Okay, we should be ready to go. Good morning, everyone, welcome to Medistim's fourth quarter presentation. Before we start, I'd like to share just a few practicalities. You will all be kept on mute during the entire webinar, and we will address questions at the end of the presentation and encourage you to type in your questions as we go along.
To write the question, simply click on the orange arrow to expand or minimize the panel and enter your query under the question section, where the blue arrow on this slide is pointed. Questions will be addressed anonymously. Lastly, I want to inform that this webinar will also be added to our investor relations sections of our website within the end of today. Yes. We're ready to start. Again, welcome everyone.
My name is Kari Krogstad, and I'm also joined by our CFO, Thomas Jakobsen, here today. We're going to go through highlights from the fourth quarter and also summarize preliminary results from the 2020 total year. We will go through, of course, the financials, talk a little bit about the updates from the business segments and how we're implementing our strategy, and then towards the end, also some comments on the situation regarding the pandemic.
Okay. The fourth quarter sales ended close to last year. As we can see, 94.2 million NOK in revenues, so a slight decline in Norwegian currency versus the same quarter last year. It's still effects of the COVID-19 pandemic that we are seeing postponing elective surgeries, and then also sales revenues. We can see that we still have some favorable currency working for us.
Taking that into account, the currency-neutral sales is declining this quarter by 7.2%. Still, this is an improvement from the second quarter and the third quarter, which showed 19.3% and 9.7% currency-neutral decline respectively. We do feel that we are at least stabilizing in this situation and probably seeing a slight recovery from the pandemic. We'll talk more about that later in the presentation.
Of course, the U.S. represents almost 1/3 of the global market opportunity for Medistim and also makes up about 45% of the sales from our own products today. What happens in the U.S.A. impacts our business in total to a large extent. The U.S.A. has decreased, as you can see, 23.2% in NOK and almost 38% in USD.
In the fourth quarter, we see effects of the very challenging period that the U.S. has been through due to the pandemic. As you will recall, we saw growth of 6.5% currency neutral in the third quarter, after the first hit of 36% decline in the second quarter currency neutral. I think all of us have followed really the U.S. pandemic situation in the fourth quarter, this result should not come as a surprise.
When it comes to the other regions, sales in Europe actually increased by 19% this quarter, both driven by good development in our own products, especially helped by some interesting developments in the Nordic area where we have a very strong position, and we'll talk a little bit more about that later on. Also very strong contribution from our third-party sales this quarter, up 33%.
Asia and rest of the world were down for the quarter 18% and 16% respectively. When it comes to the segment sales, vascular is a strategic area for us that we want to build a position and we're following that very closely. Sales for vascular was down for the quarter by 26%. Sales of our imaging portfolio was down by 13%. Everything is really reflecting the lower activity level that we're seeing as a consequence of the pandemic.
The good news this quarter is that the EBIT margin is up from 21.6% - 23.5%, and as you can see, it's a very solid result, NOK 22.1 million, growing by 12% over the same quarter last year. We're continuing to deliver good profits. Another good and important milestone for the company was that we were able to sign a distribution agreement for India with LivaNova.
This is a market where we struggled for a long time to find really the optimal partner, and by this agreement, we feel that we really have found an excellent partner. Lastly, as a highlight for the fourth quarter, the board will suggest to the general meeting to pay a dividend of NOK 3 per share for the year 2020. Also let's take a look at the full year and how it all ended up.
For the full year, the sales ended on par with 2019, so NOK 363.1 million. After three consecutive quarters with COVID-19 pandemic effects, that neutralizes the sales growth that we saw from the record start we had in the first quarter. We reached about NOK 100 million in sales for the first time and growing by 16%.
Of course, the COVID effect has led to the result that we are ending up on the same level as last year. Again, we're seeing some favorable currency effects. Taking that into account, the currency neutral sales is down by 6.1%. Making up the status here for the U.S., there's a decrease then with 7%, rest of the world with 24%, and you can see the currency neutral decline 13% and 30% respectively.
We actually are seeing for the year sales growth in Europe for own products and for Asia up 12%. Europe was up 10%. If we then again take currency into consideration, the growth is more neutral. When it comes to the annual result for the sales of the vascular portfolio, we're ending up with slight growth of 4%.
You might recall that the growth from last year for the vascular portfolio was 18%, and we started off in the first quarter with 36% of growth. It is again, definitely COVID-19 kicking in during the three last quarters in 2020 and then ends up with an annual growth of 4%. Just a comment on the cardiac portfolio, this was pretty flat for the year. When it comes to the imaging portfolio, this is down 6% for the full year.
