revenue increased by 12% and EBITDA went up by 22%. Revenue intensity went up by 14% with a lot more acute surgical cases. Inpatient admission growth was flat. This was despite divestment of Fortis, our Arcot Road Hospital in June, and a flood. There was a cyclone that affected our hospital in Chennai for a couple of weeks.
So you'll see this map, which we flashed at the last earnings call as well. You will see this is the twin growth engines that we have, Fortis Healthcare and Gleneagles India. And our footprint covers quite a significant part of India at the moment. You can see the green, which is Fortis, the blue, which is Gleneagles India. Maybe just to focus on two things, we'll be increasing bed capacity by more than a third by 2028. And we'll invest in cutting-edge medical equipment. I've spoken in the past about some of the excellent clinical work that's being done in India in all the very high-end areas, oncology, transplants, cardiology, with very good outcomes as well. So to reaffirm IHH's commitment to India, it's a very attractive market, and we really want to broaden our influence and growth there.
Fortis, to be specific, will focus on three of the five strategic priorities that we outlined earlier under the ACE strategy. One is brownfield expansion, 1,500 beds over the next five years. They've just launched a state-of-the-art niche 70-bed hospital in Ludhiana, Fortis Ludhiana. And this is actually the second facility in Ludhiana and the fourth in Punjab. So there's a very, very significant presence in Punjab, 800 beds in the Punjab region. And they will continue to explore earnings acquisitions aligned with their cluster strategy. They're in several clusters and turn around some of the underperforming assets, as you saw what they did last year. And you can see some of these, the highlights of Fortis. I just want to focus and highlight on one you see on the far right, which is the Fortis Cancer Summit.
I personally attended it, and I think it was an amazing showcase of very, very high-end cancer diagnosis and monitoring, treatment with very good outcomes. Fortis has gone into many, many areas like genomic medicine, precision medicine, and showing continued leadership in India in that space. So it was very, very fascinating to be at the summit. Now, Gleneagles India, which now it's almost fully our entity, will also expand bed capacity by about 300 beds over the next few years. A lot of upgrading is going on. If you were to visit any of our facilities, we are getting in new equipment as well. And of course, I keep saying the same thing, but I think it's worth repeating it. Transplants, Gleneagles India is right on top, excellent outcomes. One hospital alone, 800 transplants, Gleneagles Mumbai.
In order to support them, we are doing a facelift of many of the hospitals, and we're going to have a brand launch of the new Gleneagles India brand coming up soon. You'll hear more about it. Hong Kong continues to do very well. Revenue grew 34%, EBITDA margins at 13%. It broke even on an EBIT basis from last year, Q2 already. We are really targeting for the hospital to become PATMI positive as well. This slide shows you some of the main strategic priorities, opening more than 150 beds in Gleneagles Hong Kong. They are opening more ambulatory centers. Gleneagles Hong Kong today has four ambulatory centers other than the main hospital, and they will continue to expand in that space as well. IHH Laboratories.
So I think non-COVID revenue, we are—it's almost—sorry, COVID revenue is almost insignificant now. So we'll now focus on non-COVID revenue or what I call traditional BAU. And that's gone up by 16% from 2022. EBITDA dropped 6% mainly because of the rebranding of Agilus Diagnostics. You remember it was SRL, and then now it's rebranded to Agilus and some higher provision for doubtful debts. Without these two items, EBITDA would be up 1%, really. Now, one of the things about the laboratories, which I have alluded to in the past, is that other than the consumer business, the hospital business that we do, IHH Labs is moving higher up the technology ladder. I think areas like genomics, precision medicine, molecular diagnostics, and all that are going to be increasingly important in healthcare.
IHH Labs is looking at setting up reference labs in the region to support this high-end treatment as well. So maybe let's move on to the outlook. I'll summarize it in a few points. Firstly, impressive full-year results and operational growth in 2023, in my view, higher dividends paid, and an enhancement of our existing dividend policy to distribute no less than 30% of PATMI. Growth trajectory, we are very, very confident of it, anchored on our ACE framework to deliver on those five strategic priorities, which we will keep emphasizing, and notably growing beds by 4,000 in the next five years, which is a one-third increase from our existing bed capacity. Our outlook is very, very positive. We expect continued revenue growth and will focus on driving profitability and sustained double-digit ROE. Thank you very much. Let me now hand over to Penny.
Thank you, Dr. Prem. Before we start, we'll first take questions from the participants on the call before moving to the questions from the webcast participants. I would like to request for each participant to keep to two questions, and then thereafter you can rejoin the queue again. With that, operator, can you please proceed with the Q&A? Thank you.
As a reminder, to ask a question, please press star one one one your telephone and wait for your name to be announced. To withdraw your question, please press star one one again. Please stand by while we compile the Q&A roster. Our first question comes from the line of Pooja Bhatia from Morgan Stanley.
Good morning, everyone, and thanks for taking my question. On Malaysia, this quarter's margins were 21.9%, and I understand that this is ex of sales and service tax. So what was it excluding this one-off impact that we've seen in the fourth quarter? And when do we see it going back to high 20%, which was there pre-COVID?
Yeah, sure. Thank you, Pooja. Thank you for the question. So I think, look, the SST amount alone was close to about somewhere in the order of about MYR 13-odd million, which obviously skewed the EBITDA. And I think some of the cost increases that we saw late last year because of nursing wage increase will probably be set right with slight price increase as well early part of this year. And I guess with that, we'll probably see back to our erstwhile EBITDA in stabilising at about 23%-24%.
Understood. And in the past, there was a guidance given on achieving 24%-25% EBITDA margins. Every quarter, we've seen some or the other impact, whether it's one-off or whether it's to do with the macro conditions or higher staff hiring. So I just wanted to know, when do we achieve the normalized EBITDA of 24%-25%?
So as a group, we've kind of maintained that as a group, as IHH. We think we would want to stabilize somewhere between 22%-24% EBITDA margins as a group. Obviously, each country would have various impacts at various points in time, but as a group, 22%-24% is what we are looking to achieve.
So I think maybe just to emphasize that we are a global group. We've got different things happening in various countries in different quarters. But I think our strength is really that when you put all our countries together and you look at the results, there is a lot of consistency and stability. So in Malaysia, it was the one-off SST, which is inevitable. They had to do quite a bit of nursing salary adjustments last year simply to respond to the market. And you will know that this year, Singapore government has already announced a SGD 100,000 bonus scheme for the public sector nurses. So this also means that Singapore would possibly have to do some response as well to keep the nurses. They have done very well last year in recruiting the nurses. Malaysia now is also in a very good position. So we will have some of these things happening in various countries. But as a whole, I think, as Dilip mentioned, we hope to maintain our group EBITDA in the range he spoke about, 24%-25%.
And how about India? Because India, we've seen margins contract to 15.8% this quarter versus 22%, which was there in the third quarter. And Fortis has done well. So just wanted to know, how's Gleneagles doing on the EBITDA front?
Sure. I think last quarter, we definitely had a one-off item, which is basically a write-back that we had last quarter in Q3. And that's the reason why you're seeing a margin compression. But for that, actually, not only is our Gleneagles margin stabilizing, but actually improving on a quarter-on-quarter basis.
So do we see India's margins going up from 16% to 20% in this year, in 2024?
So I guess, look, as I said, Gleneagles is something that we've just taken almost full control of. And we are, as Dr. Prem highlighted, we are putting measures both in terms of enhancing our medical program, refurbishing our units as well, and also they have their own growth trajectory. So I guess we do want to look at margin expansion in Gleneagles as well, and that's happening as we speak. And we can see it on a month-on-month basis already.
Sure. Just to add, Pooja, I think if you let me start with India first. So I think in Q3, there was an exceptional write-back in Gleneagles India because we had done a set we had acquired the minority stake, which led to some book reversals, which actually made the margins go up. But otherwise, if you take that out, the margins are pretty steady.