Again, looking back, we went out of 2019 with 33% annual growth, and we started this year with 40% growth in the first quarter. Again, we're seeing the pandemic coming into play and really introduces an abruption to the expected continuation of growth. Third party products ends up then at the same level as the last year.
All in all, I would say that we are pretty happy with the sales developments all considered, and it's really great to see that we are continuing to deliver profitable results here and we're delivering the best EBIT result we've ever made. Ending up at NOK 95.5 million, up 6.4% from last year. By that introduction, I will leave it to Thomas to go through the details here, and I will revert with further comments.
Thank you, Kari. Good morning everyone. As usual, I will go straight to the numbers. Since Kari will come up more on sales later on when it comes to geographic split and sales per product, I will not spend much time on that here now. What I need to mention though is to explain the increased cost of goods sold is that we had a very strong fourth quarter when it comes to sale of third-party products.
Compared to last year, we had NOK 5 million more of sales related to third-party products compared to last year. That explains the increased cost of goods sold since we obviously have a higher expense when it comes to third-party products compared to our own products. Salary and social expenses are down compared to last year. That is the same for other operating expenses.
The reasons for that is as it was for the second quarter and the third quarter related to the COVID-19 and the pandemic situation. With lower sales, commissions for sales reps are down and also bonuses. When it comes to other operating expenses, Medistim normally has extensive traveling activity and exhibition and congress activity, which has been at a very low level also in the fourth quarter due to the pandemic.
Therefore, these expenses are reduced compared to the same period last year. This leaves us with an EBITDA of NOK 28.4 million up from NOK 24.5 million from last year and an EBITDA of over 30% compared to last year's 25.7%. The margin is strong. Depreciation has also increased, and that is due to our new and improved production facilities that we moved into in 2020.
The fact that we have increased office space in our main office here in Oslo has also contributed to increased depreciation. Our EBIT ends at NOK 22.1 million at 23.5% margin, which is up from last year's NOK 19.7 million and 20.6% margin. It's a solid EBIT despite a little bit weaker sales. Financial income net is negative, and that is related to foreign exchange.
The Norwegian krone has been very volatile during 2020 and in the second and third quarter, weak compared to USD and EUR. By the end of the year, the Norwegian krone was strengthened towards these currencies, and therefore we suffered a loss, both realized and unrealized losses related to foreign currency. Our pretax profits ends at NOK 19.9 million, about the same as last year, which was NOK 20.2 million.
The result after tax ends at NOK 13.6 million. If you go to our preliminary profit and loss for 2020, sales again ends at the same level as last year. However, our cost of sales are actually down, and this is related to product mix again. In total and in Norwegian krone, the sales of our own products are at the same level as last year, and that is also the case for third-party products.
However, we do get help from foreign currency and the underlying growth in terms of number of units and expenses related to our own products are therefore reduced. That explains the reduction in cost of goods sold. When it comes to salary and social expenses, other operating expenses, and also depreciation, the explanations are the same as for the quarter, only different numbers. I don't need to go into that detail again.
The operating result, as Kari mentioned, ends at NOK 95.5 million. Despite the COVID pandemic and all the negative effects that has had on our sales, we are actually delivering the best operating results in Medistim's history. EBIT margin is strong, up from last year's 24.6% - 26.3%.
We see the negative effect related to foreign currency, and that is again correlating with the volatile situation the Norwegian krone has had against US dollars and the euro throughout 2020, and the strengthening of the Norwegian krone by the end of the year. Our pre-tax profit ends just above last year, ends at NOK 91.6 million. Last year was NOK 91 million. Profit after tax ends at NOK 69.4 million versus last year, NOK 17.3 million, so approximately close to last year's profit. Move on to the balance sheet. Intangible and fixed assets are going down.
Intangible assets are being reduced. Fixed assets at the same level as last year, which means that we've been depreciating more of our activated development expenses than we have been activating in the balance sheet. When it comes to inventory, the inventory level is high, and that has been explained also in previous quarters and is related to end-of-life stock components and critical components that we need to secure for our products.
We also see effects of the COVID-19, where sales levels are at a lower level than we anticipated when we were actually confirming orders to our suppliers. During the quarter, the board decided to pay out a dividend of NOK 15 million. Also mentioned here by Kari, the board will also suggest for the general meeting to pay a dividend of NOK 3 per share based upon the profit from 2020.