I think Fortis has been providing an update on a regular basis in terms of their own growth trajectory. And the only thing that impacted us on the negative side, on the Gleneagles side, was, as Dr. Prem and Dilip mentioned, was floods in Chennai. Now, going forward, I think you can expect the trajectory to be better in 2024 as we expect the operations to stabilize. And on your first broader question, I think if you go back and if you look through page 13, I think a few things here. While we are trying to get the margins back to the levels you talk about, we're also trying to grow at the same time. Last year, full-year revenue growth for a group of our size of 17% is quite notable.
So I think what we are trying to deliver to our shareholders is a good balance of growth and profitability. I think that remains our big focus for 2024.
And is it possible for you to quantify what kind of growth we expect? Would it continue to be double digits? I can see that in terms of network expansion of the 4,000 beds, about 460 or 470 bed additions would be taking place this year. So how do we see revenue intensity improvements across different regions? And overall, if you could summarise what kind of top-line growth do we expect?
So I think on that, I thought we were we came and gave a lot of information this time. If you look through slide 15, we've gone into a fair amount of detail on how we expect the growth to happen over the next five years.
So I think that's the extent of details. I think that's good enough. And I think we always come back every quarter and give you more details. But I think what we can say is that, as Dr. Prem mentioned earlier, we are very focused on delivering both growth and profitability to our shareholders.
Thank you, Pooja. Perhaps we can move on, Pooja. You can rejoin the queue again, and perhaps we can move on to the next question.
Sure, no problem.
Thank you. One moment for our next question. Our next question comes from the line of Rachel Tan from DBS.
Hello. Good morning, Dr. Prem, Dilip, Penny, and team. Can you hear me? Hello?
I can hear you, but you sound a little bit muffled and a bit softer. Maybe you want to speak a bit louder.
Okay. I will speak a bit louder. Thank you so much. Congratulations on the very strong results. A few questions from me. I think firstly, I just wanted to focus on Gleneagles Hong Kong. I think you spoke about EBIT break-even in 2023. And then you are also expanding laboratory over there. So I'm just wondering, do you have an expectation when we can achieve net profit break-even and whether, with the laboratory coming in, would that cause any drag in the bottom line in the near term?
Okay. Maybe before Dilip or Ashok take the question, I just want to say something about Hong Kong. So I think many of you know Hong Kong as Gleneagles Hong Kong Hospital, right? But the team there has actually quietly expanded over the last few years into what I call the ambulatory space. And why is that important?
It's important because when you have a hospital in isolation, it depends on patients coming into the hospital or to the community at large, the GPs and various people sending in patients into Gleneagles, say, as opposed to sanatorium or Adventist, right? So Gleneagles is, in a particular location, the island, which the team there feels that they can build up the ambulatory business in the south of the island. And that's what they are doing. Other than central, where they already have two ambulatory facilities, they now have two more that have opened. And they're focusing on building up so it's like a hub-and-spoke model, if you will. And I think that is one of the things that will continue to expand GHK's capabilities as well. As you know, they still have got beds that they can open up. They are opening up more.
They can probably fully open up in due course. I stated earlier that we hope GHK Hong Kong will become PATMI positive soon. Maybe Dilip or Ashok can chime in.
So yeah. So to that, look, our expectation is that now that we are a bit breaking even at the hospital, we continue the trend and probably break-even PATMI soon as well. So that's the target for ourselves. Obviously, the ambulatory care centers that Dr. Prem mentioned are actually helping us in terms of referral volumes into the hospital as well. You can see that last year to this year, both volume as well as revenue growth. Hong Kong Hospital, the hospital itself, has achieved pretty impressive double-digit growth. The ambulatory care centers will further help accelerate that growth and ramp up in our volumes within the hospital.
Okay. Thank you. Maybe just to follow up a little bit on operational metrics for Gleneagles Hong Kong, I remember last time there was this standard package and full package or full private package. Could you give us a sense how has the standard package versus the full package been in terms of the breakdown? And are there any Chinese patients coming through, or is that number or is it still maybe local?
Just the packages? No. So Rachel, your voice was not clear. This is relating to Hong Kong still?
Yeah. Hong Kong. She's talking about Hong Kong.
Yeah. Hong Kong. Yeah.