The NOK 15 million paid in the fourth quarter was of course related to profit for 2019. The board received an authorization to pay that and kind of a wait and see attitude toward to see how COVID-19, the pandemic, was affecting Medistim. When it comes to equity and liability, total equity is solid, NOK 256.8 million and 74% equity. When it comes to long-term debt, the main portion of that is related to lease obligations.
NOK 21.6 million is related to those. Then we have NOK 7.5 million related to a loan from DNB, but also a loan in the U.S. related to the PPP program, Paycheck Protection Program, which is on the total debt in the balance sheet by the end of the year of just under NOK 30 million. With that, I leave the word to Kari to talk more about business update for the fourth quarter. Thank you.
Yes. We will start with looking at how we are doing for the imaging systems and probes. As you can see here, we are seeing COVID-19 pandemic effects. It's been difficult for us both to reach customers, but the main reason for the decline we're seeing is obviously lower activities, lower numbers of surgeries being performed around the globe. Number of imaging systems was down by 12% in this quarter.
For the year, it's down 25%. We were very happy to see in this fourth quarter, we actually had five system sales in the Nordic region, and that's pretty rare because this is a fully saturated market, and it's replacement sales, then they get new system sales here for the Cardiac side. We actually sold three systems to Haukeland in Bergen, and we had one to St. Olav in Trondheim and one to Copenhagen as well.
That's sort of nice to finish off the year with strong sales in our home market. When it comes to imaging probes, that was also down 14% and 12% for the year. While we have seen a higher decline in the imaging systems compared to flow systems, we believe that several of the sales projects that we have been working on during the year have transitioned from an initial imaging type of opportunity and ended up as a flow sales because of more cautious spending at the hospitals for the moment.
We should really remember that any sale of a flow system based on the MiraQ is field upgradeable to an imaging system at any point in time. We hope to see transitions to imaging on these platforms going forward.
When it comes to the flow probes and the systems, again, it's the same underlying explanation for the decline. Flow probes was down 6.8% for the quarter and 13.5% for the full year. I think that is a good parameter to look at when we are trying to explain and understand the real decline in activity level out there. Number of flow systems was down 20% for the quarter, but it's growing by 19% for the full year.
That is, of course, very encouraging. When we are then adding the total number of systems sold, both flow only and flow and imaging combined, we're seeing that we are growing in 2020 from 195 units to 197. That's at least encouraging during the current circumstances. Of course, growing our install base is a prerequisite for sales of probes as well, and that is all good.
Taking a look at our revenue distribution on the different geographies, we can see that, well, in Europe, there is really two things going on. We have sales of our own products, and we have sales of third-party products. This quarter, as I mentioned in the introduction, we've had the good contributions from good growth from our own products and third party as well.
In the U.S.A., we can see that there's a discrepancy between the development in NOK and in U.S. dollars. Asia, we had the slow quarter, the fourth quarter, but as you see for the year, it's been a very good year, and we had a very good start of the year with a lot of MiraQ system sales to Japan as a consequence of the regulatory approval that we achieved last year.
Rest of the world, Middle East, Canada, South Africa, and Australia, smaller regions in total, have been declining both for the quarter and the year. Yes. This is, again, looking at the revenue, then divided on the various product groups. In general, the apparent discrepancy we may see in the development of number of units sold compared to the sales development in NOK is due to a combination of sales channel.
Of course, it differs if a product is sold through the direct sales channel or own subsidiaries. That gives higher revenues and profit compared to sales through the distributor channel. The second thing is the business model. In the U.S.A., of course, the unit sold as a capital sales, that gives also immediate sales and profit impact compared to a unit sold as a PPP or a lease model.
Then last but not least, there are currency effects coming into play all along. That is the reason why we are at this slide trying to explain the differences that we're seeing if you're comparing the development in NOK versus the development in the number of units. I'm not going to go through the details here. That's for everyone who's interested to study in detail.
A couple of comments on implementing our strategy, and just a reminder here. The strategic initiatives that we have is first and foremost to continue to convert the flow market to a flow in imaging market. This is important for all the geographies where we have a very strong position. Nordics, Japan, Germany, Spain, Central Europe at large.
We are also working to develop stronger positions in some of these markets where we do not have as strong position today. U.S., U.K., France are good examples. Here it's really to work to fight, what we say, ignorance, indifference, and ease of use. It's a lot about marketing initiatives, educational programs, and also of course, working on the product to make things as attractive to start using as possible.
In the U.S., we've also over time, worked very consciously to develop the sales force. Not only the size of the sales force, but also sort of the work processes that they are adhering to. We also have a strategy to offer an entry-level solution to reach emerging price-sensitive high-growth markets, and we will come back to that. We have a dedicated strategy to build a similar position in vascular as we have today in cardiac.