So Rachel, you're talking about the agreement with the Hospital Authority, HK, for the package to patients. Well, it's still there, and it's being utilized by both the government-referred patients plus others who want to use the packages as well, from my understanding. Yeah.
With regards to China patients?
The split of the standard and the private package. Is it 50/50? Is it 60/40? Yeah.
Okay. Do we have that number?
Rachel, why don't we come back to you? We can come back to you with the exact breakup.
So you're talking about the breakdown between the packaged patients and the à la carte patients, right?
Yeah. Yes. Correct. Yeah.
Got it. Got it. Okay. We'll come back.
Yeah. We'll come back to you. But suffice to say, again, from a cash patient perspective, we are seeing ramp-up. And that's one of the reasons why also you're seeing, from a profitability standpoint, there is expansion in margin. And on the China patients that you mentioned, the hospital team is pretty actively working, organizing camps in Shenzhen and a few other places, which helps in referring patients back into our hospitals.
So that's something that the hospital team is very, very actively pursuing.
Okay. Thank you. Very quickly, I'm going to second question. I'm just wondering, what are your thoughts on share buyback, given your share price now?
I think no current comments on this, I think, at this stage.
Okay. No plans about share buyback?
Yes. Okay. Thanks. Thanks, Rachel.
Okay. All right. Great. Thank you so much.
Thank you.
Thanks, Rachel.
Thank you.
Thank you. One moment for our next question. Our next question comes from the line of Sean Tan from Goldman Sachs.
Hi. Good morning. My first question is on bed expansion. Can you guide what's the CapEx for the next five years? And also, should we expect any drag on margins as beds open?
Sure. Thank you, Sean. I think, look, we'd already mentioned last earnings call, our CapEx per year would probably go up. These are all multi-year projects. These are largely brownfield projects. So it'll be done over a period of time. And that's why if you see we've given the breakdown in terms of what is the CapEx, what is the expansion next year and thereafter for the remaining four years. So first of all, in terms of CapEx, there will be an elevation in CapEx. I mentioned last time as well, our CapEx indication for 2024 is in the order of about MYR 2.7 billion-MYR 2.8 billion, which is higher than our normal CapEx that we spend on a year-on-year basis. However, I think if you look at our cash flow, we have a pretty strong cash flow. And most of it would be funded from our free cash itself.
So going forward, I think we are pretty well-positioned from that perspective to use our free cash to accelerate the growth going forward.
I think just on your second part of the question, I think what you are seeing is across our core markets, demand remains strong. And therefore, organic bed capacity expansion is something quite natural. And it's something that we continuously do. So if you look through a period of, say, three-five years, some capacity's coming in, some new capacity's been built out. So we hopefully plan it in a manner that it doesn't have a sudden impact on the margin. So to your second part of the question, it's planned in a manner that the margins don't get impacted.
That's the reason why, again, even earlier in our last call, we'd said, "Look, we intend to maintain our EBITDA margins as a group between 22%-24%, somewhere in that order."
I think we spoke about this concept where if you are operating at 70%, 75%, every day you're actually losing patients because you can't turn around the beds to admit patients. So these are the hospitals where the moment you increase the bed capacity, it's almost immediately taken up as well. The occupancy doesn't drop drastically. We have hospitals in Malaysia that are operating at close to public hospital capacity, 100%. And that just means that the clinics can't admit patients or the emergency department can't admit patients.
So we carefully identify and prioritize which are the hospitals that we need to increase the beds as quickly as possible to ensure that we don't lose these patients but instead can admit them into our hospitals. So it benefits the hospital and the group immediately.
Got it. Thank you. That's very clear. But for the CapEx, can I just clarify? MYR 2.7 billion-MYR 2.8 billion, is this a fair assumption per-year basis for the next five years?
So look, I think 2024, that's where the number is at this point in time. And again, the reason I'm kind of unwilling to commit to beyond 2024 is, again, there could be certain bed expansions that could come up based on capacity utilizations. And this number could move as well. But in 2024, that's the number we are looking at.
Okay. Got it. Second question is on the cash repatriated from India. Proceeds-wise, will it be used towards debt repayment or M&A? Can you talk a bit more about interest cost expectation for 2024?