Last but not least, we also work to expand our direct market coverage over time. Just to follow up on the main market, where we are really concentrating our efforts. As we know, we've had a really good development in terms of growth in revenues, but also number of procedures over the years. As you can see, in 2020, we are abreast in this growth curve, and hopefully just for this year.
I don't need to repeat the results in US dollars and NOK. Number of procedures was down 11% in the fourth quarter and 10% full year. I think this compares really well to how we're seeing the development of the flow probes in the other parts of the world. That was down about 13% for the year.
That gives a good indication on the reduction of activity level that we are seeing in our business. We've also seen some slower capital sales, but not down to zero. We sold three units in the fourth quarter compared to eight last year, 26 units in total in 2020, compared to 33 last year. I'm very happy to see that we're continuing to add new customers to our customer base.
Seven new customers also achieved in Q4 and 25 in total for the year. I think this is pretty encouraging and solid results, and providing every reason to be optimistic for 2021. Okay. Let's again, just remind ourselves about the strategy to offer an entry-level solution to reach emerging price sensitive and high growth markets. India is definitely an example of such a market.
I just need to remind everyone that this is a longer-term growth opportunity for us. It's not a business which is strong today, obviously. We struggle to find really the right way to get a position in a market like this. The milestone that we have reached now with signing this distribution agreement with LivaNova, marks, I would say, a new starting point for trying to really build this position.
The Indian market is very interesting because it's large. It's about 100,000 CABGs done annually, and this is about half the size of the U.S. Of course, this is interesting for us. It's also growing at a faster speed than the Western world, where we, in many cases, are also seeing a small decline over the years. 78% annual growth is what we're seeing at the moment. This is a price-sensitive market.
About 75% of the market is private hospitals, being very price sensitive. The cost of CABG is low compared to other markets where we're operating. Typically, from NOK 2,000-NOK 8,000 is the cost of the CABG. This can be compared to a cost of maybe $40,000 in the U.S.A. That tells a lot about the price sensitivity in at least a portion of this market.
Today, we have a very low position here, but we have developed this two-tier product strategy. We realized that we will not be able to succeed only with our high-end products. They will be too expensive in this price-sensitive market. We therefore went to market with a low-end version, and it was a third-party product. The name is SonoQ.
Now we have actually made the decision to transition out the SonoQ and replace it with one of the modules in the MiraQ family and launch that as a MiraQ basic version. The rationale for doing this is really the complexity and the cost which is associated with keeping two product families alive, both from a regulatory perspective, which is just becoming increasingly demanding, and also from a pure cost perspective.
Of course, we have higher margins on our own developed products and own-produced products, and it's also just handling costs internally, which will be more beneficial. The strategy is still the same, and it's the combination of these two product types that will enable our partner to negotiate bundle deals with the hospital chains, which we think is the way to go forward and build a significant position in this market.
We have, as I have talked about many times, really been looking for the strong and right partner. LivaNova, they are a global medical device manufacturer. They also have a very strong position in Cardiac Surgery with their heart-lung machines, and they have a strong position in India in particular. They're going after exactly the same customers, meaning they already have the relationships with the customers that we are interested in.
I don't think we could have found any better partner to work with and to represent us in this challenging but very interesting market. We also have very good experience from working with LivaNova. They are also representing us in Australia. In Australia, we're actually currently having about 1/3 of the market being present at 40 of the 52 cardiac hospitals in Australia.
We have definitely had good support from LivaNova over the time there. This agreement was signed in the fourth quarter, and they are representing us now in the market as of January 1st, 2021. Again, reminding everyone that this is a longer-term growth opportunity, and things will not change dramatically in 2021. We feel that we are in great shape and position to really start seriously working on this.
Okay. Lastly, just a few comments on the situation with the COVID-19 pandemic. As we have all seen, there are continued negative effects on sales revenues in the fourth quarter. We also do see some tendency of recovery and in lower impact on sales. I mentioned that we started the year with really a record performance and 16% growth.
We had COVID-19 coming in the second quarter, which really impacted that quarter, going down 12.5% versus last year. I think what we've seen in the third and fourth quarter is definitely that the hospitals have been able to adapt to the new situation. In the second quarter, everyone was caught by surprise. There was no capacity. There was struggling to find equipment and really to find a way to handle with this new situation.
In the third quarter and in the fourth quarter, we can see that they have found a way to balance the need for allocating resources to COVID-19, and at the same time being able to take care of the cardiac patients, cancer patients, and other patient groups as well. Of course, not to 100% capacity, but at least at a higher level. I think that is what we're seeing still.