So the money that is repatriated, we've already used a big part of it to pay down our debt in December itself. And the remaining money is actually sitting as cash in bank and deposits, which I think would get utilised for some of the expansion activity as well as growth activity that we are looking at, which includes both it could be organic as well as inorganic activity. And expectation on interest cost? So the interest cost, at this point in time, given that we've been actively paring down our debt using our cash pool, we have been managing our interest costs so far.
I think we are hoping that again, the view in general and probably you guys know this better, the view in general is later part of this year, interest rates are expected to soften. So whatever little remaining debt we have, I suppose we will benefit from that too.
Okay. Thank you.
Operator, actually, I have quite a few questions on the webcast. So maybe we'll take the webcast questions first. And then once we exhaust that, we can always come back to the teleconference audience. So the first question that we have is from Chun Soon. Can IHH share what are the reasons of a quarter-on-quarter lower EBITDA margin in India and Malaysia? Is it primarily dragged by cost escalation? And can IHH share where are we now in terms of the newly added beds versus your 4,000 target? Dr. Prem or Dilip, do you want to take that?
So maybe I can take the first question. So in terms of EBITDA margin itself, first for India, as we mentioned, last quarter, Q3 versus Q4. Q3, as Ashok mentioned, we had a one-off reversal, which was related to specifically the transaction that we consummated with regards to buying out the minority interest in Gleneagles India. And hence, the base was artificially high. Without that, on a quarter-on-quarter basis, we are actually seeing a margin expansion in India, Gleneagles India specifically. So that's with regards to India. With regards to Malaysia, as I mentioned, again, there is an SST provision from a backdated provision that we had to kind of take in Q4, which amounted to a pretty significant amount. Without that, we would have been closer to the 25% EBITDA margin mark for Malaysia.
Are there cost escalations? Of course, as Dr. Prem mentioned, we have seen nursing wage inflation across all our markets and inflationary pressures across last year. And despite that, we've been kind of able to hold on to, as a group, been able to hold on to our margin profile on the EBITDA margin side.
And sharing about the number of beds.
Sure. I think we've provided a fair amount of detail on slide 15 where we are on capacity in each of our markets and our growth plans. I think hopefully that should be able to address your question.
The next question is from Paul. Can you please share your comments on news regarding the Supreme Court's directive for India's central government standardizing hospital rates? Is this doable, and how can the industry mitigate this?
I think no comments at this moment. We've also just seen the news coming through. So I think we need to see how this sort of pans out. And if there's something material, then we'll always come back and update the investors and the analyst group.
Sure. Thanks, Ashok. Next question is from Paul from Bank of America. First, what was the quantum of the SST provision in the Malaysia segment results in 4Q? And second question is, can you give greater clarity on the one-off that boosted margins in India in third quarter 2023, reference on slide 10? How much was it? Third, can you share your number of planned beds to expand by year for 2024 through 2028? Will it be flat or any years with larger step-up? And for 2024, can you provide number of expected bed increase by country?
Last, can you provide an update on the status and performance of Parkway Hospital in Shanghai? Maybe in terms of the bed capacity question, as what Ashok mentioned earlier, I think, Paul, we do have that slide 15 that maps out your operating beds that we intend to roll out from 2024. And of course, beyond that, 2025 to 2028, we also gave you a ballpark. So that should essentially cover your questions. Maybe to Dilip on the quantum of the SST provision.
Yeah. So it's roughly about, let's say, MYR 13 million thereabouts is the SST provision. And I think the one-offs in India, we mentioned, it's a one-off because of the transaction that we consummated wherein we bought back or bought over the minority interest in Gleneagles India because of which there was a specific write-back that happened in Q3, which is not available in Q4.
Perhaps Dr. Prem, can you provide an update on the status and performance of Parkway Shanghai Hospital?
Yeah. Maybe Ashok, you want to?
Yeah. So I think this is obviously, on China, our focus currently is to get our clinics revamped. We are looking at doing some new strategic initiatives around our clinics and building a stronger platform that can feed into our hospital business going forward. It's a market that we are looking into very, very carefully. The current plan around China is to continue with the platform. And therefore, the strategy in the short to medium term remains build the clinics as a feeder to the hospital. And I think to that extent, we are making some changes to our strategy and also changes to the organization to deliver these goals.
Thanks, Ashok. The next question is from Gok Siang. First one is, why is Malaysia's EBITDA margin lower at 22% compared to 25% or to 28% in previous quarters? And then next question for Acibadem. The reported EBITDA, including MFRS for Q4, was MYR 206 million. And if we adjusted the one-off MYR 255 million deferred tax credit mentioned in the quarterly report, it fell into negative territory. Any comment on it? And the last question is, can you remind us what's the EBITDA targets of each country? And please elaborate the strategies. Dilip?
Sure. So maybe you can start with Malaysia. I mentioned that if you remove the SST provision, the margin would have been closer to 25%. So I think that's something that we addressed. With regards to the MFRS adjustment, this is, if you look at the excluding MFRS number on the EBITDA margin side, we actually saw a pretty good ramp-up both in terms of number as well as the bounce-back in our EBITDA margin with regards to the Turkey business. We saw that earlier in the year, that EBITDA margins had compressed in Turkey mainly because of the earthquake and the elections, as Dr. Prem mentioned. We've seen that on a quarter-on-quarter basis come back quite strongly. And this is quite representative of what we are seeing both in Q4 as well as going forward, what we expect it to be. So the MFRS adjustment itself, it is a deferred tax credit that was available to us because of certain change in the tax regulations in Turkey. And that's the reason why you see the bump-up there.
Can you remind us on where the EBITDA target for each country is? As I said, the overall strategy for the group is to have a stabilized EBITDA of somewhere between 22%-24%. Obviously, each country would go through different cycles at various points in time. But as a group, 22%-24% is what we expect to stabilize at.
Thank you, Dilip. The next question, it's from Su, CLSA. Could we get some updates on the progress of China operations? I know Ashok basically answered the question on China. Ashok, anything or Dr. Prem, anything you want to add? If not, I can move on to Dilip.
Yeah. No, no. I think Ashok already addressed this. But just to emphasize that we are spending quite a bit of time on restructuring China operations. We previously stated that we are going to stay in China.
So obviously, we are putting in the necessary efforts and support to the China team from the senior management of the group.
Thank you, Dr. Prem. Next question is from Rahman from Kha zanah. Can you share what's the proportion of patients in IHH India that are oncology patients compared to a more mature market like IHH Singapore?
Okay. First thing I want to say is that in all our markets, we have quite a lot of focus now on cancer, oncology, simply because the data surrounding cancer incidence is actually quite scary. I quote some of these things when I talk at various forums. So in Singapore, we say that one in three Singaporeans will get cancer in their lifetime. Part of it is also due to the other than cancer incidence is longer life expectancy. So you develop a cancer.
I just saw a report that in the U.K., it's one in two U.K. residents will get cancer. So it's actually quite stark, quite scary. Hence, the Fortis Cancer Summit that I spoke about. In most of our markets, so in India, I think it's in the teens at the moment, proportion of patients in terms of if you look at our specialty mix. Because in the past, in India, there's been a lot of focus on cardiology. But as cardiac prevention, treatment of cholesterol, screening, ECG, treadmill tests, and all are done more and more commonly, cardiac incidence is coming down. I think that's a big success in terms of primary prevention. But oncology in mature markets would be in the 20s, 20%-30%. It's much higher. I'm sure this is going to track up even further.
If we focus on oncology, which we are doing, if you look at our hospital in Fortis FMRI, our main hospital in the National Capital Region, it's becoming a cancer hub. They're putting in a MR- Linac. They have got PET CTs. They've got a Gamma Knife, CyberKnife that's coming up. So it'll become something like the Mount Elizabeth Novena Hospital that we have in Singapore, which is probably one of the best-equipped cancer hospitals in the Asia-Pacific because it's got the full suite together with the proton. Yeah. So I would say, yeah, it'll move teens in many countries. You go into the more mature markets, it'll become 20%-30% or so. And I wouldn't be surprised one day if oncology really heads up towards almost half the patients that we have in our hospitals.