Internally in Medistim, I am still very happy to report that we have not had any significant problems. We have had the healthy employees, the supply chain has been intact. Our production has been running as normal. We have been able to contain costs, which is a good thing. That has enabled us to deliver the best operating profit ever for a year.
The cash flow has been solid, even taking into account that we paid a dividend of NOK 15 million for the year. All in all, there is every reason to be happy with the overall result. Again, we are not quite back to normal. We are still suffering from the lockdowns and the restrictions to getting contact with our customers.
I have to say that we have found solutions and developed ways to use, of course, all the digital platforms to perform not only customer meetings, but clinical evaluations and product trainings, which is really very hopeful, I would say, for the future. We're planning to do a lot more of those type of things also after the COVID-19 pandemic is behind us. This makes it so much more efficient to perform a lot more of these type of activities.
That's actually a very positive thing. We do believe that the continued positive development will take surgery activity back to the normal capacity. It's just a matter of time. We are very hopeful to see that the vaccination programs are accelerating and that we will move towards herd immunity in more and more countries as we move towards summer.
That is very important for hospitals also being able to allocate more resources back to all the other patient groups and getting back to normal. Yeah. I think the worst is behind us, and we are definitely looking forward to 2021 with a lot of optimism. With that, I think I will just check with my colleagues whether we have received any questions that we could answer.
Yes, we have a couple questions here, Kari.
Yeah.
We can start with India and the market there. There is a question related to the volume or numbers of procedures, and I think that has actually been answered in the presentation that we are estimating about 100,000 procedures in India per year. I think you kind of answered that question. It came in quite early.
Okay.
It's still related to India, and the question is, could you give some more color regarding the distribution agreement in India with LivaNova?
Well, it's a very standard distribution agreement, very similar to the agreements that we have with other distributors all over the world. Our distributor agreements are pretty comprehensive. Of course, it describes very well how the responsibilities of the two parties are in terms of both marketing sales, but also servicing the customers and following up on any potential patient events, et cetera. It's a rigid system.
First of all, I would say that we've always been very fortunate with the distributor network that we have been able to put in place. For the most part, we have been lucky or good, I don't know, a combination probably, to really find and develop relationship to very qualified distributors. For the most part in our network, the distributors tend to be rather small, more focused, very focused on the cardiac side, typically.
It's always been important for us to make sure that Medistim means something to our distributors, that it really constitutes a certain portion of their revenues so that we know that they will be putting in the effort. When it comes to a company like LivaNova, of course, this is a huge company with a lot of own developed products. You might say, is that a good idea when it comes to representing the Medistim products?
For many alternative distributors, I would say no, it would not be a good idea. For this particular distributor, we have so much synergies with regard to the target customers and all of LivaNova's heart-lung machine customers will also be relevant for considering buying flow meters and imaging equipment for intraoperative use. It's just a perfect combination of the two.
As I mentioned, we already have tried sort of working with this company, and we're very impressed with the team in LivaNova and also with the new team that we're starting to collaborate with in India. All in all, we're very optimistic, but of course, the job has to be done before we can say it's a success.
Thank you, Kari. We also have a couple of other questions that has come in. This is more related to general development in CABG. The question is, how do you expect the gradual improvement in the market and CABG surgeries to recover in 2021? When do you expect the U.S. market to be back at 2019 levels?
Yeah. I think this is a gradual process. U.S., since it makes up such a big portion of our total business, of course, what is happening there is impacting the total to a large extent. What we've seen was that the fourth quarter, everyone has followed the news, and they have really been in a horrible state with infection rates reaching the roof and maybe also with leadership that has not taken the situation seriously.
These things hopefully are changing. Of course, with vaccination, which I think is the critical change that we're seeing going forward, they will get control of the situation. As I said, the hospitals will be able to serve the normal patient population as they used to. It's just a matter of time. Hopefully, we will see effects, hopefully in the first quarter.
I would expect certainly in the second quarter, and then more so. Whether we will get back to the normal levels and how quickly, nobody can tell. I can't tell you. I think there's no reason why we shouldn't feel optimistic as long as the effects of the vaccination strategy and program is developing according to the plan.
Thank you. I think that concludes all the questions that have come in. I think we have answered everything that's come in here. Yes, there's no other questions. I think we're done with this part of the session.
I will just thank everybody for participating this morning. If there should be any further questions after this presentation, of course, don't hesitate to contact us here at the company. Thank you very much.