Thank you, Dr. Prem. Next question is from Guan Wen from Macquarie. With regards to IHH Labs, EBITDA margins have been falling every quarter. I understand it's due to a shift away from COVID testing, which brought higher margins. But what about IHH Lab EBITDA margin? What can we expect going forward?
Thanks. I think you're absolutely right. Our margins, because COVID testing contributed to higher margins in 2022, now I think we've stopped even looking or counting at COVID-related revenues at the labs. And therefore, the margins are now stabilized to what we call normal sort of testing. And I think the best way to answer your question is most of the margins track hospitals in each of our markets. So it's in and around, slightly higher, slightly lower than where the hospitals are going.
Because the way our labs work is we've got a large part of the business coming from our hospitals, and then there is outreach. So unlike some of the labs which are very focused only on outreach, our labs are slightly different because our first focus are our hospitals. And then we look at outreach. So I think if you look through where our numbers come out for our main markets on a quarterly basis, and then you look through our labs' margins as well, it's fairly sort of comparable.
Next question is from Jesse from AIA. So congrats on the stellar results. But notice that average revenue per inpatient for Europe and Türkiye is relatively low in ringgit terms at about MYR 10,000-MYR 15,000, which is similar to Malaysia despite the exchange rate difference. Can you kindly enlighten on why and what's the target that we have on revenue intensity for this market?
Yeah. Sure. So look, I think the intensity, if you go back in time and look at the revenue intensity, it's been around that mark. So it's not kind of changed overnight. Obviously, having said that, there have also been price increases to keep up in Turkey with the inflationary trends there. And hence, you can see that the what do you call? The absolute ticket size in terms of intensity is at about MYR 10,000-MYR 15,000, roundabout there. Having said that, I think what probably we should also focus on is the margin itself, the absolute margin itself.
Again, you can see this quarter, the margins in Turkey, the EBITDA margins in Turkey actually, as I mentioned, has moved up, has bounced back quite strongly from Q3 2023 and Q2. Q2 and Q3 had impact of elections as well as the earthquake. We see Q4 as a pretty strong quarter leaving 2023 and going into 2024. I think that's something that we need to watch out for from a margin perspective rather than just looking at absolute per-bill intensity.
Next question is Joshua from UBS. With money being released from the escrow account, how should we think about the progress in terms of MTO for Fortis? And at Fortis' current valuation, will the MTO be return accretive still?
I think we are still in discussions with the regulatory authorities on the MTO. And I think if there's any update, we will provide that accordingly. But I think just a comment on Fortis in relation to the second question. I think we are very strongly committed to our strategy in India and our strategy around Fortis. I think India offers great opportunity for us to expand and expand in a sustained, profitable manner. And I think hopefully that answers your second question in terms of the way we think about Fortis today.
Next question is from Stephanie about the recent media article stating the Indian Supreme Court that had managed to standardize hospital rates. I think, Dr. Prem, have you answered this already? Yeah. You've already answered it. So I'll move on. Next is from Raymond from Kenanga. Can IHH share outlook and expectation in Turkey and Singapore in 2024? Okay.
Maybe to address Singapore, I think you probably know Singapore is a pretty stable market, really, simply because of the political stability, economic stability, quick response to events and things that happen. So in that sense, I think Singapore is quite stable. If you look at the financials of Singapore, it's always despite only having four hospitals running at full capacity, the revenue intensity goes up because of the foreign patients who come in, the high-technology treatments. I spoke about the Proton Beam, for example, which will add to the intensity in Mount Novena. And you will see more of these things coming up. It's always one of the first technology adopters in our group. So I would say Singapore would always be you can assume it'll remain fairly stable. Turkey, and we have again said, core performance is always good.
Some of you have visited our Turkish operations last year, I believe. You have seen for yourself how well-run and how well-managed these hospitals are. Macroeconomic conditions in Turkey change from time to time. We are, of course, looking forward. If you look at the central bank's forecast, inflation is supposed to be coming down. It's still a bit sticky, but it will come down over the next few years. So I would say that we can. Our expectations are that as the macroeconomic situation improves and stabilizes, our Turkish operations will get better as well. Again, they continue to grow into Europe. They're expanding some of their hospitals there. Netherlands, they are looking at new things in Europe. And that would increase. I think it's very impressive that they have 50% of their revenue, which is euro-denominated at the moment. Thank you, Dr. Prem.
Next question is from Rachel, DBS. She's got additional questions. Now that you've hit your double-digit ROE target, what's your next target?
So I think, look, we've stated that and Ashok mentioned this, and so did Dr. Prem. Our stated objective is to grow and to grow profitably. So our trajectory will continue. We will continue to kind of retain ourselves in the double-digit ROE going forward. And that's what our objective would be really at this point in time. Rachel, on the second part of the question, I think this has come up a few times. So I think we will definitely make a note of this. And maybe going forward, next quarter, we will specifically give a little bit more details around what's happening in China, what's happening in India. This is a core part of our A strategy. So we looked through what Dr. Prem went in our main slide. This is the turnaround of underperforming assets. It comes under that. But I do note that there are a lot of questions on these two parts. And we've tried to provide you with our views. But maybe we dedicate a little bit more time going forward during 2024 so that you all have better clarity in the trajectory of these businesses.
Yeah. And the only thing that I'd probably add to your last question, could this be related to key doctor departures? I'm actually happy to say that ever since we've acquired close to 100% in Gleneagles, we've actually seen more doctor additions. Meaning to say, given by our strong brand, we're actually seeing pretty strong additions. And that's one of the key reasons why we are confident in terms of what we would be able to perform with Gleneagles India asset.
Thank you. And perhaps I'll take the last question from the webcast now from Chun Sung, RHB. Do you foresee escalated nursing wages to erode margins in 2024 and any quantum in terms of the wage hike? And had IHH adjusted pricing to pass on the cost to patients?
Okay. Maybe just on the nursing, a general comment on nursing. As I've said before, there's a global shortage of nurses. If you read various reports, WHO, International Nursing Council, they will tell you somewhere close to 9-10 million nurses. Sources of good nurses are few. We get most of our nurses from the surrounding countries, Philippines, India, Myanmar even. So we get the nurses. We have strong competition for nurses in certain countries. In Singapore, it's the public sector. They've already announced the $100,000 bonus. Singapore will have to react.
Singapore has got some, I would say, pricing power with the payers and with foreign patients who come. Malaysia, likewise, did a nursing adjustment last year. So they're comfortable for now. There's no indication that there is any specific, I would say, pressure to increase nursing. But because of the global shortage and nurses always moving, a lot of the nurses are now moving. In the past, they used to move to the Middle East. Today, they are moving to Australia, New Zealand for a different set of reasons. So I would say this is very fluid. This is something top of the priority all the time. It's not something we can take our eye off the ball. So it will happen. We can adjust pricing in some countries. In some countries, we can't. We have to cut costs in other areas.
So this is part of doing business.
Thank you, Dr. Prem. And perhaps I see one more last question. One question, then this is going to be the last one from Paul, JPM. Can you please elaborate on India EBITDA margins compared to listed peers? Fortis India in high teens versus Apollo 25% versus Max 28% versus Medanta 23%. So please share how India can move to industry. Dr. Prem, Ashok?
Yeah. I think if we go back to four, five years back, Fortis was running at a single-digit sort of margin. So I think the management has done a great job so far in bringing this up to high teens. And we are very, very focused on seeing how we can bring this, how we can close the gap with the key competitors. Now, they've already made some adjustments to the portfolio. We talked about Arcot.
We talked about Malaysia. I think now the focus goes back on core operations. But please be reassured that the Fortis management and IHH, we are quite focused around this issue around narrowing the margin gap with the competitors.
Thank you, Ashok. So with that, I think we will now conclude our IHH Healthcare fourth quarter and full year 2023 financial results briefing. Thank you for joining us again this morning. And if you have any questions, just feel free to reach out to the investor relations team at ir@ihhhealthcare.com. And with that, operator, you may disconnect.